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THE 

PRINCIPLES  AND  PRACTICE 


OF 


OBSTETRICS 


BY 

JOSEPH  B.  DeLEE,  A.m.,  M.D. 

PROFESSOR    OF   OBSTETRICS    AT    THE    NORTHWESTERN    UNIVERSITY    MEDI- 
CAL  school;      OBSTETRICIAN   TO   THE    CHICAGO    LYING-IN    HOSPITAL    AND 
DISPENSARY,    AND     TO     WESLEY     AND     MERCY     HOSPITALS;       CONSULTING 
OBSTETRICIAN   TO   COOK    COUNTY    AND    PROVIDENT    HOSPITALS,   ETC. 


WITH  913  ILLUSTRATIONS 
150  OF  THEM  IN  COLORS 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS   COMPANY 

1913 


Z^-  ''^  '  "^  "^ 


Copyright,  1913,  by  W.  B.  Saunders  Company 


Published  January,  1913  Eeprinted  May,  1913 


PRINTED      IN      AMERICA 

PRESS     OF 

W.      B.      SAUNDERS      COMPANY 
RH  I  l_ADE  l_PH  lA 


PREFACE 


This  treatise  is  the  outgi'owth  of  a  volume,  by  the  author,  entitled  Notes  on 
Obstetrics,  and  used  for  fourteen  years  as  a  text-ljook  by  the  junior  and  senior 
classes  at  the  Northwestern  University  Medical  School. 

Throughout  its  pages  the  author  has  constantly  held  in  view  the  needs  of  the 
general  practitioner  and  the  student.  Ad(^quate  space  has  been  allowed  the  purely 
scientific  sulijects,  and  their  direct  bearing  on  daily  practice  has  always  been  clearly 
emphasized. 

Diagnosis  has  been  made  a  j^articular  feature,  and  the  relations  of  obstetric 
conditions  and  accidents  to  general  medicine,  surgery,  and  the  specialties  have  been 
fully  brought  out.  Polemic  discussion  has  been  studiously  avoided,  at  the  risk, 
perhaps,  of  sometimes  being  too  dogmatic. 

In  the  preparation  of  the  volume  the  works  of  the  world's  greatest  authorities 
and  the  recent  literature  have  been  thoroughly  studied,  but  the  opinions  expressed 
are  mainly  the  result  of  the  author's  own  experience  in  hospital,  dispensary,  con- 
sultation, and  private  practice.  Twenty-one  years'  experience  as  a  teacher  of 
physicians,  students,  and  nurses  is  reflected  in  these  pages. 

Lengthy  bibliographies  have  been  avoided,  but  sufficient  recent  references  are 
given  to  enable  the  investigator  to  find  all  the  literature. 

For  the  student,  owing  to  the  crowded  condition  of  the  modern  medical  curric- 
ulum, brevity  and  system  are  essential,  and  the  underlying  principles  of  the  art 
nnist  be  brought  out.  The  practitioner  needs  a  wealth  of  detail  and  of  illustration 
to  tell  him  what  to  do  in  a  given  case.  To  accomplish  these  purposes  in  a  single 
volume  two  sizes  of  type  have  been  used.  Less  important  matter  and  details  of 
treatment  have  been  put  in  smaller  type.  For  the  same  reasons  lengthy  descrip- 
tions of  operations  are  omitted  from  the  text,  and  put  as  full  explanatory^  legends 
under  the  illustrations  depicting  the  successive  steps  of  the  procedure.  By  study- 
ing the  pictures  serially,  the  reader  will  be  better  able  to  follow  the  operation  than 
l)y  referring  to  them  from  a  distant  text. 

The  subject  matter  is  divided  into  four  parts:  The  Physiology  of  Pregnancy, 
Labor,  and  the  Puerperium;  The  Conduct  of  Pregnancy,  Labor,  and  the  Puer- 
perium ;  The  Pathology  of  Pregnancy,  Labor,  and  the  Puerperium ;  and  Operative 
Obstetrics.  Such  an  arrangement  allows  the  easy  di\'ision  of  the  subject  to  fit  the 
usual  college  curriculum,  the  Physiology  and  Conduct  of  Pregnancy,  Labor,  and 
the  Puerperium  being  in  the  junior  year,  and  the  Pathology  of  Pregnancy,  Labor, 
and  the  Puerperium,  wdth  Operative  Obstetrics,  in  the  senior  year. 

With  very  few  exceptions  the  illustrations  are  original,  ha\dng  been  drawn 
under  the  supervision  of  the  author  from  fresh  specimens,  operations  on  the  living 
and  on  the  manikin,  and  from  original  photographs  taken  by  himself.  To  Bumm's 
matchless  work  the  author  is  indebted  for  many  ideas,  and  for  these,  as  well  as  for 
permission  to  copy  some  of  his  plates,  the  author  is  profoundly  grateful. 

James  Kell}'  Parker  drew  most  of  the  pictures;  Grace  Amidon  did  all  the  mi- 
croscopic ones;  and  Hermann  Becker,  of  Baltimore,  those  of  the  pelvic  floor  and 
the  Porro  operation.  The  tireless  labor  these  artists  put  upon  their  work,  which 
has  extended  over  a  period  of  eight  years,  is  deeply  appreciated. 

The  material  for  the  illustrations  came  mainly  from  the  Chicago  Lying-in 
Hospital.     The  microscopic  and  wet  preparations  were  generouslj'  furnished  by 


IV  PREFACE 

Professor  F.  Robert  Zeit,  of  the  Northwestern  University  Medical  School.  Pro- 
fessor H.  Gideon  Wells,  of  the  University  of  Chicago,  also  placed  specimens  at  the 
disposal  of  the  author,  for  all  of  which  he  expresses  his  thanks. 

To  Dr.  Heliodor  Schiller  the  author  is  grateful  for  help  in  reading  the  proofs, 
and  to  the  publisliers,  Messrs.  W.  B.  Saunders  Co.,  for  most  unusual  generosity  in 
the  preparation  of  the  volume. 

Joseph  B.  De  Lee. 


CONTENTS 


PAGE 

Introduction xi 

PART  I 

THE  PHYSIOLOGY   OF   PREGNANCY,    LABOR,  AND 
THE  PUERPERIUM 

Section  I 
PHYSIOLOGY  OF  PREGNANCY 

CHAPTER  I 
PuBEUTY,  Ovulation,  and  Menstruation 1 

CHAPTER  II 

Development  of  the  Ovum 28 

CHAPTER  III 
The  Physiology  of  the  Fetus 61 

CHAPTER  IV 
Changes  Due  to  Pregnancy' 70 

CHAPTER  V 
The  Length  of  Pregnancy' 112 


Section  II 
PHYSIOLOGY  OF  LABOR 

CHAPTER  VI 
Definition — Causes — Clinical  Course 114 

CHAPTER  VII 
The  Effects  of  Labor  on  the  IMaterxal  Organism 132 

CHAPTER  VIII 
The  Effect  of  Labor  on  the  Child's  Organism 13S 

CHAPTER  IX 
The  Mechanism  of  Labor 14S 

CHAPTER  X 

The  Passages 152 

CHAPTER  XI 
The  Passengers 167 

V 


Vi  CONTENTS 

CHAPTER  XII  PAGE 

The  Mechanism  of  Labor  in  Occipital  Presentation 181 

CHAPTER  XIII 
The  Mechanism  of  the  Third  Stage 199 


Section  III 

THE  PHYSIOLOGY  OF  THE  PUERPERIUM 

CHAPTER  XIV 
Local  Changes 204 

CHAPTER  XV 
General  Changes  in  the  Puerperium 218 

Section  IV 
THE  HYGIENE  AND  CONDUCT  OF  PREGNANCY  AND  LABOR 

CHAPTER  XVI                       ^ 
The  Child 223 

CHAPTER  XVII 
Hygiene  of  Pregnancy 225 

CHAPTER  XVIII 
The  Diagnosis  of  Pregnancy 250 

CHAPTER  XIX 

Symptoms  and  Signs  of  the  Second  and  Third  Trimesters 258 

CHAPTER  XX 
The  Conduct  of  Labor 270 

CHAPTER  XXI 

The  Treatment  of  the  First  and  Second  Stages 291 

CHAPTER  XXII 
The  Third  Stage 310 

CHAPTER  XXIII 

The  Conduct  of  the  Puerperium 321 

Section  V  ' 

THE  NEW-BORN  CHILD 

CHAPTER  XXIV 
Physiology  of  the  New-born  Child ; . . . .     329 

CHAPTER  XXV 
The  Care  of  the  Child 336 


CONTENTS  Vll 

PART  II 

THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND 
THE  PUERPERIUM 

CHAPTER  XXVI  page 

The  Pathology  of  Pregnancy 340 

CHAPTER  XXVII 
Diseases  Incidental  to  Pregnancy. — The  Toxemias  of  Pregnancy 342 

CHAPTER  XXVIII 

The  Kidney  of  Pregnancy 369 

CHAPTER  XXIX 
Local  Diseases  Incident  to  Pregnancy 378 

CHAPTER  XXX 
Extra-uterine  Pregnancy 381 

CHAPTER  XXXI 
Displacements  of  the  Uterus 398 

CHAPTER  XXXII 

Abortion  and  Premature  Labor 416 

CHAPTER  XXXIII 
Abruptio  Placenta 437 

CHAPTER  XXXIV 
Placenta  Previa 445 

CHAPTER  XXXV 
Multiple  Pregnancy 462 

CHAPTER  XXXVI 
Prolonged  Pregnancy  and  Missed  Labor 473 

CHAPTER  XXXVII 
Diseases  Accidental  to  Pregnancy 476 

CHAPTER  XXXVIII 
The  Chronic  Infectious  Diseases 480 

CHAPTER  XXXIX 
Diseases  of  the  Urinary'  Sy'stem 496 

CHAPTER  XL 

Diseases  of  Metabolism — Diseases  of  the  Eye,  Ear,  Nose,  and  Throat 502 

CHAPTER  XLI 
Local  Diseases  Accidental  to  Pregnancy- 509 

CHAPTER  XLII 
Pregnancy  Complicated  by  Neoplasms 521 

CHAPTER  XLIII 
Minor  Disturbances  of  Pregnancy 533 

CHAPTER  XLIV 
Diseases  of  the  Ovum 535 


VIU  CONTENTS 

CHAPTER  XLV  page 

Teratology 537 

CHAPTER  XLYI 
Diseases  of  the  Fetal  Envelops 544 

CHAPTER  XLVII 

An'omalies  of  the  Cord  and  of  the  Amnion 558 


Section  VI 
THE  PATHOLOGY  OF  LABOR 

CHAPTER  XLVIII 

Anomalies  of  the  Powers 567 

CHAPTER  XLIX 
A:n-omalies  of  the  Passengers 579 

CHAPTER  L 

Anomalies  of  the  Passengers  (Continued) 603 

CHAPTER  LI 
Anomalies  of  the  Passengers  (Concluded) 636 

CHAPTER  LII 
Anomalies  of  the  Passages 644 

CHAPTER  LIII 
Anomalies  of  the  Bony  Pelvis 651 

CHAPTER  LIV 
Contracted  Pelvis 657 

.,                                              CHAPTER  LV 
Clinical  Aspects  of  Contracted  Pelvis 690 

CHAPTER  LVI 
Mechanism  of  Labor  in  Contracted   Pelvis 695 

CHAPTER  LVII 
Prognosis  of  Labor  in  Contracted  Pelvis 705 

CHAPTER  LVIII 

Treatment  of  Contracted  Pelvis 709 

CHAPTER  LIX 
The  Accidents  of  Labor 725 

CHAPTER  LX 
Injuries  to  the  Bladder,  Rectum,  Etc 763 

CHAPTER  LXI 

Postpartum  Hemorrhage 768 

CHAPTER  LXII 
Accidents  to  the  Child 797 


CONTENTS  IX 

Section  VII 
PATTIOT.OriY  OF  TTIK  PUERPERirM 

CllAl'TlOR  LXIII  PAGE 

PUKIU'KKAL    InKECTION 817 

ClIAI'TER  I>X1V 
Clinical  Types  ok  PiKurKKAL  Lnkection 833 

CHAPTER  LXV 

DlAliXOSIS    OF    PUEUPERAL    INFECTION 864 

CHAPTER  LX\  1 

Treatment  of  Puerperal  Infection 873 

CHAPTER  LXVII 

Diseases  of  the  Breasts 884 


PART  III 
OPERATIVE  OBSTETRICS 

CHAPTER  LXVIII 
General  Considerations 897 

CHAPTER  LXIX 
Preparatory  Obstetric  Operations 907 

CHAPTER  LXX 

Preparatory  Obstetric  Operations  (Co«ii/( wet/) — Preparation  of  the  Boxy  Pelvis.  .     921 

CHAPTER  LXXI 
Operations  of  Delivery 946 

CHAPTER  LXXII 
Cesarean  Section 990 

CHAPTER  LXXIII 
Mutilating  Operations  on  the  Child 1005 

CHAPTER  LXX  IV 

Induction  of  Premature  Labor 1014 


Appendix 1021 

Index 1029 


INTRODUCTION 


Obstetrics  is  that  part  of  tho  science  and  art  of  meclicino  relating  to  the  func- 
tion of  reprothiction.  The  word  obstetrics  probably  comes  from  the  Latin  oh  and 
stare,  "to  stand  before,"  "to  protect."  While,  strictly,  it  should  be  applied  to  child- 
birtii  or  parturition,  usage  justifies  its  application  to  all  the  phases  of  reproduction. 
"Midwifery"  and  "tocology"  are  synonyms  for  obstetrics.  The  function  of  repro- 
duction is  a  closed  cycle  of  events,  interposed  in  the  life  of  a  woman,  and  comprises 
five  periods — conception,  pregnancy,  labor,  lactation,  and  involution. 

The  union  of  the  male  element  of  propagation,  the  spermatozoid,  ^^^th  the 
corresponding  female  element,  the  ovum,  in  the  genital  tract  of  the  woman,  results 
in  the  formation  of  a  cell  which  is  capable  of  attaching  itself  to  the  uterine  wall  and 
developing  into  a  fully  matured  intlividual  resembling  its  parents.  The  fusion  of 
these  two  procreative  elements  is  called  conception.  The  production  of  a  ripe 
human  ovum  requires  about  ten  lunar  months— i.  e.,  pregnancy  lasts  about  two 
hundred  and  eighty  days,  and  on  the  completion  of  this  period  the  uterus  expels 
its  contents  into  the  external  world,  the  process  being  called  labor,  or  parturition. 
The  reproductive  cycle  is  continued  by  the  breasts  taking  up  the  further  nourish- 
ment of  the  child, — lactation, — and  is  completed  when  the  pelvic  organs,  concerned 
in  the  process,  return  to  their  former  condition.  This  function  is  called  involution. 
This  cycle  may  be  repeated  more  or  less  often  during  the  period  of  reproductive 
activity  of  the  woman,  which  extends  from  pubert}^  to  the  menopause.  One  de- 
mands that  it  should  not  cause  her  death  nor  injure  her  health,  and  that  the  child 
be  born  alive,  well,  and  capable  of  continued  extra-uterine  existence. 

Unfortunately,  this  standard  is  seldom  attained.  The  process  of  reproduction 
is  disturbed  by  many  pathogenic  influences  in  all  the  periods  of  the  cycle,  and  many 
permanent  structural  changes  are  inaugurated.  The  study  of  all  these  processes, 
both  normal  and  pathologic,  is  the  science  of  obstetrics;  the  application  of  this 
scientific  knowledge  and  that  derived  from  intelligent  experience  at  the  bedside  of 
the  patient  comprises  the  art. 

In  the  course  of  the  study  of  obstetrics  it  vrdl  be  seen  that  the  function  of  gesta- 
tion affects  every  organ  in  the  woman's  body,  and,  conversely,  all  conditions,  med- 
ical or  surgical,  have  a  more  or  less  direct  influence  on  the  process  going  on  in  the 
uterus.  The  child,  too,  has  its  own  physiology  and  pathology,  both  medical  and 
surgical.  The  obstetrician,  therefore,  must  not  alone  be  well  versed  in  his  particular 
science  and  art,  but  he  must  also  be  an  internist,  a  surgeon,  and  a  pediatrist.  The 
borderlands  of  obstetrics,  with  medicine,  surgery,  and  pediatrics,  are  narrow  and 
intimate.  In  some  universities  the  chairs  of  obstetrics  and  of  gynecology  are  com- 
bined, it  being  held  that  the  relations  of  the  two  branches  of  medicine  are  so  inti- 
mate that  their  separation  is  artificial  and  impractical.  The  obstetrician  should  not 
be  a  "midwife,"  caring  only  for  actual  births — his  duty  is  to  treat  all  the  diseases 
and  accidents  that  have  to  do  with  the  reproductive  function.  Thus  he  must  as 
skilfully  repair  an  old  perineal  laceration  as  a  new  one,  or  treat  sterilitj^,  as  well  as 
the  surgical  complications  of  puerperal  infection.  He  must  be  able  to  remove  a 
ruptured  uterus,  extirpate  ovarian  cysts  complicating  labor,  as  well  as  perform 
cesarean  section. 

While  obstetrics  is  the  most  difficult  and  arduous  of  medical  practice,  it  at  the 


Xll  .   INTRODUCTION 

same  time  is  the  most  satisfying.  Nowhere  can  the  physician  accomphsh  so  much, 
both  in  prevention  of  disease  and  accidents  and  in  treatment  and  operation.  The 
accouchem*  very  often  has  the  positive  conviction  that  without  him  either  mother 
or  child,  or  both,  would  have  perished.  With  the  erection  of  model  maternity 
hospitals,  the  use  of  anesthetics,  and  the  employment  of  sufficient  assistants  for  the 
conduct  of  parturition  the  practice  of  obstetrics  is  being  divested  of  most  of  its  ob- 
jectional3le  features,  and  with  the  public  there  is  a  growing  sentiment  toward  the 
emplo3anent  of  obstetric  specialists.  These  circumstances  all  tend  to  make  the 
field  of  obstetrics  more  inviting  to  the  ambitious  physician,  and  will  conduce  to 
more  rapid  advance  in  both  its  science  and  art.  The  broader  conception  of  the 
scope  of  obstetrics  referred  to  above  will  also  work  to  the  same  happy  result. 

Statistics  show  that  there  is  need  for  this.  It  is  generally  conceded  that  the 
practice  of  obstetrics  is  on  a  low  plane.  Many  reasons  have  been  advanced  to  ac- 
count for  it,  but  in  my  opinion  the  basic  cause  is  the  prevalence  of  the  notion  that 
childbirth  is  a  normal  function. 

Is  lal^or  in  the  woman  of  today  a  normal  function?  I  say  it  should  be,  but  is 
not.  Imperfect  as  our  statistics  are,  a  little  more  than  one-half  of  the  area  of  the 
United  States  being  registered,  and  the  returns  from  the  registered  portion  being 
incomplete,  we  know  that  8500  women  annually  che  in  childbirth.  We  can  form  no 
conception  of  the  late  or  postponed  mortality  from  injury  received  during  labor, 
and  diseases  acquired  during  pregnancy  and  the  puerperium,  nor  can  any  one  tell 
how  many  women  die  from  childbirth  but  are  buried  under  another  diagnosis.  I 
feel  perfectly  safe  in  stating  that  over  20,000  women  die  in  the  United  States  every 
year  from  the  direct  and  indirect  effects  of  labor. 

The  immense  amount  of  invalidism  resulting  from  childbirth  is  absolutely  un- 
measurable,  but  w^e  know  that  annually  hundreds  of  thousands  of  women  flock  to 
our  hospitals  for  the  repair  of  injuries  and  for  relief  from  the  effects  of  diseases  con- 
tracted during  labor.  It  is  safe  to  say  that  50  per  cent,  of  women  who  have  had 
children  bear  the  marks  of  injury,  and  will,  sooner  or  later,  suffer  from  them.  Lacer- 
ation of  the  pelvic  floor,  of  the  supports  of  the  uterus,  bladder,  and  vagina,  occur  in 
every  labor.  This  fact,  easily  proved  clinically  by  any  accoucheur,  recently  was 
demonstrated  by  the  anatomist  Tandler.  The  late  consequences  of  laceration  of 
the  pelvic  floor,  such  as  dislocation  of  the  pelvic  organs,  especially  uterus  and  blad- 
der, infections  of  the  genital  tract,  congestive  conditions  of  the  uterus,  tubes,  and 
ovaries,  cystitis,  ureteritis,  pyelitis,  etc.,  prolapse  of  the  rectum, — indeed,  a  host  of 
diseases,  some  fatal,  and  all  inimical  to  the  enjoyment  of  life, — all  these  conditions 
and  others  that  could  be  named  in  considerable  number  that  follow  even  natural 
delivery  stamp  the  function  of  reproduction  in  women  as  abnormal.  Between  3 
and  5  per  cent,  of  children  die  during  delivery,  and  a  great  many  are  permanently 
crippled  by  the  forces  of  labor. 

Mauriceau  epigrammatically  called  pregnancy  a  disease  of  nine  months'  dura- 
tion. Sir  James  Y.  Simpson  said  that  "parturition  is  always  physiologic  in  its 
object,  but  not  in  some  of  the  phenomena  and  peculiarities  which  attend  upon  it  in 
civilized  life."  Engelman,  after  comparing  the  labors  of  primitive  and  civilized 
peoples,  says  that  a  simple,  natural  labor  is  no  longer  possible,  and,  further,  "the 
parturient  suffers  under  the  continuance  of  the  old  prejudice  that  labor  is  a  physio- 
logical act."  Kehrer  said  that  there  was  no  sharp  line  between  physiologic  and 
pathologic  pregnancy.  J.  O.  Polak,  in  1910,  said  that  parturition  is  rapidly  becom- 
ing a  pathologic  phenomenon.  F.  S.  Newell  says  that  we  must  realize  that  "some- 
thing has  gone  -wrong  with  this  normal  physiologic  process,"  or  that  the  present 
methods  are  not  efficacious. 

Can  a  function  so  perilous,  that  in  spite  of  the  best  care,  it  kills  thousands  of 
Avomen  every  year,  that  leaves  at  least  a  quarter  of  the  women  more  or  less  invalided, 
and  a  majority  with  permanent  anatomic  changes  of  structure,  that  is  always  at- 


INTRODUCTION  xiii 

tended  by  severe  pain  uud  teurins  of  tissues,  and  that  kills  3  to  5  per  cent,  of  chil- 
dren— can  such  a  function  be  called  normal? 

A  text-book  is  not  the  pla('(i  for  an  extended  discussion  of  a  subject  of  this 
kind,  but  the  author  is  convinced  that  not  the  majority,  but  tlu;  minority,  of  lalj(jr 
cases  is  normal,  and  that  not  until  the  patiiologic  dignity  of  obstetrics  is  fully 
recognized  may  we  hope  for  any  considerable  reduction  of  the  mortality  and 
morbidity  of  childbirth. 

Literature 

Engelman:  Amer.  Sys.  of  Obst.,  vol.  i,  pp.  24  and  04. — Halban  and  Tandlcr:  Anatomic  und  Atiologio  dor  Genital- 
Prolapse  beim  Weibc,  Vienna,  Braumuller,  1907. — Kehrer:  Volk.  klin.  Vort.,  1905,  Zur  Embr.  Toxiimia  Grav. 
— Simiison:  Collected  Essays,  vol.  ii,  p.  123. 


PART  I 

THE  PHYSIOLOGY  OF  PREGNANCY,  LABOR,  AND 
THE  PUERPERIUM 

SECTION  I 
PHYSIOLOGY   OF    PREGNANCY 


CHAPTER  I 
PUBERTY,  OVULATION,  AND  MENSTRUATION 

Puberty.- — At  birth  a  girl  and  a  Ijoy  baby  are  much  ahke.  A  close  study  will 
show  small  differences;  the  boy  weighs,  on  the  average,  one-fourth  of  a  pound  more, 
the  head  is  a  little  harder  and  larger,  absolutely  and  also  relativelj^  to  the  body; 
a  difference  in  the  pelvis  is  also  discernible :  the  female  pelvis  is  larger  and  shallower 
than  the  male,  and  this  is  also  true  of  the  lower  animals.  More  boys  are  born 
than  girls — 105  to  100,  a  proportion  that  prevails  the  world  over,  and  for  all  the 
years,  but  since  more  boys  die  during  labor — 1  in  16 — and  during  the  first  years  of 
life,  this  proportion  is  reversed,  so  that  later  the  females  preponderate. 

During  the  first  years  the  characteristics  of  the  sexes  gradually  become  more 
marked,  and  as  soon  as  the  child  walks  the  differentiation  becomes  apparent.  The 
girl  develops  mentally  and  physically  earlier  than  the  boy,  and  one  can  sooner 
discover  in  her  those  traits  of  the  female  that  distinguish  it  in  later  life.  Sexually, 
the  differences  are  less  marked  until  the  age  of  eight  to  ten  years,  when  in  the  girl 
a  change  begins.  In  the  boy  it  is  noticed  a  few  years  later.  This  change  is  called 
puberty,  or  in  girls,  menarche  (from  Greek  ^x-qp  apxv),  and  may  be  defined  as  that 
period  in  the  life  of  the  individual  when  it  becomes  capable  of  reproduction.  The 
changes  are  more  rapid  and  marked  in  the  female — indeed,  her  sexual  life  is  more 
intense  and  plays  a  greater  role  in  her  existence.  Madame  de  Stael  said:  "L'amour 
n'est  qu'une  episode  de  la  vie  de  Thomme;  c'est  I'histoire  tout  entiere  de  la  femme." 

The  girl  passing  into  womanhood  changes  physically  and  psychically.  The 
pelvis  enlarges,  the  limbs  round  out  with  fat,  the  neck  grows  more  graceful,  and 
the  angularity  of  the  ]:)ody  is  replaced  by  graceful  curves.  The  general  carriage 
of  the  body  is  more  womanly,  and  the  movements  of  the  person  acquire  dignity. 
The  breasts  enlarge,  become  more  prominent,  fuller,  and  firmer,  the  result  of  gro^^th 
of  the  gland  tissue  and  the  addition  of  fat;  the  nipple  becomes  more  prominent; 
the  primary  qreola  develops.  Only  very  rarely  may  a  droplet  of  secretion  be 
squeezed  from  the  nipple.  The  skin  shoAvs  marked  changes :  its  activity  is  increased, 
that  of  the  sebaceous  glands  particularly,  so  that  not  infrequently  comedones  and 
acne  result;  in  brunets  the  pigmentation  deepens,  the  hair  takes  on  more  luxuriant 
groAvth,  and  it  also  develops  on  the  mons  pubis  and  axillae;  striae — fine  lines — 
sometimes  appear  on  the  thighs,  and  especially  on  the  breasts.  These  striae  are 
due  to  stretching  of  the  skin,  the  connective-tissue  fibers  arranging  themselves  in 
parallel  lines,  some  of  them  tearing.     They  at  first  appear  as  purplish  lines,  but 

1 


2  PHYSIOLOGY    OF    PREGNANCY 

after  several  years  turn  a  silvery  white.  The  external  genitalia  grow  larger,  darker, 
more  vascular,  have  more  secretion,  and  emit  a  faint  characteristic  odor.  The 
thyroid  enlarges,  the  larynx  changes,  especially  in  the  male.  In  the  female  the 
voice  also  is  altered,  becoming  fuller,  lower  in  scale,  and  more  melodious.  In 
brunets  the  tendency  is  toward  a  contralto;   in  blondes,  toward  a  soprano,  range. 

The  mind  undergoes  alteration  in  its  three  parts — the  will,  the  intellect,  and 
the  emotions.  The  will,  especially  during  the  change,  becomes  uncertain,  and  the 
girl  loses  to  a  good  extent  her  control  over  it.  Hysteric  manifestations  are  quite 
common.  The  intellect  broadens;  new  perceptions  give  a  grander  conception  of 
life.  The  girl  feels  that  a  great  transformation  is  taking  place  in  her  being,  and 
the  pride  of  womanhood  and  of  anticipated  wife-  and  motherhood  swells  in  her. 
The  emotions  during  the  period  of  change  also  become  unstable:  the  girl  laughs 
and  cries  often  ^^-ithout  reason,  is  happy,  gay,  or  sad  and  melancholy  without 
cause.  One  must  watch  these  manifestations — they  may  exceed  the  normal.  The 
inclination  toward  the  male  increases,  while  at  the  same  time  a  sense  of  modesty 
develops. 

This  transformation  is  the  outward  expression  of  the  changes  occurring  in 
the  internal  organs  of  generation.  The  uterus  is  developing  rapidly.  The  vagina 
lengthens  and  becomes  rugous,  the  tubes  grow  longer,  the  ovaries  take  on  a  special 
activity,  ova  develop,  the  Graafian  follicles  enlarge — in  short,  ovulation  begins. 
With  o\'ulation  comes  the  ability  to  reproduce,  but  the  girl  at  puberty  is  unfit  to 
])ring  forth  children.  Cases  are  on  record  where  girls  of  ten  and  even  of  nine  years 
bore  children,  the  one  reported  by  Bodd  w^eighing  3500  gm.  Plato  set  twenty 
years  as  the  best  age  for  the  first  child,  and  Wernich,  from  a  study  of  the  develop- 
ment of  the  children  of  young  women,  decided  on  the  age  of  twenty-three  as  the 
best.  At  this  time  also  the  pelvis  has  achieved  its  full  development;  the  bones 
are  still  somewhat  elastic,  the  joints  supple;  the  coccyx,  particularly,  can  be  pressed 
back,  and  the  pelvic  genital  tract  is  soft  and  elastic. 

The  most  important  sign  of  the  advent  of  puberty  is  the  appearance  of  the 
menses,  or  menstruation.  This  is  a  flow  of  blood  of  several  days'  duration,  recur- 
ring every  four  weeks,  attended  by  local  symptoms  referable  to  the  genitalia  and 
general  symptoms.  This  phenomenon,  again,  is  dependent  upon  or  related 
to  the  changes  going  on  in  the  ovaries,  called  ovulation.  Therefore,  puberty  is 
marked  by  the  inauguration  of  two  new  functions, — ovulation  and  menstruation, — 
each  of  which  will  now  be  considered. 


OVULATION 

Ovulation  is  that  process  by  which  an  ovum  ripens  and  is  extruded  from  the 
ovary — that  is,  it  is  the  maturation  of  the  ovum  or  egg  and  expulsion  of  same 
from  the  ovary. 

The  ovary  is  a  densely  fibrous  little  organ,  situated  in  the  pelvis  on  the  posterior  surface  of 
the  broad  ligament,  in  a  shallow  pouch— the  "fossa  ovarica."  It  is  39  mm.  long,  19  mm.  wide, 
and  8  to  1.3  mm.  thick,  and  weighs  about  5  gm.  The  right  is  usually  larger  than  the  left,  and  is 
more  liable  to  disease,  because  of  the  proximity  of  the  appendix. 

The  organ  is  shaped  like  a  large  almond,  being  attached  to  the  broad  ligament  by  two  layers 
of  the  peritoneum,  between  which  the  vessels  and  nerves  enter  its  substance.  The  outer  end  is 
attached  by  one  of  the  fimbria'  of  the  Fallopian  tube  to  the  tube.  The  ovary  was  first  mentioned 
by  Herophilus  fAlexandria,  300  b.  c),  and  received  its  name  from  Steno,  in  the  seventeenth  cen- 
tury A.  D.  (Fasbender).  The  ovaries  of  different  women  vary  much  in  size  without  apparently 
any  relation  to  fertility.  At  birth  the  ovary  is  relatively  quite  large.  Its  growth  up  to  rnaturity 
is  caased  by  the  formation  of  connective  tissue,  vessels,  and  the  enlargement  of  existing  primordial 
follicles,  ('orpora  albicantia  and  a  corpus  luteum  were  fovmd  in  the  ovaries  of  new-born  and  very 
young  chilflren  by  Runge.  Many  ova  are  destroyed  before  puberty  by  the  constriction  of  the 
fibrous  tissue.  After  the  menopause  the  ovary  shrinks,  and  in  f)ld  women  may  be  as  small  as  a 
navy  bean.  Accessory  ovaries  have  been  found  on  tli(>  broad  ligaments,  and  are  probal)ly  the 
result  of  faulty  development,  not  of  fetal  inflammation.  A  third  ovary  and  corresponding  tube 
have  been  found,  which  is  interesting  from  several  clinical  and  medicolegal  points  of  view.     The 


PUBERTY,    OVULATION,    AND    MENSTRUATION  3 

ovary  is  rovored  l)y  a  layer  of  low  coliiiunar,  lustorloss  cpitlicliuiii,  called  tlie  Kenninal  e[)itlieliurn, 
under  wliieli  is  tlie  tonsil  tunica  all)iit;inea.  Beneath  tliis  are  small  unripe  ova,  wliili;  deeper  down 
are  larger  ova  in  the  process  dl'  ripening.  'I'liese  ova  are  surroumled  liy  stroma,  made  up  (jf  elastic 
fibers,  yellow  and  white,  and  unslripecl  muscular  fibers,  .-dl  three  most  abuii<lant  at  the  hilum. 
The  blood-supply  is  abundant,  and  numerous  fine  nerves  funii  uotworks  around  the  follicles. 

The  formation  of  ova  benins  early  in  fetal  life.  On  the  posterior  wall  of  the  abdomen  of  the 
embryo,  to  the  inside  of  tlie  W'olllian  bodies,  two  liKlit  streaks  of  eelom-peritoneal  epitiielium 
appear.  They  are  supporte(l  l)y  coiuiective  tissue,  and  are  the  primary  structures  of  the  future 
ovary  or  testicle.     In  the  somewhat  proliferated  peritoneal  epithelium  (germinal  epithelium  of 


i:/". 


Fl.r.u. 


Fig.  1. — Normal  Ovary  and  Tube. 
F.I.,  Fimbria;    .4,  ampulla;    M,    mesosalpinx;    £",  parovarium;    F.o.,    fimbria   ovarica;    A.v.,   hydatid   of   Morgagni; 

Pl.r.u.,  plica  recto-uterina;  I,  isthmus  tubs. 

Waldeyer)  are  seen  many  cells  of  greater  size  than  the  others,  spheric  in  shape,  and  with  a  pale 
vesicular  nucleus,  the  primordial  eggs,  or  ova.  These  may  develop  into  primordial  seminal  cells 
if  the  fetus  is  a  male.  The  germinal  epithelium  proliferates  actively,  as  do  also  the  primordial 
ova,  and  tlips  down  into  the  stroma  of  the  ovary,  carrjdng  with  it  the  ova.  These  gi-oups  of  cells 
are  called  "egg  balls,"  or  the  Pfliiger  "ovarian  tubes."  The  connective  ti.ssue  svuTounding  these 
columns  of  epithelial  cells  grows  in  such  a  manner  that  masses  of  germinal  epithelium  containing 
one  or  two  primordial  ova  are  split  ofT,  until  finally  the  ovary  is  formed  completely  of  such  "prim- 
ordial follicles"  and  connective-tissue  stroma.  The  primordial  follicles  develop  into  the  larger 
structures,  which  de  Graaf  discovered  in  1672  and  have  been  named  after  him.  The  ova  are 
nearly  all  completed  during  fetal  life;   perhaps  some  are  formed  during  the  first  few  years  of  life. 


m 


'«»« 


Fig. 


-Primordial  Egg,  Magnified. 


The  ovary  of  the  new-born  infant  contains  ovocytes  of  a  number  variously  estimated  at  from  36,000 
to  200,000.  These  are  closely  arranged  in  the  periphery  of  the  ovary,  while  toward  the  hilum  are  a 
few  follicles  in  further  advancement.  The  main  function  of  the  ovary  is  to  mature  and  discharge 
the  o\-a  l.ving  in  the  Clraafian  follicles.  Other  functions  are  ascribed  to  the  ovary,  but  their  dis- 
cu.ssion  will  l)e  made  later. 

When  a  follicle  begins  to  ripen, — and  one  lying  near  the  hilum  usually  undergoes  this  change, 
— it  sinks  toward  the  center  of  the  ovary.  The  follicle  epithelium  undergoes  a  rapid  proUferation ; 
some  of  the  central  cells  vacuolate  and  dissolve,  a  fluid  appears  in  the  center  of  the  mass  of  cells, 
which  are  thus  pressed  against  the  wall  of  the  follicle.  This  layer  of  cells  is  called  the  membrana 
granulosa;   the  licjuid,  the  licjuor  folliculi.     The  litiuor  folliculi  is  a  clear,  viscid,  alkahne,  albumi- 


PHYSIOLOGY    OF    PREGNANCY 


noid  fluid,  containing  oil-globules  and  a  few  granules.     At  one  part  of  the  periphery  of  the  folHcle  a 
small  clump  of  cells  of  the  membrana  granulosa  is  seen,  called  the  discus  proligerus  or  cumulus 


Primordial  egg 


Primordial  ovum 


,f     Germinal  epithelium 


Pfliiger's  egg-tubea 


Blood-vessel  - 


Primordial  ova 


Fig.  3. — Ovahy  of  Five-Months'  Fetus,  Showing  Egg-tubes  and  Primordial  Follicles. 


Primordial  follicles 


Germinal  epithelium 


KVi^: 


Fio.  4. — OvABT  OP  New-bokn,  Showing  Primordial  FoLLirLi;6.   U 


Dr.  Zeit 'h  specimen.) 


oophorus,  and  in  this  von  Baer,  in  1827,  found  the  human  ovum.  The  membrana  granulosa  rests 
on  a  layer  of  loose  conn(K;tive  tissue,  the  tunica  propria,  and  this  in  turn  on  a  layer  of  closely  felted 
fibrous  tissue,  the  tunica  fibrosa,  both  of  the  latter  being  derived  from  the  stroma  of  the  ovary, 


PUBERTY,    OVULATION,    AND    MENSTRUATION  5 

and  railed  the  tliora  follifuli.  The  l)l()od-siipi)ly  of  tlio  ovary  is  incroased,  and  there  is  a  local 
con^cslion  around  ihe  {irowiiin  t'oiiiclc.  The  cells  of  the  foliielo  proliferate  rapidly,  the  liquor 
folliciili  increases,  and  I  he  folhcle  nears  the  surface  of  the  ovary.     At  the  spot  nearest  the  surface 


,/f&S^^. 


hwP- '  ■ 


fk\ 


Fig.  5. — Mature  Ovary.     Traxsver.se  Section. 


'^ 


(Dr.  Zeit's  specimen.) 
-___ NS . 


l.v-^1 


MTW- 


—  Thcca 

folliculi 


—  Membrana 
granulosa 


r^;  r. 


-Primordial 
follicle 


Vitelline 
mem-  " 
brane 


Fig.  6. 
Fics.  C  and  7.- 


Fig.  7. 

-Three  Stages  of  the  Process  of  the  Ripening  of  a  Gr.vafi.vn  Folucle. 


the  theoa  folliculi  atrophies,  or  its  fibers  separate,  an  area  of  necrosLs  appears,  and  the  follicle 
bursts  at  this  point  (the  stigma),  the  ovum,  surrounded  by  cells  from  the  discus  proligerus,  escap- 
ing. Occasionally  the  follicle  does  not  burst,  the  ovimi  dies,  and  the  follicle  undergoes  involution. 
This  is  abnormal,  and  is  not  called  ovulation.      Coincident  ^ith  this  transformation  in  the  follicle 


PHYSIOLOGY    OF    PREGNANCY 


changes  destined  to  prepare  it  for  the  reception  of  the  male  element  are  going  on  in  the  ovum  em- 
bedded in  the  discus  proligerus.  The  ovum  is  a  typical  cell,  and  consists  of  a  cell-wall,  protoplasm, 
deutoplasm,  or  yolk,  which  are  later  in  the  development,  and  a  nucleus,  or  germinal  vesicle,  with 
a  nucleolus  or  germinal  spot.  This  has  ameboid  motion.  During  the  latter  period  of  the  ripening 
the  nucleus  ncars  the  surface  and  undergoes  an  unequal  karyokinesis.  After  the  formation  of  the 
cliromosome  spindle  one-half  is  extruded  as  a  small  globule,  the  first  polar  cell,  and  comes  to  lie 
under  the  zona  pellucida.  The  remaining  half  of  the  spindle  divides  again,  grows  to  a  complete 
spindle,  splits,  and  the  process  of  extrusion  of  the  second  polar  globule  is  completed  (Fig.  9). 
The  polar  globules  were  discovered  by  Robin,  a  French  histologist,  in  1821-1825.  The  formation 
of  the  polar  globule  has  never  been  observed  in  the  human  ovum,  but  it  occurs  in  all  animals. 


Membrana  granulosa 


■  qA^' 


Theca  externa 
Fig.  8. — Further  Development  op  Ovum. 


The  germinal  vesicle  now  rests,  and  is  called  the  female  pronucleus.  It  is  smaller  than  the  germi- 
nal vesicle  was,  has  a  smaller  germinal  spot  and  no  nuclear  memljrane.  The  reasons  advanced 
for  the  formation  and  extrusion  of  the  polar  globules  are,  first,  that  it  is  an  excretion,  second,  that 
it  leaves  the  ovum  in  an  incomplete  state,  requiring  tlie  male  element  to  make  it  fertile,  otherwise 
parthenogenesis  might  occur;  third  (Hertwig),  that  the  process  is  necessary  to  reduce  the  numlter 
of  chromosomes  of  the  female  nucleus.  A  similar  extrusion  of  polar  glol)ules  is  ol)served  in  the 
formation  of  the  male  pronucleus,  and  thus  both  male  and  female  gcniiiiial  vesicles  are  reduced  to 
half  nuclei,  which,  when  tliey  unite  in  conception,  restore  the  original  num))er  of  chromosomes. 
Thus  the  size  of  the  germinal  vesicle  remains  constant.  Otherwise  in  repeated  generations  it 
would  grow  too  large  for  its  parent  cell,  the  ovum. 


PUBERTY,  OVULATION,  AND  MENSTRUATION  7 

The  ('()in])lctily  luuturccl  ovum  as  it  is  (•xi)cll('(l  from  the  Graafian  follicle 
(Fif;-.  10)  is  just  visiljle  to  the  eye  as  a  fine  white  point,  measuring,  naked, 
^  millimeter  in  diameter.  It  is  surrounded  ]>y  100  or  more  epithelial  cells  de- 
rived from  the  meml)rana  granulosa,  arrangetl  radially  around  the  ovum,  and 
called  the  corona  railiata;  inside  this  is  the  egg-shell,  oolemma,  zona  pellucida, 
a  thick  membrane  with  radial  fibrillations,  not  constant  in  all  animals;  next  comes 
a  space,  which  also  is  not  constant,  the  ])erivitelline  space  (Xagel),  and  may  be 
only  an  optical  efl'ect,  or  it  may  occur  after  the  extrusion  of  the  polar  globules; 
the  vitellus,  or  yolk,  with  a  brcnid  clear  zone  of  protoplasm  and  a  large  central 
zone  of  dark,  coarsely  giaiiuhir  dcutoplasm;  the  female  pronucleus — which  was 
the  germinal  vesicle;  the  germinal  spot;  and  several  small  dark  granules  in 
the  nucleus. 

Tho  expulsion  of  the  ovum  takes  ])lace  when  the  Ciraafian  follicle  bursts,  the 
former  having  already  been  loosened  from  its  bed  in  the  cumulus  ovigerus  by 


P^i^-i^--^/ 


.•••>v 


W)^      'WK^ 


m^'f'^^yi 


Fig.  0. — Portions  of  Eggs  of  Asterias  Gl^cialis  (1  and  2).     Formation-  of  Polar  Cells  in  Asterias  Glacialis 

(3-S;.     (From  Hertwig.) 

vacuolization  of  the  cells  of  the  membrana  granulosa.     The  ovum  finds  its  way 
to  the  tu])e,  there  to  await  fertilization  by  the  male  element. 

The  Formation  of  the  Corpus  Luteum. — After  the  escape  of  the  ovum  and 
part  of  the  licjuor  folliculi  out  of  the  Graafian  follicle  the  walls  of  the  latter  collapse, 
and  any  space  remaining  fills  with  Ijlood  from  ru]:)tured  vessels  of  the  tunica  propria. 
It  is  probable  that  a  little  blood  flows  also  into  the  peritoneal  cavity.  Rarely, 
enough  may  be  lost  to  be  of  clinical  importance — even  fatal.  ]\Iost  authors  believe 
that  the  membrana  granulosa  disappears,  and  the  cavity  is  invaded  bj'  connective- 
tissue  cells  from  the  thcca,  containing  a  yellow,  refracting  pigment — lutein.  Bisch- 
ofT  believed  the  lutein  cells  are  modified  epithelial  cells  from  the  membrana 
granulosa,  and  the  latest  work  proves  he  was  correct.  There  is  a  very  active 
production  of  lutein  cells,  which  come  to  lie  in  festoons  around  the  central  blood- 
clot.  The  small  collapsed  follicle  grows  in  the  first  two  weeks  to  the  size  of  a 
bean,  and  shows  the  irregular  yellow  outline  of  lutein  cells  around  the  red  blood- 
clot.     Fibrous  tissue  grows  into  the  lutein  mass  and  the  blood-clot  from  the  periph- 


8  PHYSIOLOGY    OF   PREGNANCY 

ery,  giving  the  structure  its  irregular  outline,  and  at  the  end  of  three  weeks  the 
corpus  luteum,  as  it  is  called,  is  the  size  of  a  kidney-bean.  Now  retrogression 
occurs,  the  connective  tissue  replacing  the  lutein  cells,  whereby  the  yellow  color  is 


Mf-m- 
braria 
granu- 
losa 


-Vitelline  mem- 
brane 

Corona  radiata 


.-•oligerus  (separated 
wall  of  follicle) 


Thcca  interna 

Thcca'  externa 
Fig.  10. — The  Mature  Ovum. 


changed  to  silvery  white,  the  corpus  albicans  (Fig.  13);    after  several  weeks  more 
the  corpus  luteum  is  represented  only  by  a  small  retracted  scar. 

If  pregnancy  supervenes  on  this  ovulation,  the  great  vascularity  of  the  parts, 
or  some  other  factor  whose  nature  cannot  be  surmised,  causes  an  excessive  growth 
of  the  corpus  luteum.  The  histologic  changes  are  the  same  as  described,  but  they 
are  greater  and  prolonged.    The  full  growth  is  attained  at  the  thirteenth  week,  when 


PUBERTY,    OVULATION,    AND    MENSTRUATION  Q 

the  yellow  body  may  take  oiic-tliird  the  extent  of  the  ovary,  being  the  size  of  a 
large  hazelnut,  sometimes  palpable  on  bimanual  examination.  It  continues  of  this 
size  until  toward  the  end  of  pregnancy,  when  regressive  changes  begin  which  are 
completed  several  months  after  delivery.  Tlie  large  c(jrf)us  luteum  of  pregnancy 
is  sometimes  called  a  true  corpus  luteum.     TIk;  small  corjjus  luteum  of  nien.stru- 


£ 


5i 


.,    ,  ,  .       -'-f'^ 


•v^,i,' 


^•^  V-.-.  --  ■■       i  '       i  ■■ :     •  V  ;  ■,  ■  •■■.■• 


"*^^^^^^^P 


Fig.  11. — Corpus  Luteum  Verum. 


ation  is  sometimes  called  a  false  corpus  luteum.  It  is  usually  possible  to  distin- 
guish one  from  the  other,  but,  as  Hirst  has  shown,  in  the  ovaries  of  two  virgins  in 
which  the  corpus  luteum  of  menstruation  was  almost  exactly  like  a  corpus  luteum 
of  pregnancy,  one  cannot  always  be  certain.     In  old  women  with  poor  circulation, 


'0}W 


r 


X 


1 

A  B 

Fig.   12. — Ovary  with  Corpus  Luteum  in   situ. 
A,  Laid  open;    B,  from  outside. 


according  to  Williams,  and  in  others  with  ovarian  affections,  the  corpus  luteum 
presents  pathologic  conditions.  Some  Graafian  follicles  do  not  rupture  after  they 
are  ripe,  and  a  process  of  pseudo-corpus  luteum  formation  occurs  also  in  them. 

The  Functions  of  the  Corpus  Luteum. — It  is  more  than  probable  that  the  corpus 
luteum  has  a  vital  relation  to  the  function  of  gestation.     G.  Born  and  L.  Fraiikel 


10  PHYSIOLOGY    OF   PREGNANCY 

sought  to  prove  that  it  has  an  internal  secretion,  which,  circulating  in  the  blood, 
stimulates  and  regulates  the  changes  of  menstruation  and  gestation.  This  peculiar 
body  resembles  in  structure  the  suprarenal  gland,  and  is  also  derived  from  the 
same  fetal  cells — the  celom.     After  castration  the  islands  of  Langerhans  and  the 


'  i'^'-'r 


Fig.  13. — Corpus  Albicans.     Seven  Weeks. 


hypophysis  cerebri  hypertrophy.  Investigators  are  devoting  much  attention  now 
to  the  corpus  luteum,  and  through  it  we  may  get  some  light  on  the  formation  of 
neoplasms.  The  already  immense  literature  may  be  found  in  Chirie's  review  or 
in  Frank's  article.     Leo  Loeb  has  conclusively  shown  that  the  corpus  luteum 


^' 


r 


^-     V®,      |-    \     V*'  "^  ^»  ®     -      ^     . 

Fig.  14. — Coki>u«  Luteum  Verum.     Individual  Cells. 

prepares  an  internal  secretion,  ferment,  or  hormone,  which  sensitizes  the  uterine 
mucosa  so  that  it  reacts  to  the  stimulation  of  the  ovum  (or,  indeed,  any  foreign 
body),  with  the  production  of  exuljerant  decidua  or  maternal  placenta.  Loel^ 
also  believes  that  the  same  ferment  inhibits  ovulation  during  pregnancy,  though 


PUBERTY,  OVULATION,  AND  MENSTRUATION 


11 


clinical  exporiencc  sliows  tluit  this  is  not  invarialjle.  It  sccnis  that  the  nidation 
and  stabiHty  of  the  pregnancy  are  dei)endent  on  the  corpus  luteuni,  because  removal 
of  the  same  in  the  early  months  usually  causes  abortion.  Later,  pregnancy  is 
less  likely  to  be  interrupted — a  point  of  practical  importance.  The  breast  changes 
in  i)r('gnancy  are  also  due  to  this  ferment  in  the  blood. 

The  ovary  has  other  functions.  The  mighty  changes  in  the  whole  s\'stem  of 
the  female  occurring  at  puberty  are  ascribable  to  influences  emanating  from  the 
ovary.  Whether  this  influence  is  spread  partly  by  means  of  the  nervous  system, 
or  whether  thc^  new(>r  theories  of  Ilalban  and  Frankel  {loc.  cit.)  explain  the  changes, 
is  not  yet  decided.  Ilalban  transplanted  ovaries  to  various  portions  of  the  body, 
thus  destroying  all  nerve  connections,  and  decided  that  the  pubertj^  and  menstrual 
changes  in  the  breasts  are  due  to  chemical  substances  prepared  in  the  ovary  and 
set  free  in  the  blood.  That  the  ovary  has  an  internal  secretion  is  now  doubted 
by  few.  The  syin])toms  of  the  menopause,  especially  the  exaggerated  phenomena 
in  the  nervous  system  and  in  metabolism,  observed  so  often  after  castration,  and 
the  occasional  relief  obtained  by  the  administration  of  ovarian  extract,  justify 
this  assumption.  Ovarian  extract  reduces  the  coagulabilit}^  of  the  blood  and 
lowers  blood-pressure.  In  animals  the  presence  of  an  "interstitial  gland"  in  the 
ovary  has  been  demonstrated.  The  ovary  has  an  influence  on  the  formation  of 
bone,  e.  g.,  osteomalacia,  also  on  the  thyroid.  The  most  important  function 
ascribed  to  the  ovary,  next  to  ovulation,  is  the  superinduction  of  menstruation. 

MENSTRUATION 

Menstruation,  also  called  the  menses,  the  "periods,"  "catamenia,"  "monthl}^ 
sickness,"  "the  monthlies,"  "cleansing,"  "the  flowers,"  may  be  defined  as  a  periodic 
flow  of  blood  from  the  genitals,  recurring  every  four  weeks,  accompanied  by  general 


9  -o  SfO  fuo:, 


o.Vo^ 


Fig.  15. — Cross-sectiox  of  UxEnrs  tnder  Low  Power,   Near  Menstrcal  Period. 

sjTiiptoms  of  malaise,  nervous  manifestations,  etc.,  and  local  symptoms  of  pelvic 
congestion.  This  phenomenon  occurs  during  the  normal  reproductive  period  of 
women,  the  menacme  (Kisch),  which  begins  with  puberty,  and  continues  up  to 
about  forty-five  years.  At  this  age,  among  other  changes,  the  periods  cease  and 
the  menopause,  the  cHmacteric,  or  the  "change  of  life,"  takes  place. 


12 


PHYSIOLOGY    OF   PREGNANCY 


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PUBERTY,  OVULATION,  AND  MENSTRUATION 


13 


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The  mcnstriuil  flow  bcfijiiis  as  a  whitish  (hschars*',  but  soon  becomos  bloody, 
and  contains  red  and  white  bh)<;(l-('ori)ns<'l('s,  dcj^cncratcd,  ciliated,  and  columnar 
epithelium,  \-af;inal  and  ulciiiie  secret  ions,  and  niaii.\-  micnjorganisms,  some  of  them 
pathogenic. 

The  Anatomy. — \\  hcii  the  utonis  is  quiescent,  that  i.s,  l)otwcon  two  periods,  the  mucoas 
meinl)i!ine  is  tliin  (1  to  2  nun. J,  pale,  and  snu)otli,  the  fjlands  are  small,  the  .secretion  scant,  the 
arteries  and  veins  not  i)roniinent,  but  on  I  lie  injeete*!  .spccinuju  they  are  seen  to  be  numerous. 
Especially  thick  is  (he  capillary  network  just  under  the  epithelium  and  aivnuid  the  glands.  The 
cylindric  ciliated  epithi-lium  is  contiinied  iiitf)  the  glands.  It  is  higher  in  the  (ilaiid  luiiiina.  The 
coiniccti\'e  tissue  around  the  glands  contains  many  larj^e  I'ound-cells  with  larfic  nuclei  (Vm.  \7). 
About  ten  days  before  the  ai)p('arance  of  the  menses  the  uterus  becomes  confjested,  enlarges, 
grows  .softer,  the  endometrium  thickens  to  5  or  even  7  mm.,  the  comiective  tissue  is  infiltrated  with 
serum,  the  capillaries  are  tilled  to  bursting,  the  ei)ithelial  cells  enlarfz;e,  anrl  the  large  round-cells 
in  the  connective  ti.ssue  are  found  to  be  proliferating  rajjidly.  The  glands  increase  in  length, 
change  form,  become  complex, 
and  are  filled  with  secretion. 
Viewing  the  surface  with  a  lens, 
one  sees  man3'  furrows  with  in- 
tense superficial  hyperemia;  it  is 
sliiii}',  but  of  a  velvety  ap])ear- 
ance.  The  mouths  of  the  glands 
are  open,  like  minute  funnels. 
This  is  the  decidua  menstrualis. 
The  change  is  strictly  limited  to 
the  mucosa  of  the  corpus;  the 
cervical  mucous  membrane  does 
not  take  part. 

At  the  height  of  the  con- 
gestion the  surface  vessels  are 
most  strongly  distended  bj^  blood, 
which  often  ruptures  the  thin 
capillaries  and  undermines  the 
epithelium  and  superficial  layers 
of  the  decidua  menstrualis.  Small 
hematomata  may  form  under  the 
epithelium;  these  burst,  and  the 
blood  appears  cxternalh^  Some 
blood  simply  exudes  through  the 
capillary  walls,  and  many  leu- 
kocytes pass  through  by  dia- 
pedesis.  Menstruation  is  now 
at  its  height. 

Whereas  Sir  John  Williams 
believed  the  whole  mucosa  down 
to  tlie  muscularis  was  removed, 
and  Kundrat  and  Engelman  that 
only  the  upper  laj'ers  were  cast  off 
by  a  process  of  fatt  j'  degeneration 
which  also  afTectcd  the  blood-ves- 
sels, and  Leopold  thought  that 
the  most  superficial  laj'ers  only 
were  exfoliated,  the  most  recent 
studies  have  proved  that  really 
very  few  epithelial  cells  are  cast 
off  in  normal  menstruation.  In 
pathologic  cases  the  superficial  layers  may  exfoUate,  and  these  women  often  have  dj-smcnorrhea 
and  are  sterile. 

After  a  few  days  regression  begins,  the  interglandular  cells  in  the  area  of  greatest  congestion 
undergo  a  fatty  degeneration,  as  do  also  a  few  of  the  epithelial  cells.  The  remaining  portions  are 
gradually  regenerated.  The  congestion  subsides,  the  surface  becomes  anemic,  the  exuded  serum 
ami  the  small  hematomata  are  absorbed,  the  endometriuin  becomes  thinner,  the  ca^^ty  of  the 
uterus  gradually  reduces  in  size,  and  the  organ  comes  to  rest,  the  process  requiring  about  eight 
days.  This  period  of  rest  lasts  only  a  few  days,  because  the  preparation  for  the  next  menstruation 
begins  again.  The  changes  described  are  called  the  menstrual  cycle,  and  this  cycle  is  repeated 
every  four  weeks  during  the  menacme,  unless  interrupted  by  pregnancy,  lactation,  or  some  patho- 
logic condition. 


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Fig.  17. — Uterine  Mucos.v.  Five  D.\^ys 
(Ancestrumj  . 


Before  Menstruation 


The  cause  of  the  phenomenon  of  menstruation  is  still  unkno\m.  The  most 
generally  accepted  theory  is  that  an  influence  of  some  sort  emanates  from  the  ovan' 
during  ovulation,  and,  reaching  the  uterus,  causes  a  severe  congestion  and  the 
changes  above   described   (Bischoff,    18-i-i).     PflUger  believed  that   the   Graafian 


14  PHYSIOLOGY    OF   PREGNANCY 

follicle,  by  its  gradual  enlargement,  exerted  a  compression  on  the  nerves  in  the 
stroma  of  the  ovary;  this  irritation  of  the  nerves  was  at  first  mild,  but  periodically 
reached  an  acme  of  intensity  which  caused  a  congestion  of  the  blood-vessels  of  the 
pelvis;  that  this  hastened  the  maturation  of  the  ovum  and  the  bursting  of  the 
Graafian  follicle,  on  the  one  hand,  and,  on  the  other,  caused  the  changes  in  the 
endometrium  which  were  described  as  the  anatomic  basis  of  menstruation.  There 
are  many  arguments  for  the  theory  that  ovulation  causes  menstruation — (1)  In 
animals,  copulation  during  heat  causes  conception,  therefore  ovulation  must  occur. 
Heat  in  animals  (oestrus)  is  analogous  to  menstruation.  (2)  At  operations  and  at 
postmortems  on  women  dying  during  the  menstrual  period  fresh  corpora  lutea  or 
fully  developed  follicles  are  almost  always  found.  Bimanual  examination  in  favor- 
able cases  will  often  show  an  enlargement  of  one  ovary,  and  one  may  feel  the 

Graafian  follicle  burst  under 
the  pressure  of  the  fingers. 
In  an  ovarian  hernia  the 
periodic  swelling  of  the 
ovary  has  been  observed. 
(3)  Hyrtl  describes  the  case 
of  a  girl  who  died  after 
eight  periods,  where  he 
found  four  corpora  lutea  in 
each  ovary.  (4)  Removal 
of  the  ovaries  causes  cessa- 
tion of  the  menses,  and  in 
cases  of  congenital  absence 
of  the  ovaries  there  are  no 
menses.  (5)  There  must 
be  some  dependence  of  the 
uterus  on  the  ovary,  be- 
cause when  the  ovary  is  ex- 
tirpated early  in  life,  the 
uterus  does  not  develop  nor 
does  the  pelvis.  (See  Meno- 
pause.) 

That  the  direct  con- 
nection between  the  two 
functions  is  not  so  clear  is 
shown  by  these  facts:  (1) 
Ovulation  may  occur  at  any 

Fig.   is. — Uterine  Mucosa  One  Day  Before  Menstruation  tmie,  aS   IS  prOVeu  by   lapa- 

(Procestrumj.  rotomies  and  autopsies.    (2) 

Ovulation  occurs  before  the 
Vjirth  of  th(;  child,  during  childhood,  and  after  menstruation  ceases.  Pregnancies  have 
occurred  before  puberty  (see  p.  2) — the  child  may  have  "fruit  before  flowers"  (De 
la  Motte) .  Conception  has  occurred  during  the  prolonged  absence  of  the  menses,  dur- 
ing the  amenorrhea  of  lactation,  and  also  after  the  menopause.  (3)  In  some  animals 
ovulation  occurs  long  Ijefore  heat.  (4)  Copulation  has  an  influence  on  ovulation,  as  is 
proved  })y  the  fact  that  puberty  occurs  earlier  when  coitus  is  performed  early,  as  in  the 
countries  of  early  marriages ;  (2)  in  rabbits  it  has  been  shown  that  copulation  hastens 
the  rupture  of  the  Graafian  follicle,  and  (3)  certain  tortoises  cohabit  two  years  before 
the  eggs  are  fertile.  Nevertheless,  ovulation  is  by  no  means  dependent  on  coitus, 
as  virgins  perform  the  function  regularly.  Experiments  on  animals  have  been  made 
by  Frankel,  Bouin,  Ancel,  Loeb,  and  others  to  determine  this  relation.  All  that 
can  reasonably  be  deduced  from  a  study  of  the  facts  is  that  there  is  a  strong  con- 


■•4  ft*^i»  «»»«•#?»»*/' 


PUBERTY,  OVULATION,  AND  MENSTRUATION  15 

ncctiuu  hc'twi'cu  tlu'  I'uncliun.s  of  the  ovary  and  (jf  tiie  uterus;  lliat  tiie  impulses 
leave  the  ovary  and  affect  the  uterus;  that  the  phenomenon  of  menstruation  is, 
probably,  the  result  of  the  stimulation  of  ovulation,  and  that,  while  ovulation  may 
occur  at  any  time,  the  monthly  ovulation  is  the  usual  one,  and  affects  tlu?  uterus, 
therefore  monthly  also. 

It  is  not  nec(>ssary  that  the  Clraafian  follicle  ru])ture  to  i)roduee  menstruation. 
The  devx'lopment  and  regression  alone  suffice.  How  the  influence  of  the  ovary  is 
transmitted  to  the  uterus  is  not  known.  Pflufi;er  believed  the  .stretching  of  the 
ovary  caused  by  the  growing  (iraafian  fcjlliele  irritated  the  nerves  of  the  ovary  and 
thus  the  reflex  was  elicited.  Strassman  injected  fluids  into  the  ovaries  of  animals 
and  produced  evidence  of  heat.  Prol)ably  it  is  not  via  the  nervous  system,  though 
nerves  have  been  demonstrated  even  in  the  membrana  granulosa  (Mandl).  Many 
e.xperiments  and  clinical  ob- 
servations point  to  the  ac- 
tion of  an  internal  secretion. 
Hall)an  has  sought  to  ])rove 
that  the  internal  secretion  of 
the  ovaries  causes  the  men- 
struation. He  transplanted 
ovaries  to  distant  parts  of 
the  body  of  monkeys,  and 
a  sort  of  pseudo-menstrua- 
tion continued.  Then  he 
removed  the  ovaries  and 
the  menses  disappeared. 
Knauer  transplanted  the 
ovaries  to  another  part  of 
the  abdomen  in  animals, 
and  saw  even  pregnancy 
follow.  F.  H.  Martin,  of 
Chicago,  has  often  success- 
fully transplanted  human 
ovaries.  He  gives  com- 
plete literature.  Trans- 
planted portions  of  the 
mammary  gland  react  to 
the  stimulation  of  preg- 
nancy (Pfister).  Perhaps 
the  internal  secretion  of  the 
corpus  luteum  is  here  active, 

Qg  T      TTranlrpl   trlcS  tO  DrOVe  ^'°*   ^^' — Endometrium  During  Height  of  Menstruation   (Zeit). 

We  know,  for  example,  that 

certain  ferments  are  produced  at  one  point  of  the  intestinal  tract,  and  are  carried 

by  the  blood-stream  to  another  point,  and  there  awaken  the  action  of  the  intestinal 

glands. 

Most  recently  the  hypothesis  has  been  advanced  that  menstruation  is  caused 
by  cyclic  biochemical  changes  in  the  blood,  having  to  do  with  the  metaboHsm 
of  calcium. 

The  object  of  menstruation  has  also  given  rise  to  much  theorizing.  The  oldest  notion  re- 
garding the  menstrual  discharge  is  that  it  is  the  result  of  a  general  plethora.  The  woman  is  en- 
dowed with  greater  blood-making  powers,  as  she  must  nourish  the  fetus  also.  If  she  remains 
sterile,  there  is  no  need  for  this  extra  blood,  and  it  is  thus  gotten  rid  of.  While  by  no  means  accept- 
ing this  theory,  it  is  interesting  to  note  that  in  poorly  nourished  girls,  or  those  of  a  tuberculous 
type,  nature  withholds  the  menses  for  no  other  reason,  obviously,  than  to  save  the  organism  tliis 
useless  waste  of  blood.     Another  theory,  little  less  old,  is  that  of  a  purification.     Even  yet  by 


16  PHYSIOLOGY    OF    PREGNANCY 

some  races  women,  while  menstruating,  are  regarded  as  unclean.  The  substances  which  were 
passed  in  the  monthly  discharges  were  supposed  to  be  poisons.  Recently  a  southern  writer  said 
that  cases  of  retention  of  the  menses  could  result  in  headache,  neuralgia,  and  rheumatic  pains, 
even  epilepsy.  In  Germany  the  term  "monatliche  Reinigung,"  "monthly  cleansing,"  is  still  used. 
Sclmioulker  and  Ivieffer  declared  that  the  menstrual  blood  is  an  excretion,  relieving  thus  a  toxemia. 
Charrin  proved  that  the  woman's  blood  is  more  toxic  before  and  during  menstruation.  Turenne 
explained  the  toxemia  of  pregnane}-  as  a  menorrhemia,  and  administered  ovarian  extract  as  a 
remedy,  but  has  no  followers. 

Pfliiger  said  the  hemorrhage  prepared  the  mucous  membrane  of  the  uterus  in  the  manner  of 
an  inoculation  surface  for  the  reception  of  the  egg.  Power  said:  "A  woman  menstruates  because 
she  does  not  conceive."  The  mucous  membrane  is  prepared  each  month  for  the  reception  of  the 
fertilized  oviun.  Aveling  called  it  "nest  building."  If  conception  does  not  occur,  the  nest  is  not 
needed — the  mucous  membrane  undergoes  regressive  changes  imder  the  clinical  picture  of  men- 
struation. We  now  know  that  the  uterus  is  sensitized  for  the  ovum  by  the  ferment  from  the  corpus 
luteum. 

Tiihal  Menstruation. — There  are  reasons  for  believing  that  the  Fallopian  tubes 
also  take  some  part  iu  menstruation — fu'st,  because  tubes  fastened  in  the  abdominal 
wall  often  have  periodic  bloody  discharges;  second,  cases  of  hematosalpinx  point 
to  this  action;  and  third,  a  decidua  menstrualis  has  been  found  in  the  tube  (Arendt). 
One  might  argue  against  this  supposition  that  the  blood  regurgitated  from  the 
uterus;  that  in  all  these  cases  the  tube  was  diseased,  which  holds  true  for  the 
first  two  cases,  at  all  events.  The  mucous  membrane  of  the  tubes  may  undergo 
changes  similar  to  those  of  the  endometrium  without  the  escape  of  blood,  as  one 
also  ol^serves  a  marked  congestion  of  the  cervix,  vagina,  and  vulva,  with  increased 
secretion  of  the  glands,  during  menstruation. 


THE  CLINICAL  ASPECTS  OF  MENSTRUATION 

Time  of  Appearance. — In  about  2  per  cent,  of  new-born  girls  there  appears  a 
bloody,  mucoid  discharge  from  the  vagina,  which  lasts  one  to  four  days.  This  is 
called  pseudo-menses,  usually  indicates  nothing  pathologic,  and  requires  no  treat- 
ment unless  prolonged  and  profuse.  Bayer  ascribed  it  to  the  ovarian  influence  of  the 
mother  transmitted  as  an  internal  secretion  to  the  fetus  by  waj'  of  the  placenta.  It 
may  be  due  to  ovulation  going  on  at  the  time  of  birth  in  the  mother,  or  even  in  the 
child.  Almost  always  this  pseudo-menses  does  not  recur,  but  cases  of  precocious 
menstruation  are  on  record.  Plumb  reports  the  case  of  a  nine-pound  girl  with  genitals 
like  a  fifteen-year-old,  whose  periods  began  six  weeks  after  birth,  and  continued  everj^ 
sLx  weeks  thereafter.  Cases  of  the  menses  begimiing  in  the  third  and  fifth  month, 
with  development  of  the  genitalia  and  ^\dth  hair  on  the  pubis  before  the  sixth  year, 
are  on  record.  This  precocity  is  sometimes  inherited.  Often,  however,  it  is  the 
evidence  of  cUsease.  The  author  saw  very  profuse  pseudo-menses  in  two  infants 
that  died  of  cerebral  hemorrhage.  Several  cases  of  precocious  menstruation  had 
hydrocephalus,  sarcoma  of  the  ovary,  tuberculosis,  or  other  disease. 

The  time  of  the  advent  of  puberty  and,  with  it,  the  menses,  varies  according 
to  climate,  environment,  race,  heredity,  condition  of  life,  and  type  of  person. 
Warm  climate  seems  to  bring  on  early  menstruation:  the  Hindus  having  the  menses 
at  twelve  years,  and  English  women  living  in  India  are  affected  likewise.  In 
Greenland  puberty  begins  from  the  seventeenth  to  the  twenty-third  year,  and  some 
of  the  Eskimos  menstruate  only  in  summer. 

Races  show  marked  variations.  The  Aryans  and  Slavs  menstruate  late,  the 
Jews  and  most  Orientals  early.  Brunets  and  red-haired  girls  menstruate  early; 
blonds,  late  (Kisch).  Environment  exerts  a  strong  influence.  The  highly  strung 
citj'-bred  girl  has  early  periods,  the  country  girl,  later;  the  poor  overworked  factory 
girl,  later;  the  girl  reared  in  luxury,  who  has  dances,  sees  plays,  reads  novels,  early. 
Chlorotic  and  tuberculous  girls,  by  a  wise  conservatism  of  nature,  do  not  menstru- 
ate or  do  so  toward  the  twentieth  year.  Indeed,  the  late  or  scant  appearance  of  the 
flow  should  warn  to  a  careful  examination  of  the  patient. 


PUBERTY,    OVULATION,    AND    MENSTRUATION  17 

If  the  inothcr  iiu-nst runted  curly,  the  (lauftlitcr  may  also.  Tlic  same  is  true 
of  the  cessation  of  tiie  jjcriocls. 

Sjnnptoms.— ^At  the  onset  of  the  menses  the  woman  usually  has  symptoms 
referal:)le  to  the  j^enitaHa  and  general  symptoms, which  are  called  menstrual  molim- 
ina.  Headache,  throbbing-  in  ciiaracter,  malaise,  and  a  feeling  of  lassitude, 
neuralgias,  esjK'cially  of  the  face,  chilliness,  flashes  of  heat,  all  these  occur  and  show 
the  powerful  effect  of  ovulation  on  the  entire  body.  Sexual  desire  is  usually  exag- 
gerated; there  is  increased  sensibility,  both  of  the  skin  and  of  the  mind,  and  in 
those  pr(>(lisposed,  hysteric  outbreaks  are  common.  The  ennmctories  are  more 
active, anil  the  patient  more  likely  to  take  cold  at  this  time.  Th(>  skin  often  emits 
a  slight  odor;  attacks  of  urticaria,  acne,  and  eczema  have  been  noticed.  The 
eyes  often  have  dark  circles;  occasionally  the  lids  darken  as  well;  hordeolum, 
slight  astlKuiojiia,  muscular  and  neural,  have  been  often  observed  (Berger). 

The  bowels  are  disturbed,  diarrhea  and  tym])any  occasionally  occurring,  and 
the  appetite  may  l)e  capricious.  Mild  attacks  of  tonsillitis  are  not  uncommon. 
There  is  pain  in  the  back,  in  the  groins  (ovaries),  sometimes  exaggerated  to  path- 
ologic dysmenorrhea,  irritation  of  the  bladder,  and  slight  polyuria.  The  tempera- 
ture is  raised  a  degree,  the  pulse  is  faster  and  harder,  the  blood-pressure  being 
raised  20  nun.  until  the  bloody  flow  begins.  Then  it  drops  until  the  flow  c(>ases, 
when  a  slow  rise  is  observed.  The  erj-throcytes  increase  before,  and  diminish 
during,  the  flow.     The  amount  of  urea  excreted  is  decreased,  the  CO  2  increased. 

The  external  genitalia  are  somewhat  engorged,  darker,  succulent;  the  dis- 
charges from  the  vulva,  vagina,  and  cervix  are  augmented;  indeed,  the  endome- 
trium secretes  freely  only  just  before  and  during  menstruation  (Hirschmann). 
The  cervix  and  vagina  are  more  open;  the  uterus  is  larger  and  softer;  indeed,  the 
whole  pelvis  suffers  from  an  acute  vascular  engorgement.  The  acme  of  the  changes 
is  reached  on  the  first  day,  after  which  the  changes  gradually  subside.  The  l)reasts 
also  enlarge,  become  tender,  and  not  seldom  a  few  drops  of  colostrum  may  be 
squeezed  from  the  nipple.  The  nipples  are  more  erectile  and  darker,  the  findings 
thus  resembling  those  of  early  pregnancy.  The  thyroid  enlarges  at  puberty,  and 
this  may  be  permanent;  it  also  swells  during  the  period,  but  this  engorgement 
subsides.  A  relation  between  the  ovary  and  the  thyroid  gland  is  apparent  in  more 
than  one  condition. 

The  character  of  the  flow  varies  in  different  women.  It  also  changes  from  day 
to  day.  At  first  it  is  nuicoserous,  then  bloody,  then  almost  pure  blood,  which  does 
not  coagulate.  The  color  is  dark  maroon,  but  in  chlorotic  girls  it  may  be  watery 
or  even  colorless.  It  is  alkaline  in  reaction,  slightly  irritating,  and  has  an  odor 
like  marigold.  This  depends  on  the  constitution  of  the  woman — some  having  a 
fetid  odor — and  the  bacteria  in  the  discharge.  The  menstrual  blood  is  infectious 
for  puerperse.  Clots  normally  are  not  j^resent.  The  amount  varies  from  four  to 
six  ounces,  l)ut  this,  as  well  as  the  duration  of  the  flow,  is  not  constant  in  the  same 
woman  nor  the  same  in  all  women. 

The  duration  of  the  flow  varies  within  wide  limits,  but  it  usually  lasts  three  to 
seven  days.  The  English  and  American  women  flow  three  to  five,  the  French 
five  to  seven,  days.  At  the  beginning  of  pulierty  the  flow  is  moderate;  later  more 
profuse  and  prolonged,  especially  after  marriage,  the  result  of  the  physiologic 
stimulation  of  intercourse  or  of  endometritis,  one  of  the  late  effects  of  gonorrhea  or 
childbirth.  Sexual  stimulation  increases  the  flow  and  sometimes  its  frequency. 
Brunets  flow  more  than  l)londs;  warm  climates  increase  the  discharge.  The  test 
whether  the  flow  is  normal  or  not  is  the  effect  on  the  woman.  If  she  is  well,  a  short 
flow  or  a  long  flow — even  its  entire  alisence — should  give  no  concern. 

Periodicity. — At  least  71  per  cent,  of  women  menstruate  every  twenty-eight 
days,  and  the  majority  during  the  new  moon.     If  the  flow  starts  a  day  earlier  or 
later,  it  is  of  no  importance.    There  are  several  types,  as  a  twenty-eight -day  type 
2 


18 


PHYSIOLOGY    OF   PREGNANCY 


(71  per  cent.),  a  twenty-one-day  type  (2  per  cent.),  a  thirty-day  type  (14  per  cent.), 
a  twenty-seven-day  type  (1  per  cent.),  though  some  women  flow  every  six  weeks 
and  are  healthy.  If  one  studies  the  life  of  woman  carefully,  clinically,  and  with 
the  help  of  phj'sical  methods,  one  can  determine  an  ebb  and  flow  in  her  activities, 
mental  and  physical.  This  cyclic  movement,  described  by  Goodman  in  1878,  or 
"Wellenbewegung,"  or  periodicity,  reaches  the  highest  point  of  its  tide  just  before 
the  appearance  of  the  menses.  Fig.  20,  from  v.  Ott,  shows  this  graphically.  The 
functions  of  the  body,  reflex  excitability,  the  pulse,  the  blood-pressure,  pulmon- 
ary capacity,  heat  radiation,  temperature,  excretion  of  urea,  muscular  power,  all 
increase  according  to  the  line  in  the  figure,  up  to  within  a  day  of  the  menses;  on 
this  day  there  is  an  abrupt  regression,  then  a  gradual  recovery,  which  rebounds 
and  drops  to  normal  about  the  seventh  day  after  menstruation  (Reinl).  This 
periodicity  is  slightly  manifest  in  the  male,  and  recurs  in  five  to  six  weeks'  intervals. 
Perhaps  it  is  the  external  evidence  of  the  formation  of  spermatozoids. 

The  menopause,  the  ''change  of  life,"  "the  climacteric,"  "die  Wechseljahre," 
"losing  the  periods,"  takes  place  between  the  fortieth  and  the  fiftieth  year.  Thus 
the  average  length  of  the  reproductive  era  of  a  woman's  life  is  about  thirty  years. 


a 


100 


75 


60 


25 


14  15  16  17  18  19 
Fig.  20. — Von  Ott's  Table  of  Peeiodicity. 


Statistics  prove  this  for  nearly  all  countries.  The  extremes  are  six  to  forty-six 
years.  Krieger  collected  2291  cases,  and  found  the  menses  ceased  in  12  per  cent, 
of  cases  between  the  thirty-sixth  and  the  fortieth  year;  in  26  per  cent,  between  the 
forty-first  and  the  forty-fifth  years;  in  41  per  cent,  of  the  cases  between  the  forty- 
fifth  and  fiftieth  years,  and  15  per  cent,  of  the  cases  from  the  fiftieth  to  the  fifty- 
fifth  years,  the  balance,  7  per  cent.,  being  distributed  before  the  thirty-fifth  and 
after  the  fifty-fifth  years. 

The  climacteric  occurs  earlier  in  sterile  women,  in  cold  than  in  warm  countries, 
in  the  poor  than  in  the  rich,  in  black  than  in  white  women.  If  puberty  is  early, 
menopause  is  late,  the  sexual  function  being  strongly  developed;  but  if  the  repro- 
ductive organs  are  overused  or  diseased,  the  menopause  may  be  earlier.  The  menses 
may  return  after  having  ceased.  Meissner  (quoted  by  Krieger,  loc.  cit.)  tells  of 
this  case:  Menses  at  twenty;  first  child  at  forty-seven;  up  to  sixty  years,  7 
children;  cessation  of  the  menses;  seventy-five  to  ninety-eight  years,  regular 
periods;  five  years  absent ;  one  hundred  and  four  years,  menstruation  again;  end  not 
known.  Charpentier,  quoted  by  Parvin,  reports  a  case  of  menses  ceasing  at  forty- 
eight,  beginning  again  at  sixty,  then  continuing  for  two  years.     In  all  such  cases 


PUBERTY,    OVULATION,    AND    MENSTRUATION  19 

one  should  search  carefully  for  pathologic  conditions,  as  fibroid,  cancer,  atheroma, 
senile  endometritis,  etc.  Pregnancy  has  occurred  after  the  menopause.  In  addi- 
tion to  the  aljove,  Renaudiu  reports  a  case  where,  twelve  years  after  the  menses 
ceased,  a  living  child  was  l)orn.  Kemuidy  njports  tlie  case  of  a  woman  who  had 
five  labors  and  one  al)ortion  after  the  fiftieth  year. 

Usually  the  advent  of  the  menopause  is  announced  by  alteration,  diminution, 
or  irregularity  of  the  flow.  The  amount  of  blood  diminishes,  mucus  or  serum 
replacing  it.  When  the  flow  l)ecomes  more  profuse  than  usual,  attention  should 
be  directed  more  closely  to  the  woman.  The  cessation  of  the  menses,  especially 
in  nullipara?,  is  often  attended  by  nervous  symptoms,  such  as  loss  of  vasomotor 
control,  flushings  of  the  face  and  the  body,  flashes  of  heat  and  cold,  trembling, 
hyperexcitability,  cerol)ral  and  spinal  irritability,  indigestion,  constipation,  tym- 
pany, nosebleed,  bleeding  from  hemorrhoids,  prof  use  sweats,  hysteric  manifestations, 
and  many  of  the  symptoms  that  accompany  the  beginning  of  the  function  (Currier). 
The  body  puts  on  fat,  which  often  hangs  in  ungainly  masses  on  the  back,  thighs, 
buttocks,  or  abdomen;  hair  often  appears  on  the  face,  and  the  habitus  in  general 
takes  on  a  masculine  type.  All  these  symptoms  are  the  result  of  the  atrophy  of 
the  genitalia.  The  ovaries,  tubes,  uterus,  vagina,  and  vulva  undergo  a  process  of 
senile  involution  and  atrophy.  For  further  information  on  the  changes  of  the 
menopause  the  reader  is  referred  to  Kisch  {loc.  cit.)  and  A.  F.  Currier. 

Vicarious  menstruation  is  a  periodic  discharge  of  l)lood  from  some  surface 
other  than  the  uterus,  which  discharge  is  to  represent  the  monthly  flow,  such  flow 
being  absent  from  the  uterus.  In  the  typical  cases  three  conditions  must  be  ful- 
filled— the  uterine  flow^  must  be  absent;  the  periodicity  absolute,  and  the  organ 
from  which  the  vicarious  discharge  comes,  normal.  Such  cases  are  rare,  but  authen- 
tic ones  have  been  reported  (Kisch,  loc.  cit.).  Hemorrhages  have  been  observed 
coming  from  the  nose,  stomach,  lungs,  breasts  or  nipples,  mouth,  gums,  ear,  arms, 
bladder,  conjunctiva,  named  approximately  in  the  order  of  frequency.  Sometimes 
the  organ  from  which  the  hemorrhage  comes  is  diseased,  as  ulcer  of  the  stomach, 
tuberculosis  pulmonum,  ulcer  of  the  nasal  septum,  hemorrhoids,  chronic  otitis 
media,  and  in  themselves  "would  give  rise  to  a  bleeding  surface,  but  when  the  peri- 
odicity of  the  flow  corresponds  to  that  of  the  menses,  the  latter  being  absent,  we 
still  speak  of  vicarious  menstruation.  Occasionally  the  usual  flow  is  combined  with 
a  bloody  discharge  from  another  organ.  After  castration  vicarious  menstruation 
has  been  occasionally  observed,  and  during  pregnancy  and  the  amenorrhea  of 
lactation  a  vicarious  flow  may  occur  from  another  part  of  the  bodj'.  The  author 
had  a  case  where,  for  nine  months  after  delivery,  the  patient  had  a  bloody  discharge 
from  the  nipples  lasting  several  days  and  recurring  every  twenty-eight  days.  The 
nipples  were  healthy  and  the  patient  amenorrheic.  These  hemorrhages  are  similar 
to  the  nosebleeds  observed  during  pregnancy,  the  puerperium,  and  the  menopause. 

Occasionally  one  notices  not  a  bloody  flow^,  but  an  increased  chscharge  from 
some  organ,  such  as  leukorrhea,  diarrhea,  otorrhea,  salivation,  recurring  periodi- 
cally at  the  time  of  the  menses. 

Midperiod  Suppressed  Menses. — Between  the  periods  some  women  com- 
plain of  menstrual  molimina  without  the  discharge  of  blood.  The  pain  sometimes 
necessitates  rest  in  bed  or  even  an  anodjoie.  Fasbender  described  the  s\nBptoms, 
and  Martin  named  it  "Mittelschmerz,"  or  pain  between  the  periods.  There  may 
be  a  slight  increase  of  the  leukorrhea  at  this  time.  It  may  have  to  do  with  an 
atypical  ovulation,  or  perhaps  it  is  the  evidence  of  mild  disease  of  the  ovary,  or 
a  specially  impressionable  nervous  system. 

Literature 

Arendt:  "  tjber  Decidua  Menstrualis  Tubarum,"  Verhandl.  der  Versammlung  Deutscher  Naturforscher,  1905. — Aveling: 
Obstetrical  Journal  of  Great  Britain,  July,  1874,  p.  209. — Berger  and  Loeiry:  Diseases  of  the  Eyes  of  Sexual  Origin. 
Translated  by  Dr.  Beatrice  Rossbach,  1906. — Bischoff:   Zeitschr.  f.  rationale  Medizin,  von  Henle  und  Pfeiffer, 


20  PHYSIOLOGY    OF    PREGNANCY 

1S55,  vol.  xiv. — Bodd:  L'Abeille  med.,  1S82,  No.  4. — Charrin:  Arch,  de  Physiologie,  October,  1898. — Chirie: 
L'Obstetrique,  May,  1911. — Clark:  "The  Origin,  Growth  and  Fate  of  the  Corpus  Luteum,"  Johns  Hopldns  Hos- 
pital Reports,  1S9S,  vol.  vii,  p.  ISl. — Currier,  A.  F.:  The  Menopause,  New  York,  1896. — Fasbender:  Geschichte 
der  GQburtshiUe.—Frankel,  L.:  Centralbl.  f.  Gyn.,  1904,  p.  621. — Frank:  Surg.,  Gyn.,  and  Obstet.,  July,  1911.— 
Goodman:  Amer.  Jour.  Obstet.,  1878,  vol.  ii,  p.  673. — Gottschalk:  "Relation  of  Ovulation  to  Menstruation," 
Arch.  f.  Gyn.,  1910,  vol.  xci. — Halhan:  Arch.  f.  Gyn.,  vol.  Ixxv,  H.  2. — Hirst:  Text-book  of  Obstetrics,  1903. — 
Hitschman:  Zeitschr.  f.  Geb.,  1907. — Keiffer:  L'Obstetrique,  1897. — Kennedy:  Transactions  of  the  Obstetrical 
Sec.  of  Edinburgh,  1882,  vol.  ^^i. — Kisch:  Das  Geschlechtsleben  des  Weibes,  1904,  1906. — Knauer:  Centralbl. 
f.  Gyn.,  1896,  No.  20;  1897,  No.  27. — Krieger:  Die  Menstruation,  Berlin,  1869. — Loeh:  Jour.  Amer.  Med.  Assoc, 
February  25,  \9\\.—Mandl:  "  Anord.  u.  Endig.  der  Nerv.  im  Ovar.,"  Arch.  f.  Gyn., vol.  xlviii,  p.  276. — Martin: 
"Ovarian  Transplantation,"  Surg.,  Gyn.,  and  Obstet.,  July,  1911. — Nagel:  "Anatomie  der  weiblichen  Geni- 
talien,"  v.  Bardeleben's  Handbuch,  1896. — v.  Ott:  Nouvelles  Arch.  d'Obstetrique  et  de  Gynecologie,  1890. — 
Pfister:  Beitrag  z.  Geb.  u.  Gyn.,  vol.  v,  p.  421. — Plumb:  New  York  Med.  Jour.,  1897.— Reinl:  "Die  Wellenbe- 
wegung,  etc.,"  Volkmann's  Sammlung  klin.  Vort.,  No.  243. — Renaudin:  Compt.  rend,  de  la  Soc.  de  Med.  de 
Nancy,  1861. — Runge:  Arch.  f.  Gyn.,  1907,  Heft  1. — -Schmoulker:  Arch,  de  Gyn.  et  Tocologie,  December, 
1897. — Turenne:    L'Obstetrique,  December,  1904. — Waldeyer:   Eierstock  und  Ei,  Leipzig,  1870. 


CONCEPTION 

Conception,  in  its  obstetric  sense,  means  the  union  of  the  male  and  female 
elements  of  procreation,  from  which  union  a  new  being  is  developed.  It  is  the 
means  for  the  propagation  of  the  species,  and  has  variously  been  termed  fecundation, 
impregnation,  fertilization,  incarnation. 

The  ovum  is  the  female  unit,  or  element,  of  procreation,  and,  as  has  been  learned, 
is  prepared  in  the  ovary  for  the  reception  of  the  male  unit,  which  is  the  spermato- 
zoid,  derived  from  the  testicle.  In  the  male  the  testicle  is  the  important  organ  of 
reproduction;  it  is  analogous  to  the  ovary,  and,  like  it,  has  many  organs  accessory 
to  it.  The  testicle  produces  an  internal  secretion,  the  interstitial  cells  of  Leydig 
probably  making  it. 

The  testicle  and  the  ovary  are  developed  in  the  fetus  from  identical  structures — 
the  germinal  folds  along  the  inside  of  the  Wolffian  bodies.  The  germinal  epithelium 
in  the  one  case  develops  into  Graafian  follicles;  in  the  other  it  lines  the  tubuli 
contorti  of  the  testicle.  The  genesis  of  the  spermatozoids  is  very  similar  to  that 
of  the  ovum.  Whereas  the  spermatozoid  is  destined,  in  a  sort  of  division  of  labor, 
to  be  the  more  active,  aggressive  agent  in  the  function  of  impregnation  and  must 
seek  the  ovum,  by  a  process  of  evolution  it  is  given  a  shape  which  is  capable  of 
rapid  locomotion.  It  is  made  very  small,  being  the  smallest  of  cell  elements, 
having  been  divested  of  all  that  is  not  needed  for  the  performance  of  its  function, 
which  is  to  seek  out  the  female  pronucleus  and  fuse  with  it.  The  ovum,  on  the 
other  hand,  must  possess  the  nourishment  needed  for  the  new  life  until  the  egg  can 
derive  nourishment  from  its  parent.     It  is  the  largest  cell  in  the  body. 

The  spermatozoids  were  considered  animalculse  by  their  discoverers,  J.  Ham 
and  Leuwanhoek  (1677),  but  in  1840  Kollicker  and  Lallemand  proved  their  origin 
from  the  epithelial  cells.  Spallanzini,  in  1768,  proved  that  they  were  the  active 
fertilizing  elements  of  the  semen. 

The  .spermatozoids  are  developed  in  the  tubuli  contorti,  not  in  the  rete  or  epididymis.  The 
periphery  of  the  tubule  is  covered  by  a  many-layered  epithelium,  similar  in  origin  to  the  germinal 
epitheUum  of  the  ovary.  Like  the  latter,  it  can  be  differentiated  into  two  varieties  of  cells,  sper- 
miogone.s,  or  spermatoblasts,  analogous  to  the  primordial  ova,  and  supporting  cells,  or  Sertoli's 
cells,  analogous  to  the  cells  of  the  primordial  follicles  of  the  ovary.  Different  parts  of  the  tubuli 
are  active  or  cjuiet,  and  one  may  observe  all  the  various  stages  of  spermatozoid  formation  going  on 
in  the  .same  testicle  fllertwig). 

The  spermatogones  divide  into  two  cells  called  spermocytes;  these  again  divide  and  again, 
reducing  at  tlie  same  time  tlu;  numb('r  of  chromosomes;  thus  out  of  two  spermatoblasts  eight 
speririifls  develop.  These  obtain  nourishment  from  Sertoli's  cells.  The  nucleus  goes  off  to  one 
side,  and  its  chromatin  forms  the  head  of  tlie  finished  spermatozoid;  the  nucleolus  anfl  the  eentro- 
some  form  the  neck;  the  protoplasm  of  the  cell,  the  tail.  Fig.  22  shows  human  spermatozoids 
under  high  power.  They  are  Tyrt  micra  long.  The  head  is  a  flattened  ovoid;  the  neck  is  short  and 
granulaterl;   the  tail  is  long,  ending  in  a  pointed,  unsheathed  prolongation. 

These  organisms  have  great  enduranct^  and  power  of  locomotion.  By  rapid  undulations  of 
the  tail  forward  progression  is  produced,  m\(\  they  travel  (juickly  all  over  the  genital  tract  of  the 
female.     The  life  tenacity  of  the  spermatozoids  is  remarkable:  one  may  freeze  them,  and  they  be- 


PUBERTY,  OVULATION,  AND  MENSTRUATION 


21 


gin  to  move  asiiin  on  hcinK  tliawctl  out ;  ufids  kill  tlioili;  woak  alkalis  favor  the  motions;  thcj'  will 
live;  for  niiK!  days  in  the  incubator  and  for  two  to  tlircc;  days  in  decomposing  urine;  they  live  at 
least  three  weeks  in  the  Fallopian  tube;  in  tlu;  bat  they  live  for  six  months,  and  in  the  hen  for 
at  least  eij^hteen  days. 

The  finished  spermatozoids  in  clumps  are  i)ushed  out  of  the  testicle  into  the  epididymLs  by 
th(!  formation  of  sperm-cells  behind,  and  the  small  amount  of  fluid  s(!creted.  In  the  epididjTnis 
the  s|)ermat()zoids  Ijreak  out  of  tlu;  clumps  and  attain  the  pcnver  of  locomotion,  which  is  enhanced 
by  prostatic  secretion.  The  ciliated  epithelium  of  the  ductuli  elTerentes  d(jes  not  wave  and  can- 
not aid  in  the  propulsion  of  the  sperma,  which  now  is  auKUiented  by  tiie  .secretion  of  the  ductus 
epididymidis.  The  motion  of  the  body  in  walkiiifi,  compression  of  the  testicle  when  sitting,  the 
contraction  of  the  muscular  fibers  of  the  tunica  albuginea,  the  elas- 
ticity of  tiie  same  when  distended,  have  been  advanced  as  cau.ses  of 
the  movement  of  sperma  out  of  tin;  testicle  and  epididymis.  The 
pa.ssage  of  the  semen  along  the  vas  defereiLs  Ls  accomplished  by  the 
contraction  and  expansion  of  the  vas,  perhaps  peristaltic,  aided  by 
the  ciliated  epithelium.  When  the  semen  reaches  the  ampulla;  of 
the  vas  deferens,  it  accumulates  here,  awaiting  ejaculation.  With 
tlie  ejaculation  a  mixtiu'c  occurs  with  the  seci'ction  of  the  vesicula* 
seminales,  the  prostate,  Cowper's  glands,  and  the  glands  of  the  ure- 
thra. The  vesicuhe  seminales  are  not  receptacles  for  the  semen,  but 
a  gland  which  furnishes  a  thick  yellowish  secretion  made  up  of  glob- 
ulin. The  function  of  th(!  vesicula-  as  storehouses  for  the  semen  is 
much  questioned.    They  may  be  organs  for  the  reabsorption  of  unased 


End-segments 


Spiral  liiyt'r 
Outer  layer 


Closinsj;  plate 


Axial  thread 


End-piece 


Fig.  21. — Diagram,  .^fter  Koll- 

M.VX. 


Fig.  22. — Sper.matozoids  ifrom  nature). 


semen.  The  prostatic  secretion  stimulates  the  spermatozoids  to  active  movement,  perhaps  by 
cheraic  influence  or  by  dilution.  The  spermatozoids  from  the  epididymis  of  the  dog  have  been 
found  capable  of  fertilization. 

The  semen  is  a  thin,  j'ellowisli-white,  creamy  fluid,  alkahne,  mucilaginous, 
and  has  an  odor  peculiar  to  itself.  The  odor  is  due  to  a  mixture  of  the  various 
glandular  secretions,  particularly  that  from  the  prostate,  called  spermin.  The 
amount  discharged  varies  from  1  to  10  c.c;  the  average  is  3  c.c,  but  much  larger 
amounts  have  been  collected.  It  contains  the  spermatozoids,  the  spermatic  cells, 
epithelium,  leukocAi:es,  and  crystals.  The  number  of  spermatozoids  in  a  given 
ejaculation  is  sometimes  enormous — 227,500,000  in  one  discharge  (Lode).      With- 


22 


PHYSIOLOGY    OF    PREGNANCY 


Fig.  23. — Cross-section  of  Tube  at  Ampulla  (low  power). 

out  doubt  many  are  killed  by  the  acid  secretions  of  the  vagina.     The  number 
decreases  to  nil  if  cohabitation  is  carried  out  many  times  in  rapid  succession,  but 

regains    the  normal    after  a 
day's  rest. 

The  specific  gravity  of 
the  semen  varies  from  1027 
to  1046;  it  has  90  per  cent, 
water  and  6  per  cent,  mucin, 
the  rest  being  albuminoids, 
fats,  and  salts.  Spermin,  the 
odorous  element  of  the  semen, 
comes  mostly  from  the  pros- 
tate, but  it  has  been  found 
in  other  organs  and  fluids 
(Schreiner),  as  the  blood  of 
leukemia,  the  sputum  of  bron- 
chiectasis, the  testicle,  the 
ovary,  the  pancreas,  the 
spleen,  and  the  thyroid 
(Poehl). 

Copulatio  n.— Concep- 
tion, impregnation,   incarna- 
tion, and   fecundation  must 
be    well    distinguished    from 
copulation,  which  means  the  sexual  union  of  the  male  and  the  female. 


if/^f  ■',^*  i^j^  "fif-'^-  .-.f^^'-    ,  -  ■•■^v^J.^vl-v    ^Jv 


fie 


■-'^*>::=-c 


•Si-.'--* 


Fio.  24. — Cross-section  of  Tube  near  Uterus. 


PUBERTY,    OVULATION,    AND    MENSTRUATION  23 

The  object  of  the  voluntary  act  of  copulation  is  solely  to  place  the  semen  in 
such  a  location  that  its  livinji;  elements,  tiie  spermatozoids,  may  reach  the  ovum. 
The  rest  of  the  function  of  reproduction  is  entirely  involuntary.  The  act  of  copu- 
lation is  not  absolutely  necessary;  if  the  semen  is  injected  into  the  vagina  or  even 
on  tiie  introitus  vulvie,  c(Micei)tion  may  take  j)lace.  'J'he  union  of  the  spemiato- 
zoid  with  tiie  ovum  occurs,  in  all  iJi-obability,  in  the  outer  end  of  the  Fallopian  tube — 
its  pavilion.  The  frequency  of  tubal  j)regnancies  inchcates  this.  That  the  impreg- 
nation may  occur  in  the  ovary  is  proved  by  authentic  ovarian  pregnancies, — indeed, 
several  primary  abdominal  ]iregnancies,  one  attached  to  the  omentum,  liave  been 
reported, — and  that  the  union  of  the  two  elements  may  occur  in  the  uterus  itself 
is  not  impossible. 

How  docs  the  ovum  reach  the  tube  from  the  ovary?  The  ovar>'  hes  in  a 
Uttle  depression, — the  fossa  ovarica  (Fig.  1), — and  is  covered  in  part  by  the  mesen- 
tery of  the  tube,  whos(^  fimbria  are  in  close  proximity.  The  pavilion  of  the  tube 
opens  outward  in  numercjus  projections — the  fimbria,  the  prolongations  of  the 
longitudinal  foldings  of  the  tube  (Figs.  23  and  24).  These  are  covered  with  ciliated 
epithelium.  The  waving  of  the  cilia  being  toward  the  uterus,  a  powerful  aspiratory 
current  is  produced  in  the  peritoneal  fluid  of  the  neighborhood  of  the  end  of  the 
tube.  Experimentally  in  ral)l)its  Lode  saw  tiny  particles  placed  near  the  tubes 
gradually  sucked  into  the  fimbriated  end.  They  appeared  finally  in  the  vagina. 
It  is  very  questionable  if  the  erection  of  the  tubes  on  the  ovary,  formerly  held,  could 
possibly  occur.  The  tube  is  too  delicate  to  lift  the  heavy  intestines.  The  ovum 
as  it  appears  on  the  surface  of  the  ovary,  with  its  clump  of  cells  from  the  discus 
proligerus  and  a  few  drops  of  liquor  folliculi,  is  caught  in  this  current  and  led  to  the 
tube.  Once  in  the  tube,  the  peristaltic  action  of  the  wall  of  the  latter  will  aid  its 
progression  toward  the  uterus,  aided  by  the  ciliary  wave.  The  length  of  time 
required  for  the  passage  from  ovary  to  uterus  in  the  dog  is  eight  to  ten  days;  the 
mouse,  four  to  five  days;  the  guinea-pig,  seven  days;  the  opossum,  five  days; 
in  the  human,  four  to  eight  days — but  of  this  one  cannot  be  certain.  The  figures 
are  for  the  fertilized  ovum.  The  only  unfertilized  human  ovum  found  outside  the 
ovary  was  in  the  case  of  Hyrtl,  where,  four  days  after  the  beginning  of  the  period, 
the  woman,  a  virgin,  died,  and  at  the  microscopic  autopsy  an  unquestionable  ovum 
was  found  in  the  interstitial  portion  of  the  tube. 

How  do  the  spermatozoids  reach  the  o\'um  Ijnng  in  the  pa^'^lion  of  the  tube? 
There  are  several  theories  which  are  more  or  less  accepted: 

1.  That  the  semen  is  ejaculated  directly  into  the  uterus  is  disproved  by  the  anatomy  of  the 
parts. 

2.  That  the  penis  acts  as  a  piston,  forcing  the  semen  into  the  uterus,  is  not  plausible.  It 
occurs  only  in  pigs. 

3.  That  the  uterus  in  a  state  of  erection,  after  coitus,  relaxes  and  aspirates  up  the  semen, 
which  lies  in  a  pool  in  the  back  of  the  vagina,  into  wMch  the  cervix  dips.  There  is  some  color  to 
this  \'iew,  but  if  so,  the  uterus  ought  to  suck  up  the  various  germs,  etc.,  existing  in  the  vagina, 
which  is  contradicted  by  the  fact  that  the  uterine  cavity  is  aseptic.  That  the  semen  is  held  back 
in  the  vagina  by  contraction  of  the  pelvic  floor  muscles  is  proved.  O^nng  to  the  coagulation  of  the 
semen,  the  result  of  the  mixture  of  the  prostatic  with  the  secretion  of  the  seminal  vesicles,  the  early 
discharge  from  the  vagina  is  hindered.  If  the  pelvic  floor  is  lacerated,  this  retentive  action  is  lost 
and  may  give  the  cause  of  sterilit3\ 

4.  That  during  copulation  a  piece  of  cer\'ical  mucus  hangs  from  the  cer\'ix,  and  on  relaxa- 
tion this  goes  back  into  the  uterus,  carrying  the  semen  with  it  (Kristeller).  Same  objections  as  to 
No.  3. 

5.  Capillarity  of  the  cervix. 

6.  The  spermatozoids  get  into  the  uterus  by  their  own  natural  movements.  This  is  the 
most  generally  accepted  theory,  and  is  the  most  natural.  The  other  factors  may  help,  but  that 
the  wriggling  motion  is  sufficient  to  bring  a  spermatozoid  to  the  tube  is  shown  by  the  numerous 
cases  of  fertilization  where  the  semen  has  been  deposited  on  the  external  genitals,  as  in  cases  of 
attempted  rape.  If  the  woman  is  strong  enough  to  resist,  there  is  no  immissio  penis,  and  the 
semen  may  be  discharged  on  the  vulva.  In  cases  of  pin-hole  h>Tnen  or  others,  where  immissio 
penis  is  impossible  or  was  not  permitted,  pregnancy  has  repeatedly  taken  place,  the  semen  being 
deposited  on  the  ^^Jlva. 

The  vaginal  mucus  is  acid  and  kills  the  spermatozoids,  but  that  of  the  cervix  is  alkaline, 
wherefore  the  uterus  would  have  a  chemotactic  attraction  for  the  spermatozoids — at  least  they 


24 


PHYSIOLOGY    OF    PREGNANCY 


would  find  conditions  much  more  favorable  to  their  movement.  The  cilia  of  the  tubes  and  uterus 
move  in  the  direction  of  the  internal  os,  and  this,  of  course,  would  hinder  the  upward  progress  of 
the  genoblasts,  but  they  overcome  tliis.  The  rate  of  travel  of  the  spermatozoids  has  been  variously 
estimated  from  1  to  4  mm.  a  minute.  Assuming  the  average  rate  to  be  2  mm.,  the  70  mm.  long 
trip  through  the  uterine  cavity  would  require  thirty-five  minutes,  and  the  120  mm.  tube,  60 
miiuites  more.  It  is  not  hkcly  that  the  movement  is  aided  by  antiperistalsis  of  the  tube;  rather 
one  would  imagine  the  labyrinthine  formation  of  the  tubal  passage  would  liinder  progress.  Sper- 
matozoids are  found  in  the  tube,  the  pelvic  peritoneum,  in  the  ovary,  witliin  a  few  hours  after 
cohabitation.  They  may  he  for  at  least  three  weeks  (Diihrssen)  in  the  favorable  conditions  sup- 
plied by  the  infundibulum  of  the  Fallopian  tube.  Therefore,  if  there  is  no  ovum  ready  to  be 
fertilized  on  their  arrival  in  the  neighborhood  of  the  ovary,  they  wait  until  one  is  ripened  and 
expelled.  This  fact  is  very  important  in  medicolegal  cases,  where  the  question  of  legitimacy 
arises,  and  for  the  exact  computation  of  the  length  of  pregnancy. 

When  the  spermatozoid  meets  the  ovum,  its  head  penetrates  the  zona  pellucida, 
which,  according  to  Fol,  of  Geneva,  is  soft.  It  loses  its  tail,  becomes  round,  is 
surrounded  by  a  halo  of  radiating  lines,  and  progresses  toward  the  female  pronu- 
cleus. Fusion  takes  place.  The  rest  of  the  spermatozoids  die — at  least,  they 
disappear.     Kohlbriigge  says  that,  in  bats,  the  spermatozoids  enter  the  blastula 


CORPUS    LUTEUM 


Fig.  2.5. — Di.\Gn.\M  to  Show  the  External  Wandering  op  the  Spermatozoid. 
Red  dotted  line  indicates  course  of  spermatozoid. 


and  affect  the  ovum,  and  that  they  also  enter  the  mucosa  uteri  and  unite  with  the 
colls.  If  this  is  proved  for  the  human,  it  may  explain  several  phenomena  of  con- 
jugal life.  Millions  che  in  the  acid  vaginal  secretion;  others  are  lost  in  the  intricate 
passages,  but  since  only  one  is  necessary  for  fertilization,  nature  has  provided  in 
the  immense  number  for  all  contingencies. 

The  woman  is  now  pregnant,  the  fertilized  ovum  proceeds  to  the  uterus, 
propelled  by  the  cilia  of  the  tube  and  aided  by  its  peristalsis.  The  uterus  has  been 
prepared  for  the  reception  of  the  egg  (see  anatomic  changes  of  uterine  mucosa 
during  menstruation),  the  egg  attaches  itself  to  the  decidua  menstrualis,  and  the 
development  of  a  new  individual  is  begun.  These  processes  do  not  always  occur 
in  the  exact  order  (h^scribed;  observers  have  for  a  long  time  been  aware  that  vari- 
ations occur.  The  spermatozoids  may  pass  out  through  one  Fallopian  tube  and 
fertilize  an  ovum  lying  in  the  closed  uterine  horn  of  the  opposite  side.  This  is 
external  wandering  of  the  spermatozoid  (Fig.  25).  The  ovum  may  wander  from 
th(!  ovary  of  one  side  into  the  tube  of  the  other,  as  in  a  case  of  extirpation  of  the 
right  tulje  and  left  ovary,  the  ovum  crossed  over  and  entered  the  healthy  tube 


PUBERTY,    OVULATION,    AND    MKXSTUUATION 


25 


(Fig.  20).  In  a  case  of  oxtra-utcrinc  j)r('gnancy  the  corpus  luteuin  was  found  on 
the  right  side,  the  ovum  in  the  left  tube  (Fig.  27).  In  animals,  too,  one  has  found 
more  fetuses  in  one  liorn  of  the  uterus  than  there  were  corpora  lutea  in  the  corre- 
sponding ovary.  It  iuis  been  believed  that  the  iinj)regnated  ovum  could  wander 
tln-ough  the  uterus  up  into  the  tube  of  the  opposite  side,  because,  if  in  animals  the 


CORPUS    lUTEUM 


Fig.  26. — Exteuxal  Wandering  of  the  Ovum. 
Dotted  red  line  indicates  course  of  ovum. 


ovary  and  part  of  the  tul)e  of  one  side  be  extirpated,  ova  are  found  in  l^oth  horns 
of  the  uterus.  All  these  experiments  and  clinical  observations  must  be  taken  with 
a  great  deal  of  reservation,  because  the  permeability  of  the  stump  of  the  tube 
comes  into  question.     The  operations  to  procure  sterility  by  cutting  and  tying 


CORPUS    LUTEUM 


4^- 


Fig.  27. — External  Wandering  of  the  Uvlm  (Oldham's  case). 


the  tube  have  often-been  failures  l^ecause  the  stump  becomes  pervious.  The  only 
sure  method  of  permanently  interrupting  the  connection  between  ovary  and  uterus 
is  to  bury  the  cut  ends  of  the  tube  under  the  peritoneum,  or  to  exsect  the  uterine 
portion  of  the  tulie.  In  the  above  discussion  accessory  tubes  or  accessory  ostia 
of  the  tubes  must  be  considered. 


26  PHYSIOLOGY    OF   PREGNANCY 

It  is  easy  enough  to  explain  the  occurrence  of  external  wandering  of  the  ovum. 
The  ovaries  are  movable  organs,  and  by  certain  positions  of  the  parts,  e.  g.,  retrover- 
sion of  the  uterus  with  prolapse  of  the  tubes  into  the  culdesac  of  Douglas,  are  brought 
close  together.  One  could  also  imagine  the  filling  of  the  rectum  and  sigmoid  as 
means  of  displacing  the  tubes.  Pathologic  adhesion  of  the  tubes  and  ovaries  may 
result  in  abnormal  currents  of  serum  created  by  the  cilia  of  the  tubes.  For  internal 
wandering  of  the  human  ovmn  there  is  no  proof. 

The  Time  of  Conception. — It  is  important  to  know  the  time  pregnancy  begins, 
but,  unfortunately,  we  are  in  a  position  as  yet  only  to  guess  at  the  exact  date.  The 
knowledge  is  wanted  in  order  to  determine  the  day  of  confinement,  for  practical 
reasons,  for  the  scientific  study  of  the  development  of  the  ovum  in  the  uterus  and 
for  medicolegal  processes  in  the  question  of  legitimacy  of  a  child  or  its  paternity. 
All  the  points  on  which  such  a  determination  could  rest  are  uncertain,  as:  (1)  The 
date  of  the  fruitful  coitus  (the  woman's  word  must  be  accepted) ;  (2)  the  date  the 
ovum  left  the  ovary,  and  whether  it  was  ripe  or  not ;  (3)  how  long  it  takes  the  ovum 
to  reach  the  tube  and  uterus — all  unknown  factors.  The  oldest  theory,  and  prob- 
ably the  correct  one,  is  that  ovulation  occurred  every  month,  coincident  with 
menstruation,  and  that  the  pregnancy  supervened  directly  after  the  flow  ceased, 
the  o^oim  of  that  menstruation  having  been  fertilized.  Pregnancy  being  established, 
the  next  menses  did  not  appear.  As  far  back  as  we  have  authentic  records  the 
women  have  computed  their  time  of  pregnancy  from  their  last  menstruation. 
ExjDerience  has  shown  that  the  most  favorable  time  for  conception  is  just  after 
the  periods  have  ceased,  and  the  next  in  frequency,  just  before  the  periods  begin. 
Very  often  a  woman  will  have  one  period  even  after  pregnancy  has  been  established. 
The  newer  theory,  held  by  Reichert  and  Lowenhardt,  that  it  is  the  ovum  of  the 
first  menses  missed  that  is  fertilized,  has  many  points  in  its  favor.  First,  of  16 
embrj^os  examined  by  Reichert,  12  showed  that  in  all  probability  they  had  been 
fertilized  about  the  time  the  menstruation  should  have  appeared.  Second,  very 
few  abortions  have  resulted  from  the  frequent  use  of  the  uterine  sound.  Every 
gjTiecologist  believes  it  is  safe  to  sound  the  uterus  if  the  woman  has  not  missed  a 
period.  If  so  many  pregnancies  begin  with  the  last  menstruation,  it  should  have 
happened  that  the  young  ovum  has  been  frequently  injured.  On  the  other  side, 
it  must  be  said  that  probably  many  such  abortions  never  were  reported  or  even 
chagnosed;  they  may  have  been  delayed,  and,  further,  the  introduction  of  a  sound 
into  the  pregnant  uterus  does  not  always  cause  abortion.  Third,  the  Jews  are 
among  the  most  prolific  of  races.  The  law  required  their  women  (Leviticus  xv  :  19) 
to  leave  the  bed  of  the  husband  during  and  for  one  week  after  the  period,  at  which 
time  a  purifiying  bath  must  be  taken,  and  only  after  this  could  they  be  considered 
clean.  The  Jewish  women  date  their  pregnancy  from  the  first  night  after  this 
period  of  isolation.  This  might  prove  something  for  the  new  theory,  since  it  is 
not  probable  that  the  ovum  can  live  longer  than  eight  days.  In  the  lower  animals 
it  has  been  observed  that  if  the  ovum  remains  a  short  time  outside  of  the  ovary,  the 
zona  pellucida  becomes  impervious  to  the  spermatozoids. 

It  is  certain  that  conception  may  occur  at  any  time  during  the  reproductive 
life  of  women.  An  ovum  may  be  fertilized  ])y  spermatozoids  which  have  been 
waiting  for  many  days.  We  know  that  ovulation  occurs  between  the  periods. 
It  is  probable  that  most  conceptions  occur  just  after  and  just  before  the  time  of  the 
menses,  and  these  two  periods  must  be  considered  the  usual  ones.  No  doubt  the 
menses  may  occur  after  conception  has  taken  place.  It  is  customary  to  reckon 
the  length  of  pregnancy  as  of  nine  calendar  months,  or  ten  lunar  months,  two 
hundred  and  eighty  days'  duration,  dating  from  the  first  day  of  the  last  menstrua- 
tion. Clinical  experience  shows  that  most  labors  occur  at  this  time.  If  the  newer 
theory  is  true  for  the  majority  of  cases,  one  will  have  to  concilude  that  the  normal 
length  of  pregnancy  is  two  hundred  and  fifty-two  days,  and  this  is  contradicted 


PUBERTY,    OVULATION,    AND    MENSTRUATION  27 

by  tho  loiiKth  of  time  occun-iii^  fr(jin  the  date  of  a  .sinj^lc  insemination  to  lal)or, 
i.  e.,  two  hundred  and  seventy-two  days,  wliieh  is  the  average  of  a  large  number 
of  authentic  cases. 

Again,  if  the  tlieory  that  the  ovum  from  the  first  menses  missed  is  fertihzed 
is  the  true  theory,  tiie  majority  of  women  ought  t(j  have  a  period  of  amenorrhea 
of  three  humh-ed  and  eight  days  instead  of  two  hundnnl  and  cigiity  days,  during 
which  time  they  considered  tliemselves  pregnant.  But  we  know  that  in  the  great 
majority  of  the  cases  the  period  of  amenorrhea  is  of  only  two  hundred  and  eighty 
days'  duration.  Therefore  unless  we  are  willing  to  admit  that  pregnancy  lasts 
only  two  hundred  and  fifty-two  days,  we  nmst  concede  that  the  majority  of  con- 
ceptions occur  at  the  time  around  the  last  menses  present. 

The  season  of  the  year  influences  the  number  of  conceptions.  The  months  of 
May  and  June  show  the  most,  perhaps  as  an  analogon  to  the  mating  of  birds  and 
animals.  In  many  countries  ]\Ia>%  June,  and  OctoIxT  are  favorite  months  for 
marriages.  In  country  tlistricts  during  the  harvest-time  there  are  fewer  concep- 
tions. The  body  is  tired  with  hard  work.  After  the  harvest  an  increase  is  notice- 
able. In  countries  where  conscriptions  for  soldiers  take  place,  there  are  many 
conceptions  before  the  time  the  men  leave  for  the  army.  Illegitimate  conceptions 
occur  most  often  during  the  summer  months.  Climate  exerts  an  influence,  too; 
in  the  very  cold  regions  the  frequency  of  conception  is  less;  in  warm  zones  the 
contrary  is  true.  Among  the  educated  classes  conception  is  voluntarily  much 
interfered  with,  but  there  are  those  who  believe  that  the  number  of  impregnations 
falls  off  among  them  from  natural  causes. 

Literature 

Benham:  Edin.  Med.  Jour.,  August,  1873,  No.  xix. — Heriwig,  Oscar:  Lehrbuch  der  Entwickelungsgeschichte,  eighth 
edition,  pp.  21-24. — Hyrtl:  "Beitrag  zur  Lehre  von  der  Menst.  und  Befruchtung,"  Zeitschr.  f.  rat.  Med.,  N.  F., 
vol.  iv,  p.  1,50. — Kohlbriiaoe:  Zeitschr.  f.  Morph.  u.  Anthrop.,  1910,  vol.  xiii,  H.  2. — Lode:  Arch.  f.  d.  ges.  Phys., 
Vienna,  No.  50. — Ibid.:  Arch.  f.  Gyn.,vol.  xlv,  p.  292. — Minol:  Text-book  of  Embryoiogj'. — Newes:  Ergebnisse 
der  Anat.  and  Entw.,  vol.  xi,  p.  197. — Poehl:  Die  physiol.  Grundlagen  d.  Spermintheorie,  St.  Petersburg,  1898. 
— Schreiner:  Annalen  der  Chemie  und  Pharm.,  1878,  vol.  cxciv. — Waldeyer:  Die  Geschlechtzellen,  Jena,  Fischer, 
1903. 


CHAPTER  II 

DEVELOPMENT  OF  THE  OVUM 

The  union  of  the  spermatozoid  and  the  ripened  ovum  has  never  been,  observed 
on  the  liigher  animals,  but  Sobotta  has  described  the  phenomenon  as  it  occurs  in 
the  mouse,  and  Wilson  and  Matthews  and  Hertwig,  in  the  sea-urchin.  It  was 
first  observed  by  Barry  in  1838.     The  process  in  all  is  about  the  same,  and  probably 


#^ 


Fig.  28. — Entry  of  Spermatozoid  into  Ovum  (Fol). 


Fig.  29. — Entry  op  Spermatozoid  into  Ovum  (Koll- 
man). 


Fig.  30. 


Fig.  31. 


Figs.  30  and  31. — Fusion  of  Spermatozoid  and  Ovum  (after  Hertwig). 

in  the  human  varies  little  from  what  we  observe  in  animals.  The  spermatozoid — 
and  only  one — burrows  with  its  head  into  the  zona  pcUucida,  which  rises  in  a  little 
hill — ^the  "cone  d' attraction"  of  Fol — to  meet  it.  This  is  probably  the  result  of 
chemic  action  (Fig.  28).     After  the  head  has  passed  into  the  ovum,  the  tail  dis- 

28 


DEVELOPMENT   OF   THE   OVUM 


29 


appears  and  the  cell-membrane  thickens,  which  prevents  other  spermatozoids 
from  entering  the  egg.  The  neck  of  the  spermutozoid  becomes  the  centrosome 
(not  present  in  all  s|)ecies) ;  the  head  swells  up  and  becomes  the  male  pronucleus. 
Botii  nuclei  are  made  uj)  almost  wholly  of  chromatin  (nuclein).  The  protoplasm 
is  arranged  in  radiating  lines.  The  nuclei  gradually  approach  each  other  and  fuse, 
the  chromatin  of  the  two  forming  one  long  convoluted  thread.  The  nucleus  is 
now  cai)able  of  equal  division;  it  is  the  primary  "segmentation,"  or  "embryonal 
nucleus."  The  centrosome  forms  the  starting-point  of  the  first  karyokinetic 
figure  (Fig.  32). 

When  the  first  division  of  the  embryonic  nucleus  has  been  completed,  each 


X^X'^^'•^\ii:^////?>X 


Fig.  32. 


Fig.  33. 


/^pi^fc^ 


\^m^^^^' 


f$^lii)ilife 


^#^i^-5^ 


^/!lj^m0^ 


Fig.  34. 


Fig.  35. 


Figs.  32-3.5. — First  Cell  Division.     Egg  of  SEA-rRCHix  (Hertwig). 

daughter  nucleus  receives  an  equal  number  of  chromosomes;  therefore  each  cell 
is  endowed  with  half  paternal  and  half  maternal  qualities  and  attributes.  The 
heredity  of  race,  of  external  form,  of  family  traits,  of  susceptibility  to  disease,  and 
in  rare  instances  of  disease  itself,- — insanity, — is  transmitted  to  the  new  individual 
through  the  chromatin  of  the  male  and  female  pronuclei.  This  must  have  chemic 
and  structural  qualities  which  are  far  beyond  our  physical  powers  of  discovery, 
since  within  the  microscopic  mass  of  chromatin  are  contained  the  elements  that 
develop  into  millions  of  cells,  of  the  most  diverse  description,  and  carrying  on 
most  varied  functions. 

The  segmentation  nucleus  forms  a  spindle  with  a  centrosome  at  each  end;   the 


30 


PHYSIOLOGY   OF   PREGNANCY 


chromatin  is  arranged  around  the  middle  at  first,  then  it  divides  in  two  equal  parts, 
going  toward  the  ends.  The  achromatic  fibers  of  the  spindle  dissolve  in  the  middle, 
forming  thus  two  nuclei,  and,  while  this  process  goes  on  inside,  the  cell  protoplasm 
outside  divides  also.  The  process  of  karyokinesis  is  now  complete.  Two  cells  are 
formed,  and  thus  the  new  individual  is  begun.  Each  daughter-cell  divides  again 
into  two  and  again  in  geometric  progression  until  a  mass  of  cells  results  (Fig.  36). 
This  mass,  which  resembles  a  blackberry  in  shape,  is  called  the  morula.  All  its 
cells  have  the  same  qualities  as  the  parent  cell,  because  broken  pieces  of  the  morula 
have  been  found  to  grow  into  a  complete  embryo  (Driesch).  These  changes  occur 
inside  the  zona  pellucida,  while  the  ovum  is  passing  down  the  tube.  The  cells  of 
the  corona  radiata  are  lost  during  the  transit  through  the  tube.  When  the  morula 
has  passed  the  uterine  end  of  the  tube,  at  which  time  it  cannot  be  much  more  than 
0.2  mm.  in  diameter,  it  attaches  itself  to  the  wall  of  the  uterus. 

The  next,  step  in  the  development  of  the  egg  is  the  blastula  formation.  The 
cells  of  the  morula  multiply  with  great  rapidity,  and  a  serum  appears  in  their 
center  which  forces  the  cells  to  arrange  themselves  around  the  periphery  of  the  egg, 
forming  the  blastodermic  vesicle.  The  zona  pellucida  is  stretched,  persisting  a 
varying  lengi:-h  of  time  after  the  impregnation  of  the  egg. 

The  blastodermic  vesicle  (Fig.  37)  at  first  consists  of  a  single  layer  of  cells. 


Primary 
ectoderm  y 


Macula  embry- 
onalis 


Primary  lymph 


Fig.  36. — ^The  Morula    (Mottse) 
(Sobotta). 


Fig.  37. — The  Blastodermic  Vesicle   (Rabbit)    (E.  v.  Beneden). 


with,  at  one  pole,  an  accumulation  of  darker  pigmented  cells — the  later  area 
embryonalis.  This  layer  divides  into  two — an  outer,  called  epiblast,  ectoderm,  or 
ectoblast,  and  an  inner,  the  endoblast  or  entoderm,  separated  by  a  space.  The 
egg  is  now  called  a  gastrula  (Fig.  38),  and  a  third  layer  of  cells  develops  between 
the  other  two,  called  the  mesoblast,  or  mesoderm.  This  later  divides  into  two — 
the  splanchopleure  and  the  somatopleure;  thus  are  we  introduced  to  the  study  of 
embryology,  which  does  not  belong  in  the  pages  of  this  book.  Only  such  points 
as  are  necessary  for  the  consideration  of  the  formation  of  the  fetal  envelops  will 
be  presented. 

The  uterine  mucosa  has  already  been  described.  Under  the  influence  of  the 
corpus  luteum  it  has  been  prepared  for  the  reception  of  the  fertilized  egg.  It  is 
thicker,  velvety,  soft,  spongy,  vascularized,  and  the  glands  are  full  of  clear  secre- 
tion. The  condition  of  the  ovum  as  it  enters  the  uterine  cavity  is  unknown; 
probably  it  is  in  the  blastula  or  gastrula  formation.  Probably  the  zona  pellucida 
has  disappeared,  and  with  it  the  cells  of  the  membrana  granulosa,  the  corona 
radiata. 

One  of  the  earliest  human  eggs  ever  described  is  that  of  Kretz-Peters,  and 
since  the  findings  in  this  egg  are  supported,  in  the  main,  by  those  of  other  human 
ova  (v.  Spee)  and  of  animals  (Hul)recht  and  others),  the  conclusions  drawn  by 
Peters  will  be  generally  accepted  in  the  following  description.     (See  also  Bryce, 


I'l  \  I  I   I 


[>  -     r-'  •>  V-'       , '»«i'**--a'-v  >*•  ••'"""'4 


i 


■'p. 


# 


fet-/...  P 


,4s 


/-?-• 


^<>: 


:^- 


Q 


C5o 


p    - 
2vi 


e  o 

o  so 

'Z 

A^ 

X     * 

's~^ 

C-: 

asog 

^■^ 

>^ 

ip'^ 

> 

./r/>.  ■ 

6  § 

.;0 


Sag- 


Sjr^ 


DEVELOPMENT    OK    THE    OVUM 


31 


Teacher,  and  Kerr.)     Horzog  puljlishcd,  in  1900,  a  classic  description  of  an  early 
human  ovum,  and  pcnnits  liis  i)lat('  to  l)0  here  reproduced  (Plate  I). 

Embedding  of  the  Ovum  in  the  Uterine  Mucous  Membrane. — The  ovum  is 
pressed  into  the  soft  mucous  membrane  by  the  elastic  pressure  of  the  walls  of  the 


Blastoderniir 
vesiclo 


Primary  Ijiupli 


Mafula  embrj'onalis 


Zona  pc'llucida 


Primary  ecto- 
derm 


Fig.  3S. — The  Gastruly  (Rabbit)   (E.  von  Benedcn). 


uterus,  or,  and  more  probably,  its  epiblastic  cells  eat  their  way  through  the  epithelium, 
and  the  ovum  thus  arrives  in  the  edematous  subepithelial  connective-tissue  stroma. 
The  ovum  does  not  enter  the  mouth  of  a  uterine  gland;  it  does  not  necessarily 
fall  into  one  of  the  uterine  folds,  though  it  is  possible,  but  then  the  changes  that 


Connective  tissue 


-^pK —    Border  of  connec- 


Capillarj- 


Fio.  39. — Embedding  of  Ovum  is  Mucosa  (Guixea-pig)   (v.  Spee). 

would  follow  would  not  vary  from  the  usual;  it.  by  a  process  of  arrosion,  burrows 
into  the  endometrium.  This  reacts  to  the  invasion  bj-  a  local  congestion,  vrith. 
edema,  diapedesis  of  white  and  red  blood-corpuscles,  and  a  thickening  of  the  outer 
layers  of  the  stroma  cells  of  the  mucous  membrane.     The  spindle-shaped  cells 


32 


PHYSIOLOGY    OF   PREGNANCY 


under  the  epithelium  and  around  the  glands  quickly  form  large  rounded  or  ovoid 
cells  with  a  single  nucleus,  the  decidual  cells.  These  are  much  more  numerous 
near  the  surface,  forming  a  rather  compact  layer.  The  glands  widen  and  undergo 
proliferation  at  the  base,  and  are  filled  with  secretion.  In  olden  times  this  was 
caUed  the  uterine  milk.  The  decidua  menstruationis  is  being  transformed  into  a 
decidua  graviditatis,  and  the  two  layers,  compacta  and  spongiosa,  are  already 
being  differentiated.  (See  pp.  13  and  14,  under  Menstruation.)  In  the  early 
stages  the  two  may  hardly,  if  at  all,  be  differentiated. 

The  ovum  sinks  into  the  compacta;  the  opening  through  which  it  entered  is 
closed  by  a  mushroom-like  cap,  or  by  the  growth  of  the  lateral  portions  of  the 
decidua  and  epithelium  over  the  tiny  aperture.  The  changes  in  the  human  ovum 
up  to  this  time — about  the  eighth  day,  not  as  Peters  would  have  it,  the  third  or 
fourth  day — are  unknown.     In  the  Kretz-Peters  egg,  the  first  fetal  formation  was 


Decidua  reflexa  or  capsularis 


Fig.  40. — Ovu.m  Distending  Mucosa.     Shows  Arrangement  op  Uterine  Gl.\nds  (semidiagrammatic). 


already  in  progress,  the  amniotic  cavity  and  chorion  being  completed.  The  epi- 
blast  or  ectoderm — rather,  that  layer  not  concerned  in  the  formation  of  the  embryo — 
grows  into  the  decidua,  and  provides  for  the  nourishment  of  the  egg.  It  is  the 
epithelium  of  the  chorion,  and  is  called  trophoblast,  because  of  its  nutritive  function. 
The  cells  are  irregularly  cubic,  with  a  large  round  or  oval,  slightly  granular  nucleus, 
and  sometimes  with  a  nucleolus.  Possibly  they  secrete  an  enzyme  which  destroys 
the  superficial  cells.  The  trophoblast  grows  into  the  compacta  in  all  directions, 
but  irregularly,  and  when  it  meets  the  dilated  capillaries,  it  pushes  into  them,  the 
endothelium  of  the  latter  being  destroyed,  thus  allowing  the  blood  to  wash  the 
surface  of  the  trophoblast.  This  causes  the  cell  protoplasm  to  swell  up,  the  cells 
to  form  a  homogeneous  mass,  and  the  nuclei  to  alter  and  assume  irregular  forms— 
the  syncytium.  The  trophoblast  forms  a  shell  around  the  egg,  which  lies  free  in 
the  dilated  capillaries  of  the  thickened  mucosa.     The  area  around  the  trophoblast 


DEVELOPMENT   OF   THE    OVUM 


33 


dilated  vessels,  serous  imbibition,  and  hj-per- 


W;rWil 


is  called  the  trophosphere,  and  it: 
tropiiic  antl  hyperplastic  decidual 
cells  provide  the  most  favorable 
conditions    for   the    nourishment 
and  the  growth  of  the  ovum.     In 
early  fetation  the   uleiine  glands 
are  filled  with  bluud,  and  this  oc- 
curs so  regularly  in  all  the  latest     ^(;, , 
specimens  that  it  may  i)e  consid-     ^w:i:^?|pi^-;v 
ered  normal.  The  blood  also  flows     ^iWf^^'^^ 
in  tunnels  and  lacunae  formed  in 
the  trophoblast.     We  thus  see  the 
first  act  of  the  formation  of  the 
intervillous  spaces. 

From  the  mesublastic  layer 
of  the  ovum  connective  tissue 
brought  by  the  allantois  and 
carrying  fetal  blood-vessels 
presses  into  the  irregular  in- 
growths of  the  trophoblast  (see 
Plate  I),  and  thus  the  first  villi 
are  formed. 

The  growth  of  the  ovum  is 
favored  by  the  thickening  or 
hyperplasia  of  the  mucous  mem- 
brane, which  is  soon  bulged  out- 
ward toward  the  cavum  uteri  in 
the  form  of  a  hemisphere.  The 
glands  are  separated  from  each 
other  (Fig.  40) ,  and  arrange  them- 
selves tangentially  to  the  grow- 
ing ovum.  The  layer  of  mucous 
membrane  that  is  pushed  up  in 
the  form  of  a  cover  is  called  the 
decidua  capsularis;  that  portion 
on  which  the  ovum  rests,  the 
clecidua  basalis,  and  all  the  rest 
of  the  lining  of  the  uterus,  the 
decidua  vera.  The  term  mem- 
brana  decidua  was  applied  to  a 
supposed  fibrinous  exudation  on 
the  lining  of  the  uterus  during 
pregnancy,  and  named  "decidua," 
or  "caduca,"  because  it  is  cast  off 
during  lal)or  and  the  puerperium. 

Matthew  Baillie  taught  that  preg- 
nancy caused  an  exudate  to  appear  on 
the  surface  of  the  endometrium,  and 
that  the  ovum  coming  down  the  tube       ^sfei^!ii$^^ ;■.'/..  y  6 

pushed    this    membrane   ahead   of    it,       ^^i^>^^^^§l:^r  ::':r)-'.^  :     •■;;•;    ^^■^Mfi-^.'/.'JfMW 

wherefore  this  latter  portion  was  called      il^l^°^1:°<-M^%^'       ■-.-—.-■-.:•-       ^r..  o.ooo.... ,,.... .4.. 

decidua  roflexa.     Since  the  same  kind  ■"'\J:;Hj{io°;v: 

of    membrane   was    found    under    the  "'"-■"■' 

ovum,  it   was    thought    that    this   was  Fig.  ■41.- 

formed   later,  therefore,  deciilua   sero- 

tina.     Wm.  Hunter  (1774)  retained  these  names,  but  described  a  different  mode  of  formation  of  the 

r^exa,  according  to  which  the  ovum  is  surrounded  by  a  reduplication  of  the  decidua  vera,  is  walled 


^;. 


WAsX 


-Decidt'a  at  Third   Month   (low  power). 


34 


PHYSIOLOGY    OF    PREGNANCY 


around,  and  co^'ered  over  by  the  growth  of  the  exuberant  decidua.  Another  notion  was  that  the 
ovum  was  cauglit  between  "two  folds  of  the  thickened  decidua  menstruaUs.  This  may  be  true  in 
some  cases.  Many  authors  still  retain  the  old  names  reflexa  and  serotina,  but,  according  to 
modern  ideas  of  the  histology  of  the  endometrium,  the  terms  capsularis  and  basaUs,  proposed  by 
His,  are  better. 

The  endometrium  undergoes  many  changes  from  the  beginning  to  the  end  of 

pregnancy.       The    cervical    mucous 


5/ 


^i^.    -^ 


Fc 


-^ 


ssr 


*  * 


'  a. 

9       «        «!>    « 


membrane  normally  takes  no  part  in 
the  formation  of  the  decidua.  It 
undergoes  marked  changes  which 
will  be  considered  later.  Sometimes 
the  ovum  becomes  attached  in  part 
to  the  cervix,  but  this  is  pathologic 
(placenta  praevia) .  In  the  first  weeks 
the  lining  of  the  uterus  is  hardly  dis- 
tinguishable from  the  membrane  of 
menstruation.  The  marked  prolifer- 
ation of  the  glands,  resulting  even  in 
a  papillary  formation  with  clumped 
epithelium,  which  Opitz  declared 
characteristic  for  pregnancy,  the  vas- 
cularity, the  beginning  formation  of 
decidual  cells,  the  thickening,  all  these 
are  similar,  so  that  no  one  can  positively  identify  a  given  bit  of  tissue  as  having  come 
from  one  or  the  other  condition.  At  the  end  of  the  third  month  the  decidua  vera  has 
reached  its  greatest  development.  The  membrane  on  the  anterior  and  posterior  walls 
is  thickest,  even  as  much  as  1  cm.,  the  areas  at  the  sides  of  the  uterus,  and  usually  the 
fundus,  are  less  thickened,  and  when  the  lining  is  cast  off,  as  in  abortion  at  this  time, 
the  edges  present  a  sieve-like  appearance  from  the  openings  of  the  uterine  glands 


•-  0 


••• 


Fig.  -12. — Section'  at  Junction  of  Decidua   and  Muscu 
LABIS  (high  power). 


•     <» 


\(         >i 


,•5 


ft.    ^"^ 


Fig.  43. — .\rea  Compacta  through  Oblique  Section 
OF  Gland.     Third  Mo.vth  (high  power;. 


^  •f>   1^  ••  ,«'  ^O  ^     c^ 


•-•• 

W"" 


»3 


Fig.  44. 


«H*^» 


1*1 


fS 


Area  Spongiosa    (Third   Month)    (high 
power). 


through  the  thinned  portions  (Fig.  374,  p.  419).  The  inner  surface  is  rugous — that 
is,  thrown  into  deep  folds,  but  smooth ;  the  outer,  detached,  is  shaggy.  Microscopi- 
cally we  distinguish:  (1)  The  epithelium,  in  most  places  absent;  if  preserved,  it  is 
around  the  openings  of  the  glands  and  in  the  deeper  portions  of  the  same ;  (2)  the 
compact  layer  of  the  decidua,  nearly  one-half  of  the  whole  thickness,  made  up  of  the 


DEVELOPMENT   OF   THE    OVUM 


35 


swollen  and  hyperi)Ui.sti('  fibrillary  stroma  and  many  decidual  eells,  which  are  large, 
ovoid  or  spindle-sliaped  cells,  with  nmeh  protojjlasm,  with  sinj^le  or  rarely  s(;veral 
large  vesicular  nuclei,  and  derived  from  the  stroma,  not  from  epithelium,  which  they 
so  much  resemble;  (o)  the  glandular  or  ampuUary  layer,  (jr  sp(Migiosa  (Fig.  44),  con- 
sisting of  the  enlarged,  elongated,  and  convoluted  uterine  glands,  often  with  j^apillary 
growths  of  the  eiiitlHliuni,  wliicli  is  low  and  cuboid  without  cilia,  and  containing 
fewer  decidual  cells;  (4j  a  snuill,  unaltered  layer  through  which  the  glands'  fundi 
pass  to,  and  sometimes  slightly  into,  the  nmscularis.  The  glands  pursue  a  straighter 
course  in  the  basilar  jjortions  of  the  compacta  than  in  the  sp(jngi(jsa.  The  arteries 
rise  in  spirals  around  tlie  glands,  up  to  the  surface,  where  they  break  int(j  cai)illaries. 
Around  the  insertion  of  the  ovum  the  blood-vessels  are  most  numerous  and  the 
caiMllari(^s  most  dilated.  The  veins  here  are  enlarged,  and  open  into  the  inter- 
villous spaces.     The  glands  are  pushed  aside  l)y  the  growing  ovum  (Fig.  40j. 


jMWf^" 


Amnioa 


Chorion 


'\  Decidua  vera 


Muscularis 


Fig.  45. — DErrDU.v  .vt  Fifth  Month  (from  Bumm). 


The  decidaa  basalis  or  serotina  is  a  portion  of  the  decidua  vera  altered  only  by 
the  superimposed  growing  ovum.  It  has  the  compacta  and  spongiosa,  but  the 
glands  and  blood-vessels,  which  latter  are  enormously  developed,  are  stretched  to 
a  plane  parallel  to  the  wall  of  the  uterus,  and,  at  the  junction  of  the  reflexa,  curve 
in  arches  upward  into  it.  (See  Fig.  40.)  The  portion  of  the  basalis  next  to  the 
chorion  or  trophoblast  is  called  the  trophosphere,  and  will  be  again  considered 
under  the  head  of  Placentation.  The  basalis,  of  course,  must  grow  rapidly  in  the 
fiat  to  keep  n\)  with  the  growing  ovum,  and  this  it  does  l)oth  ]\v  its  own  hyperplasia 
and  by  the  splitting  of  the  compacta  of  the  neigh))oring  vera.  The  glands  of  the 
basalis  (or  serotina)  degenerate  early,  and,  owing  to  the  great  and  rapid  growi:h 
of  the  area  of  insertion  of  the  ovum  (the  site  of  the  future  placenta),  are  compressed 
into  a  low,  lamellous  layer  of  spongy  tissue.  The  basalis  shows  productive  as  well 
as  degenerative  changes,  and  they  will  also  be  considered  under  Placentation. 

The  decidua  reflexa,  or  capsularis,  is  that  portion  of  the  vera  which  is  stretched 


36  PHYSIOLOGY    OF   PREGNANCY 

over  the  ovuni.  It  is  thick  at  the  equatorial  portion  and  thin  at  the  outer  pole. 
This  is  the  point  where  the  egg  buried  itself  in  the  mucosa.  This  point,  which  is 
microscopic,  is  soon  covered  in,  so  that  in  later  stages  it  cannot  be  found.  The 
portions  near  the  base  resemble  the  vera;  the  blood-vessels  are  more  numerous; 
the  veins  larger,  and  the  capillaries  open  into  intervillous  spaces.  The  glands  are 
arranged  tangentially  around  the  ovum,  and  one  finds  glands  opening  obliquely 
on  the  surface  (not  into  the  cavity  of  the  trophosphere) ,  almost  up  to  the  vertex  of 
the  reflexa.  The  tissue  is  soft;  the  decidual  cells  numerous;  also  the  so-called 
S3'nc^'tial  giant-cells.  The  uterine  epithelium  is  flattened  at  the  vertex,  cuboid  at 
the  sides,  without  cilia,  and  disappears  early.  The  portions  of  the  decidua  near 
the  top  of  the  capsularis  early  assume  a  fibrinous  character,  without  glands,  vessels, 
or  epithelium,  all  these  disappearing  as  the  apex  is  reached. 

As  the  ovum  grows  and  fills  out  the  cavity  of  the  uterus  the  deciduse  undergo 
many  and  material  changes.  The  reflexa  is  stretched  over  the  ovum,  and  soon  reaches 
the  opposing  wall  of  the  uterus,  on  which  it  lies,  but  does  not  adhere.     The  uterine 

CAaaaaoao-vv       LIXloa-voti         !cytOLCX/>-*-ai/  ..■■.•:■.■■;-"-•':'.• •.••;■•. •,•■:•.■-'."-.•• 


Fig.  46. — Decidua  Veka  at  Term  (low  power). 

cavity  is  completely  obliterated  by  the  fourth  month.  The  reflexa  undergoes 
coagulation  necrosis,  and  is  absorbed  at  the  sixth  month,  though  occasionally 
portions  of  it  can  be  found  on  the  membranes  at  term.  At  the  edges  of  the  placenta 
one  usually  finds  a  thick  layer  of  decidua  in  fibrinous  degeneration,  the  site  of  the 
transition  of  vera  and  basalis  into  reflexa.  This  is  the  closing  ring  of  Nitabuch- 
Winkler. 

The  decidua  vera  grows  rapidly  in  thickness  until  the  end  of  the  third  month; 
from  then  on  it  thins  out  until  at  term  (Fig.  47)  it  is  only  1  mm.  thick  or  in  places 
even  less.  It  must  grow  actively,  also,  because  it  has  not  enough  tissue  to  stretch 
and  cover  the  immense  ovum  at  term.  The  epithelium  is  all  gone  except  in  the 
glands  of  the  lowest  layers  of  the  spongiosa  and  those  between  the  muscle-bundles. 
From  these  remnants  the  new  uterine  mucosa  is  reconstructed.  The  compacta  is 
reduced  to  a  narrow  strip,  and  most  of  the  decidual  and  stroma  cells  are  in  a  process 
of  coagulation  necrosis.  The  glands  of  the  compacta  are  separated  from  each  other, 
while  in  the  spongiosa  they  form  a  thin,  loose,  flattened  network,  and  since  the 


DEVELOPMENT   OF   THE    OVUM 


37 


stroma  here  too  is  beginning  to  degenerate,  separation  of  the  ovum  from  the  uterine 
wall  is  easy.  Nature  is  thus  prcjiaring  the  way  for  the  r(!lea.se  of  the  product  of 
conception.  The  hasalis  uiulcrf^ocs  the  most  marked  transformation,  because  here 
the  e^K  is  inserted  and  the  ])lacenta  is  situated.  Its  stru{;ture,  therefore,  is  inti- 
mately associated  with  the  ])lacenta,  and  the  description  of  the  two  will  be  combined. 


PLACENTATION 

We  have  learned  how  the  ovum  attaches  itself  to  the  uterine  mucosa  by 
])urr()wing  through  the  epithelium  into  the  stroma.  At  this  time  it  probably  has 
passed  the  morula  stage  into  the  blastula  stage,  and  although  it  cannot  he  proved, 
probably  there  exists  at  this  time  an  outer  epiblastic  layer  with  syncytial  character- 
istics, i.  e.,  a  troplioblast.     At  this  time,  also,  and  certainly  within  a  few  days,  there 


IXwi 


ac 


v.Mt..«»»>#*.i*»5**^*»^vH- •*"**••••••• 


Fig.  47. — Decidua  Vera  at  Term  (high  power). 


exist  the  three  layers  of  the  ovum — the  ectoderm,  the  entoderm,  and  the  mesoderm. 
The  amniotic  cavity  also  is  formed,  because  one  of  the  j'oungest  human  eggs,  Peters', 
whose  age  is  estimated  at  not  over  eight  days,  shows  this.  The  ectoderm  is  spUt 
by  the  amnion  (Fig.  61),  the  outer  layer  forming  the  trophoblast,  the  inner  layer 
sinking  toward  the  center  of  the  ovum,  and,  with  the  central  mesoderm  and  ento- 
denn,  forming  the  embryo.  While  the  trophol)last  grows  into  the  decidua  in  all 
directions,  the  mesoblast  grows  out  underneath  it,  and  blood-vessels  with  connective 
tissue  spread  out  in  the  latter,  coming  from  the  abdominal  pedicle  of  the  embryo. 
Thus  we  have  a  condition  represented  in  Fig.  63. 

The  trophol^last  sends  finger-like  processes,  called  villi,  into  the  decidua,  the 
cells  of  which  are  dissolved  and  absorbed,  perhaps  used  in  the  nourishment  of  the 
ovum.  These  villi  are  at  first  solid  masses  of  cells,  and  they  break  into  the  dilated 
and  new-formed  capillaries,  pushing  the  endothelium  before  them,  and  destroying 
it.  The  maternal  blood  now  ]:)athes  the  outside  of  the  trophoblast,  and  by  its 
action  changes  the  superficial  layers  of  epithelium  into  syncytium  (Peters),  and 


38  PHYSIOLOGY    OF    PREGNANCY 

forms  irregular  blood-spaces  or  lacunae  in  it.  The  lacunae,  tiherefore,  are  both 
intravascular  and  extravascular,  i.  e.,  are  both  dilated  capillaries  and  new  spaces 
formed  in  the  trophoblast,  and  they  are  the  beginnings  of  the  intervillous  caverns 
soon  to  be  described. 

The  solid  trophoblastic  processes  or  villi  are  invaded  from  the  embryonal  side 
by  mesoblast  carrying  the  blood-vessels,  and  thus  typical  villi  with  an  inner  core 


A». 


*r% 


^1   s  %     ^ 


9 


% 


Langhana' 
layer 

Syncytium 


Fig.  48. — Chorionic  Villi.     Third  Month. 
Compare  with  hydatid  mole,  Figure  481. 

of  mosoblastic  tissue,  and  a  covering  of  trophoblast,  in  which  two  layers  can  early 
be  distinguished,  are  formed.  The  outer  layer  is  a  strip  of  protoplasm  without 
cell-walls  and  with  numerous  large  oval  nuclei,  the  syncytium.  In  places  this 
syncytium  is  massed.  Underneath  is  a  layer  of  low  cuboid  mononucleated  cells, 
which  take  the  stain  better — the  Langhans'  layer.  Langhans,  in  1882,  proved 
that  there  were  two  layers,  and  the  lower  one  is  named  after  him.  Preparations 
fixed  in  Flemming's  mixture  show  the  syncytium  to  be  covered  with  cilia.     The 


DEVELOPMENT   OF   THE   OVUM  39 

function  of  these  cilia  is  unknown.  In  the  \illi  at  term  the  cilia  are  low,  almost 
indistinsuishtible,  and  the  layer  of  Lauj^liun.s  also  lias  nearly  all  disappeared.  The 
slronuiot'  the  early  villus  is  made  u])  ol'  a  reticulated  substance,  fibronmcoid,  spin- 
dle, or  star-shaped  cells,  separated  by  spaces  resembling-  l^'inph-spuces.  ""J'here  are 
also  large  vacuolatetl  cells,  often  containing  fat-globules  distributed  through  the 
stroma  (Figs.  48  and  49).  These  cells  probably  are  much  concerned  in  the  bio- 
cluMnic  ('hang(>s  occuri'ing  in  the  placenta.  In  the  later  and  mon;  developed  villi, 
and  in  the  trunks  of  the  villi,  hl)rous  tissue  pi-eponderates  in  the;  stroma.  In  the 
stroma  li(^s  a  niesh  of  (•ai)illaries,  fed  by  an  arteriole  and  em])tied  by  a  venule. 
These  blootl-vessels  are  found  as  early  as  the  second  week,  and  are  brought  with 
connective  tissue  from  the  abdominal  pedicle  of  the  embryo  communicating  with 
the  aorta.     Thus  it  is  seen  that,  from  the  start,  the  eir-culations  of  the  mother  and 


I 


.^*^        ••"•'.    <*„V.%  *:*,V«e»jtj?' 


..  K 


••        iV  aaS,"'.     <»e  ®   ®  ^«  Trophoblast 

•  *>..       ^   °   €■    fe     -®    '  ^  ,. 


/  t 


.  •'  .    r«         PA  •.  «> «.  *  /   »  * 

6 


V''         •."  .     /! 


-nfViU 


'«.'*       "A*^*  \  i*       '"     '•^.r-,..^-..^.-.  ;-i-    ^    Blood-vessel 


A. 


•A-     ,/♦  ^..  *.     v.,  •/', '•' 

./^'  ?^  >•'  \  X  ;-^ 


^v-^ 

.;>' 


Syncytium 


r 


Fig.  49. — Section  of  Pl.\cexta,  Second  Month. 

the  fetus  are  distinct  and  do  not  intermingle.  The  blood  of  the  child  circulates 
inside  the  villus;  the  blood  of  the  mother  circulates  outside,  around  the  villus. 
As  the  ovum  grows  the  villi  increase  in  number  and  complexity.  They  branch 
again  and  again,  forming  long  tufts,  and  soon  the  whole  surface  of  the  chorion  is 
covered  by  a  thick  fur  of  villi  (Fig.  50).  Those  villi  that  grow  toward  the  reflexa, 
or  capsularis,  find  scant  nourishment,  and,  too,  a  decidua  that  is  being  stretched 
and  undergoing  necrosis,  wherefore  they  also  soon  atrophy  and  disappear.  The 
process  is  started  in  the  fourth  week  and  is  finished  by  the  ninth,  but  sometimes 
villi  persist  in  the  capsularis,  forming  a  reflexa  placenta.  The  basalis  is  very  richly 
supplied  ^\^th  blood;  indeed,  its  structure  is  almost  cavernous,  and  the  villi  here 
take  on  luxuriant  gro^^i:h  (Figs.  51  and  52).  This  is  the  future  placenta  or  chorion 
frondosum.  The  atrophied  chorion  is  called  the  chorion  Iseve.  In  the  first  weeks 
of  life  the  ovum  is  firmly  embedded  in  the  uterine  wall;    then,  oAA-ing  to  the  rapid 


40 


PHYSIOLOGY    OF   PREGNANCY 


growth  of  the  vilh  and  their  loose  attachment  (but  still,  attachment)  to  the  dilated 
newly  formed  blood-vessels,  it  is  possible  easily  to  lift  the  ovum  out  of  its  bed. 
Early  abortions  then  give  us  specimens  as  in  Figs.  50  and  51.  There  are  in  such 
cases  many  villi  and  pieces  of  villi  still  remaining  adherent  to  the  basalis,  or  serotina. 
These  are  called  anchoring  villi,  because  the  syn- 
c}i;ium  on  them  has  burrowed  deeper  into  the 
decidua,  and  sometimes  even  has  pierced  into  a 
dilated  vein  at  the  site  of  the  placenta  (Fig.  53). 
The  villi  continue  to  multiply,  growing  into  the 
decidual  base,  which  also  grows  outward  among 
the  tufts  of  the  villi.  These  outgrowths  of  de- 
cidua carrv  the  arteries  and  veins  of  the  uterus, 
and  in  the  ripe  placenta  are  represented  only  by 
thin  partitions  between  the  large  lobes  or  coty- 
ledons of  the  placenta.     The  arteries  pursue  a 


Fig.  50. — Three  Weeks'  Ovum  (natural  size). 


Fig.  51. — Six  Weeks'  Ovum. 


spiral  course  through  the  uterine  muscle,  the  basalis,  and  the  septa,  while  the  veins 
are  straight.     As  these  vessels  approach  the  placental  site  they  lose  all  their  coats 


I  iiibilical  vesicle 

Fig.  52. — Nine  Weeks'  Ovum. 
The  amniotic  .lac  with  fetus  has  escaped  from  the  reflexa. 


save  one  layer  of  endothelial  cells,  forming  large  sinuses,  really  not  distinct  vessels, 
between  the  muscular  lamella;  and  in  the  decidua. 

We  have  seen  how  the  villi  come  to  dip  into  the  maternal  blood,  which  flows  in 
lacuna?  formed  by  the  dilated  capillaries  and  spaces  in  the  periphery  of  the  tropho- 


DEVELOPMENT    OF   THE    OVUM 


41 


sphere.      'I'hc  ra|)i(lly   ji;n)\\iii<;   \illi   invade  tlicse  jjlood-spaces,  whidi,  of  course, 
coniiiuuiiciiU'  with  those  in  tlic  decitlua  serotina,  and,  finally,  as  the  result  of  coni- 


Pcrlmctrium 

Muse,  uteri 
Venae  utcro- 
placcntalcs 


l)ccidua   scro- 
tina  =  basalis 


Septum 
decidualc 


Spatia 
intervillosa 


Fig.  53. — Anchoring  Villi   (Kollmann). 


Fig.  54.— Tuee  of  Villi   from  Three  Months'   Pl.*.centa. 
Drawn  floating  in  water. 


42 


PHYSIOLOGY    OF    PREGNANCY 


pression  and  absorption  by  the  trophoblast,  the  compacta  is  nearly  all  destroyed, 
the  villi  lying  against  the  spongiosa  and  a  few  (anchoring  villi)  dipping  into  it. 


Muscularis 


Fig.  55. — Scheme  of  Placent.vl  Circulation   (Kollmann,  Hand  Atlas). 
Arrows  indicate  supply  and  exhaust  of  blood  in  the  intervillous  spaces. 


/■  '\r 


Decidual  ves- 
sel 


.^"^-v: 


Fig.  50. — The  Circular  Sinus  of  the  Placenta. 


DEVELOPMENT    OF   THE    OVUM  43 

Tlic  villi  grow  in  the  direction  of  the  venous  openings  and  away  from  the  arteries, 
the  blood-streuni  naturally  swimming  them  in  this  direction.  They  stretch  the 
vouous  sinus(!S,  and  by  pressure  necrosis  dcstnjy  the  decidua  compacta  between  the 
veins,  until  only  the  sei)ta  carrying  the  arteries  are  left  (Fig.  55).  The  capillaries 
and  veins  of  the  compacta  are  developed,  as  the  placenta  grows  large  and  heavy, 
into  extensive  caverns  filled  with  the  inextricably  mingled  l^ranched  trees  of  villi 
floating  in  maternal  blood  (Fig.  54).  These  cav(Tns  are  fed  by  the  arteries  which 
ascend  tiie  septa  i)lacentic,  and  are  emptied  by  the  veins  of  the  placental  site. 
These  vessels  may  be  easily  seen  on  the  full-term  placenta  (Fig.  56). 

The  maternal  blood  in  the  intervillous  spaces  is  in  constant  circulation.  The 
arteries  in  the  septa  bring  it,  the  veins  on  the  surface  of  the  cotyledons  empty  it, 
into  the  uterine  sinuses.  The  circular  sinus  also  collects  tho  blood  from  all  the 
cotyledons,  serving  as  an  anastomosis.  The  movement  of  the  blood  is  aided  by 
uterine  contractions  which  occur  at  intervals  throughout  pregnancy. 

The  placenta  grows  in  the  fiat  and  in  thickness,  and  a})out  the  fourth  month 
takes  up  one-half  of  the  area  of  the  uterus;    at  the  end  of  pregnancy  the  placenta 


Fig.  .57. — ^Venous  Ofe.m.ngs  in  the  Placenta  (magnified). 
Author's  specimen  (idea  from  KoUmann,  Hand  Atlas) . 

occupies  one-fourth  to  one-third  of  the  uterine  expanse.  Its  weight  increases  at 
the  rate  of  60  gm.  a  month  until  the  seventh  month,  then  50  gm.,  and,  in  the  tenth 
month,  less  than  10  gm.  The  growth  of  the  villi  in  the  flat  is  permitted  bj-  a  split- 
ting of  the  decidua  vera  at  the  periphery  of  the  placenta,  and  at  the  same  time  by 
an  increase  of  the  area  of  the  placental  base  caused  by  the  gro^vih  of  the  uterus. 
When  the  reflexa  unites  definitely  with  the  vera,  there  remains  a  thickened  ring  of 
decidua  at  the  junction  of  the  serotina  and  reflexa,  and  the  villi  of  the  reflexa  atrophy- 
ing, while  those  of  the  serotina  grow,  the  latter  spread  out  under  the  attached  ring 
of  decidua  for  a  short  distance.  This  is  exaggerated  when  there  is  a  pathologically- 
early  adherence  of  the  deciduae,  or  if  the  natural  splitting  of  the  vera  is  interfered 
with.  A  placenta  marginata  and,  in  marked  instances,  placenta  circumvallata, 
are  thus  produced.  The  ring  of  decidua  is  called  the  decidua  subchorialis.  By 
some  it  is  referred  to  as  the  Waldeyer  closing  ring;  by  others,  the  edge  of  the  closing 
plate  of  Winkler.  The  placenta  is  seen  to  be  composed  of  two  parts — one,  very 
minute  in  quantity,  derived  from  maternal  tissues;  the  other  from  fetal,  both 
inextricably  intergrown. 


44 


PHYSIOLOGY    OF   PREGNANCY 


The  two  umbilical  arteries  from  the  child  spread  out  on  the  fetal  surface  of  the 
placenta,  di^dde  and  redivide,  until  each  cotyledon  is  provided  with  a  branch. 


Decidua  reflexa 


Decidua  vera 


Decidua  basalis 
Fig.  58. — Diagram  Showing  Decidua  Subchorialis  (Pfannenstiel). 


These  branches,  which  have  vasa  nutrientia,  split  up  into  numerous  twigs,  and  from 
each  twig  a  bunch  of  viUi  hangs.     Each  villus  is  provided  with  an  arteriole  which 

breaks  into  a  convolution  of  intercommunicating 
capillaries.  The  blood  is  gathered  by  a  venule  to 
which  the  venules  of  the  other  villi  are  joined,  until 
large  venous  trunks  are  formed  which  unite  on  the 
fetal  surface  of  the  placenta  to  form  one  large  vein, 
— the  umbilical  vein, — which  passes  in  the  navel- 
string,  the  umbilical  cord,  to  the  child.  The  cir- 
culation in  the  villi  is,  therefore,  absolutely  distinct 
from  that  of  the  intervillous  spaces,  as  was  proved 
by  William  Shippen  in  1761,  and  the  interchange 
of  gases,  water,  and  nourishment  must  take  place 
through  the  villus-wall,  by  osmosis  and  by  the  vital 
action  of  the  cells  themselves,  particularly  the 
latter.  The  villus-wall  consists  of  the  following 
layers,  naming  them  from  within  outward :  endo- 
thelium of  capillary,  reticular  mucoid  stroma, 
Langhans'  layer,  syncytium,  both  of  the  latter 
from  the  fetal  epiblast.  Later  in  pregnancy  Lang- 
hans' layer  disappears  or  thins  out;  the  syncytial 
band  also  grows  narrower,  until,  at  term,  the  villus 
has  only  a  single  layer  of  the  stretched  syncytium 
over  it  (Fig.  60). 


'> 


The  Development  of  the  Amnion  and  Umbilical 
Cord. — According  to  the  latest  researches  of  Graf  Spee, 
the  amnion  in  the  human  is  formed  in  a  manner  similar 
to  that  of  many  mammals.  Very  early  a  split  appears  in 
the  epiblast  of  the  germinal  area;  this  fills  with  fluid  and 
forces  the  embryonic  plate  toward  the  center  of  the  egg. 
The  mesoblast  grows  rapidly  and  separates  this,  the  primary 
amniotic  cavity,  from  the  epiblast,  all  over  except  at  the 
area  of  insertion  of  the  abdominal  pedicle,  at  the  same  time 
itself  splitting  into  two  layers— the  somatopleure,  external; 
_  the  splanchnopleure,  internal.    A  fluid  appears  in  the  space 

between  them,  which  is  called  the  exocelom,  and  takes  in  almost  the  entire  content  of  the  egg  at  this 
time.  By  the  development  of  the  exocelom  the  entoderm  is  separated  from  the  periphery  of  the  ovum 


m  .!'•*■ 


V^ 


Fig.  59. — CincrLATiON'  of  a  Villus  (from 
an  injected  placenta). 


DEVELOPMENT   OF   THE    OVUM 


45 


ami  the  vitelline  sue  is  formed.  The  vilelline  sue  is  developed  on  the  abdominal  side  of  the  embryo, 
while  the  aiimiotie  sac  is  formed  on  itsdoi-sal  asi)ect.  The  vitelline  sa(;,  consisting  of  a  layer  of  endo- 
blast  and  ont;  of  mesoblast,  and  containiiifi  albuminoid  matter,  at  first  is  much  tlie  larger;  later  the 
amnioti(!  cavity  is  larger.  The  vitelhis  conmumicates  broadly  with  the  primitive  intestinal  tube, 
and  has  blo()d-ve.s.sels,  the  vasa  omplialomesenterica,  whi(;h  convey  the  nourishment  contained  in 
the  vitelline  .sac;.  The  continued  development  of  the  cavity  of  the  aimiion  and  the  closing  in  of 
the  lateral  walls  of  the  embryo  force  the  xiteHine  sac  to  assume  the  shape;  of  a  jx-dunculated  vesicle, 
and  as  its  contenis  are  absorbed,  it  shrinks  until,  at  the  end  of  the  sixth  week,  it  is  repre.sented 
only  by  the  thin  ductus  om[)halomesen1ericus  and  the  umbilical  \-esicle.  The.se  structures  may 
often  be  found  on  the  full-term  placenta  between  the  chorion  and  anuiion,  more  or  less  distant 
from  the  insertion  of  the  cord.  The  vesicle,  which  uj)  to  the  fourth  month  measures  7  to  10  mm., 
is  then  the  size  of  a  split-pea,  yellow  and  fibrous,  and  shows,  leading  from  it,  lost  in  the  cord,  a 
fine  white  thread,  the  relics  of  the  duct.  Schultze's  fold  is  a  duplication  of  amnion  (Fig.  06;  at 
the  point  where  the  original  omphalomesenteric  duct  left  the  abdominal  pedicle. 

The  vitelline  circulation  cea.ses  as  the  .sac  shrinks,  and  as  the  embryo  receive.s  its  nourish- 
ment from  the  chorion  frondosum,  through  the  two  veins  and  two  arteries  of  the  abdominal  pedicle. 


*    \ 


/>^^      V^'-r^  •"■*■    ^^     O" 


Fig.  go. — Ripe  Placenta. 
a,  Intervillous  space;   6,  syncytium. 


*aV- 


The  amniotic  cavity  enlarges  rapidly,  and,  coming  around  the  embryo  from  all  sides,  causes  the 
disappearance  of  the  exocelom,  and  forces  the  abdominal  pedicle,  with  its  rudimentary  bUnd 
allantoic  stalk,  and  the  four  blood-vessels,  and  the  omphalomesenteric  duct  together  into  a  single 
short  peduncle,  the  beginning  of  the  umbilical  cord.  This  occurs  in  the  fourth  week,  and  the  am- 
nion completely  fills  the  egg  in  the  second  month,  coming  to  lie  on  the  chorion  tliroughout  its 
extent.  The  embryo  now  floats  freely  in  the  cavity  of  the  amnion,  surrounded  by  the  fluid  there 
produced,  the  liquor  amnii,  and  united  to  the  chorion  frondosum  b\-  the  umbilical  cord.  It  is 
nourished  by  the  blood  which  circulates  between  it  and  the  chorion  fi'ondosum.  The  nutritional 
organs  arc  all  formed  as  they  will  continue  throughout  pregnancy,  requiring  only  further  enlarge- 
ment to  accommodate  the  rapirlly  growing  fetus.  (For  further  details  the  reader  is  referred  to 
text-books  on  embryology.  Th(>  al)ovc  description  was  necessary  for  the  proper  studj^  of  the 
clinical  side  of  conditions  met  daily  hy  the  obstetric  practitioner.) 

The  placenta  at  term  is  a  cake-like  organ,  and  weighs  about  500  gm.,  the 
proportion  to  the  weight  of  the  child  being  as  one  to  six.  Placentas  vary  in  weight, 
size,  thickness,  form,  and  consistence  (Fig.  69).  Placentas  from  large  children  are 
heavier.     In  s^-philitic  cases  the  placenta  is  hea^'ier  than  with  normal  children  of 


46 


PHYSIOLOGY   OF   PREGNANCY 


the  same  size,  and  the  proportion  may  be  reduced  to  one  to  three.  A  placenta  may 
be  small  and  thick  or  large  and  thin,  the  usual  thickness  being  l^^  to  2  cm.,  and  the 
breadth  15  to  18  cm.  The  form  is  usually  irregularly  round,  but  the  organ  may 
assume  any  shape,  depending  on  its  direction  of  growth  on  the  uterine  wall.  Bilo- 
bate  (the  usual  shape  is  apes),  trilobate,  and  horseshoe  shapes  are  observed,  and 


Amniotic  cavity 


Fig.  61. 


Amniotic  cavity 


Fig.  62. 


Amniotic  cavity 


Exocelom 


Fig.  63.  Exocelom 

Amniotic  cavity 


Pedicle 


Exocelom 


Exocelom 


Umbilical  vesicle 

Fig.  64. 

Figs.  01,  02,  G.3,  04. — Diagrams  by  Pfannknstiel,  to  Show  Formation  of  Embryo  and  Amniotic  Cavity. 

the  placenta  may  be  spread  out  over  a  large  area — placenta  membranacea.  In  ad- 
dition to  a  main  placenta,  there  may  exist  accessory  portions  connected  to  the  former 
by  an  artery  and  vein;  these  are  called  placentae  succenturiatse,  or,  if  very  small, 
placentulae  succenturiatse.  If  no  blood-vessels  can  be  seen,  the  piece  is  termed  a 
placenta  spuria.     These  extra  placentas  are  of  immense  clinical  importance.     The 


DEVELOPMENT    OF   THE    OVUM 


47 


shape  of  the  placenta  depends  on  the  first  location  of  the  ovum  after  it  enters  the 
uterus.  If  the  ovum  attaches  itself  to  the  center  of  either  the  anterior  or  the 
posterior  wall,  the  placenta  prol)ably  will  be  round  or  oval.  If  it  is  embedded 
near  one  of  the  lateral  anfi;l(>s  of  the  uterus,  the  decidua,  beiiifi;  thin  at  this  point, 
offers  poor  uourisiinieut  to  the  villi,  which  then  grow  eccentrically,— either  on  to 
the  fundus  or  on  to  the  other  wall  of  the  uterus, — a  liilobate  or  a  trilobate  placenta 
resulting.  Such  a  division  into  lobes  may  also  result  from  tlic  jjuthoiogic  formation 
of  fibrinous  masses  in  the  placenta. 

Fig.  65. 


Amnion 


Amnion 


Chorion  laeve 


Allantois 
Alxloniinal  pfdicle 


Chorion 


Allantois 


Umbilical  vesicle 


Fig.  66. 

Figs.  65  and  66. — Diagrams  by  Pfannenstiel,  Showing  Form.\.tion  of  Abdominal  Pedicle  and  All.\xtoi8. 

V.V.,  Vitelline  vesicle;    a.c,  amniotic  cavity;    s.f.,  Schultze's  fold;    a.s.,  Amnion  covering  of  umbilical  cord. 


Some  placentas  are  soft  and  very  vascular;  others  are  harder  and  more  fibrous, 
without  being  pathologic.  The  tissue  of  the  organ  is  dark  red,  soft,  friable,  but 
interwoven  with  tough  fibrous  tissue  and  blood-vessels.  The  maternal  surface — 
that  surface  which  lies  on  the  wall  of  the  uterus — is  covered  with  a  thin,  grayish, 
translucent,  slightly  roughened  membrane,  which  cannot  be  peeled  off,  but  tears 
away  from  the  underlying  soft  pulp  of  the  placenta.  This  is  that  part  of  the 
decidua  serotina  called  the  compacta,  and  which  normally  separates  from  the 
spongiosa  and  comes  away  wdth  the  placenta  when  it  leaves  the  uterus.  This 
gray  membrane  is  broken  here  and  there;   small  bits  are  absent,  and  in  places  it  is 


48 


PHYSIOLOGY   OF    PEEGNANCY 


thicker  and  opaque.     At  the  rim  of  the  placenta,  and  extending  a  little  under  the 
amnion,  the  decidua  accumulates,  the  closing  ring  of  Waldeyer,  or  the  clecidua 


Schultze's  fold 

Relic  of  umbilical  vesicle  and  duct 


Fig.  G7. — Schultze's  Fold. 


subchorialis.  If  you  scrape  into  this  area,  you  will  find  a  large -sinus,  the  circular 
or  marginal  sinus,  and  it  may  be  followed  all  around  the  circumference  of  the  pla- 
centa.    (See  Fig.  55,  p.  42.) 


Fig.  G8.— Normal  Placenta   (Maternal  Surface). 


The  maternal  surface  of  the  organ  is  divided  by  decidual  septa  into  numerous 
lobes  called  cotyledons.     If  one  pushes  the  cotyledons  asunder,  the  septum  is 


DEVELOPMENT    OF   THE    OVUM 


49 


split,  and  the  arterial  sinuses  wliich  lead  \nU)  the  intervillous  spaces  are  disclosed. 
(See  Fig.  57,  p.  43.)  Occasionally  a  cotyledon  will  l)e  sessile  on  the  surface  of  the 
placenta,  and  may  be  left  in  the  uterus.  The  most  careful  examination  of  the 
deliverecl  j)lacenta  will  fail  to  disccjver  the  absence  of  such  a  piece,  and  serious 
illness  of  tlu^  mother  may  result  from  its  retention,  such  as  hemorrhage  or  sepsis. 

The  fetal  surface  of  the  placenta  is  covered  by  the  thin,  glistening  amnion, 
through  which  one  sees  the  placental  arteries  and  veins  coming  from  the  cord  and 
branching  in  all  directions  until  the  smallest  twigs  disappear  about  one-fourth  of 
an  inch  from  the  edge  of  the  i)lacenta.  The  surface  is  uneven,  gray,  and  reddish, 
sometimes  dotted  with  whitish  and  yellowish  areas  of  fi)>rous  tissue.     These  are 


Fig.  69. — Normal  PL.vrENXA   (Fetal  Surpac  e). 


called  white  infarcts,  are  very  common,  and  will  be  considered  under  the  pathology 
of  the  placenta  (p.  551).  The  amnion  may  be  stripped  off  the  fetal  surface  except 
at  the  insertion  of  the  cord.  It  is  attached  only  by  the  jelly  of  Wharton.  In  rare 
cases  the  amnion  may  be  stripped  off  the  cord  also,  the  jelly  of  Wharton  being 
present  here  too.  The  chorion  Iseve,  that  portion  of  the  periphery  of  the  o\aim 
which  lay  against  the  decidua  reflexa,  and  in  which  the  villi  have  atrophied,  together 
with  the  amnion,  forms  a  veil-like  structure  hanging  from  the  placenta,  and  called 
the  membranes.  The  chorion  is  the  outer  layer,  thicker,  cloudy,  somewhat  opaque, 
and  easily  torn.  On  its  maternal  surface  are  the  remains  of  the  decidua  vera  and 
reflexa,  which  can  be  scraped  off  with  the  finger-nail  as  debris.  Early  in  pregnancy 
4 


50 


PHYSIOLOGY    OF   PREGNANCY 


and  in  pathologic  cases  it  is  a  thicker  membrane.  Occasionally  one  sees  blood- 
vessels running  in  the  decidua,  especiall}^  in  the  neighborhood  of  the  placenta. 
The  amnion  is  tougher  and  transparent. 

The  umbilical  cord  is  inserted  about  the  middle  of  the  placenta,  but  it  may  be 
found  at  any  point — at  the  edge  (insertio  marginalis)  or  even  in  the  adjacent  mem- 


FlG. 


"0. — BiLOBATE    Placenta   with   Velamentous 
Insertion  of  Cokd. 


Fig.  71. — Trefoil  Placenta. 


branes  (insertio  velamentosa) .  At  its  insertion  are  occasionally  found  small 
epithelial  amniotic  growths  or  caruncles,  also  the  fold  of  amnion,  carrying  the 
ductus  omphalomesentericus,  Schultze's  fold.  At  some  point  in  the  membranes 
there  is  an  opening  through  which  the  fetus  passed.     This  lies  usually  10  cm.  from 


Fig.  72. — Horseshoe  Placenta. 


the  edge  of  the  placenta,  showing  that  such  was  the  distance  from  the  internal  os 
of  the  uterus  to  the  edge  of  the  placenta.  The  opening  may  he  close  to  the  edge, 
which  shows  that  the  placenta  lay  near  the  internal  os,  or  even  over  it — placenta 
prajvia.  The  placenta  is  situated  usually  on  the  anterior  or  the  posterior  wall  of 
the  uterus,  seldom  over  the  internal  os  (placenta  prsevisL),  and  most  rarely  in  the 


DEVELOPMENT    OF   THE    OVUM 


51 


fundus.  It  may  hip  over  from  one  side  to  the  other.  Tho  causos  of  particular 
msertions  of  the  ])hic('nta  arc  unknown.  ]Mi(h)mctntis  and  subinvolution  certainly 
have  somethiiiu;  lo  do  with  Ihc  location  of  the  placenta  low  in  the  uterus. 

The  umbiHcal  cord  connects  the  fetus  with  the  placenta,  and  is  the  means  of 
conveyance  of  the  fetal  blood  to  and  from  the  latter.  It  is  formed  by  the  abdominal 
pedicle  of  the  embryo,  ;is  \v;is  described  on  p.  IT).  TIk;  anmion,  as  it  develops, 
surrounds  the  cord,  but  is  not  attached  to  it.     This  occurs  later.     On  cross-section 


Fig.  73. — Placenta  Sttccenturiata. 

the  cord  shows  the  covering  of  amnion  epithelium,  two  arteries  (sometimes  one) 
and  one  vein  (sometimes  two),  the  relics  of  the  omphalomesenteric  duct  (often 
lost),  remains  of  the  allantois,  the  jelly  of  Wharton,  which  binds  all  together.  If 
there  is  much  jelly  of  Wharton,  we  speak  of  a  fat  cord;  if  little,  of  a  lean  cord. 
The  amnion,  with  its  pavement  epithelium,  passes  over  into  the  skin  of  the  fetus 
at  the  navel,  where  there  is  a  sharp  line  of  demarcation  between  them.  A  plexus 
of  cu^)illaries  ascends  the  amnion  for  one-eighth  of  an  inch,  but  there  are  no  blood- 


Fio.   74. — Battledore  Placenta. 


vessels  in  the  cord  except  those  mentioned.  Vasa  propria  do  not  exist  here,  but 
they  do  in  the  vessels  of  the  placenta.  Nerves  were  not  found  by  Virchow  and 
most  searchers,  but  KoUiker  and  \'alentine  found  them.  At  first  the  cord  is  very 
short,  but  as  the  child  grows  it  lengthens  until,  at  term,  it  measures  about  50  cm. 
This  varies  from  a  few  millimeters  to  300  cm.  A  length  of  over  100  cm.  is  very 
rare.  The  spiral  twdsts  in  the  cord,  of  which  there  may  be  several  hundred,  are 
best  explained  by  the  movements  of  the  child,  but  the  direction  of  the  growth  of 
the  arteries,  and  the  effect  of  the  pumping  action  of  the  fetal  heart,  may  be  partly 


52 


PHYSIOLOGY    OF   PREGNANCY 


causative.     Stowe  found  that  the  tensile  strength  of  the  cord  was  from  8  to  15 
pounds. 

The  uinbihcal  arteries  are  continuations  of  the  hypogastric  vessels;  the  vein 
comes  from  the  umbilical  vein.  The  arteries  are  twisted  on  themselves;  they  are 
twisted  around  the  vein,  and  the  vein  is  also  twisted,  and,  as  a  result,  there  seem 
to  be  valves  in  the  vessels,  called  valvules  hobokenii.  The  arteries  usually  anasto- 
mose near  the  placenta.  In  6  per  cent.  (Hyrtl)  only  one  umbilical  artery  exists. 
They  have  a  strong  middle  coat.  The  arteries  and  vein  are  sometimes  curled  into 
nodes  which,  covered  by  the  jelly  of  Wharton,  form  the  so-called  false  knots  on 
the  cord.     True  knots  are  also  found. 

The  Amnion  and  Liquor  Amnii. — The  thin,  transparent,  silvery,  tough  mem- 
brane lining  the  chorion  Iseve  and  frondosum  (placenta)  is  the  amnion.  Its  forma- 
tion has  already  been  considered.  (See  p.  44.)  Occasionally  a  little  of  the  jelly 
of  "\Miarton  exists  between  the  two  structures.  The  liquor  amnii  is  produced  by 
the  amnion  at  the  very  earliest  period  of  fetation,  and  at  first  it  is  crystal  clear; 
later  it  becomes  more  opaque.     The  amount  at  full  term  varies  from  500  to  2000  gm., 

depending  on  many  conditions,  one 
of  which  is  the  size  of  the  child,  an- 
other multiparity — more  liquor  in 
each  instance.  Quantities  less  than 
500  gm.  and  more  than  2000  are 
pathologic,  the  former  being  called 
oligohydramnion,  the  latter  polyhy- 
dramnion.  The  amount  of  the  fluid 
increases  up  to  the  seventh  month; 
from  then  on  it  regularly  decreases 
until,  at  term,  there  is  usually  but 
enough  to  fill  out  the  spaces  between 
the  irregular  contour  of  the  fetus  and 
the  uterine  wall.  It  is  a  clear  fluid, 
more  or  less  milky  from  suspended 
particles  of  vernix  caseosa.  This  is 
the  accumulated  and  exfoliated  epi- 
dermis, sebaceous  matter,  and  lanugo 
from  the  skin  of  the  child.  There  are 
also  some  leukocytes  and  unclassified 
cells.  If  the  fetus  dies,  the  liquor 
amnii  becomes  blood  stained,  and  if 
the  child  is  asphyxiated,  one  finds  it  green  and  thick  from  the  admixture  of  meconium. 
It  has  a  peculiar  sperma-like  odor,  and  a  specific  gravity  varying  from  1006  to  1015, 
which  diminishes  as  pregnancy  advances.  The  reaction  is  faintly  alkaline  or  neutral. 
The  cryoscopic  (freezing)  point  of  the  liquor  amnii  is  slightly  higher  than  that  of 
the  maternal  blood  (A  0.56).  Therefore,  speaking  generally,  the  liquor  is  destined 
to  Vje  absorbed  (Keim).  Clinically,  one  can  observe  fluctuations  in  the  amount  of 
liquor  amnii.     At  the  seventh  month  a  sudden  increase  may  often  be  noted. 

The  chemic  analyses  of  liquor  amnii  vary  considerably.  Prochownik  found 
the  following: 


Arterv 


Fig.  75. — Section  of  Umbilical  Cord  at  Term. 


Reaction. 


1.  Neutral 

2.  Neutral 

3.  Neutral 


Specific  Gravity. 


1081..-, 
1006.2 
1007.1 


Albumin. 


G.Sl 
7.70 
8.20 


Fats. 


0.20 
0.10 
1.22 


Inorganic. 


6.27 
.5.. 50 
.5.68 


Water. 


986.62 
986.09 
985.30 


DEVEL<JP.\IKNT    OF    THE    OVUM  53 

Sandmcyor  pxamincd  llic  li(iuor  aiiinii  with  a  view  to  (IctcniiininK  its  food  value,  and  found 
it  contains  an  avera}i;(;  of  0.22  per  cent,  of  albumin.  Thcsaits  arc  in  alnjut  the  same  i)roportion  as 
human  hlood-scrum,  /.  c,  U.")  ])('r  cfiit.,  and  arc  the  ciiioiids,  phosphates,  sulpliatcs,  and  carbonates 
of  .sodium  and  calcium,  with  vciy  little  pota.ssium. 

An  important  lindiiifi  is  urea,  which  was  foimd  by  I'rodiownik  a.s  early  a.s  the  fourth  week, 
and  which  increases  toward  I  he  cud  of  prcffuancy  and  with  the  size  of  the  fetus.  The  amount 
varies  from  0.02  to  0.4  per  ccnl.  .Milfeld,  in  a  ca.se  where  the  bafi;  of  waters  had  ruptured  thirty- 
one  days  before  labor,  could  lind  .so  little  urea  in  the  collected  licjuor  amnii  that  it  could  not  be 
measureil.     Jiarnes  .says  that  since  there  is  urea  in  the  egs,  the  fetus  must  e.xcrele  it. 

The  albumins  in  the  licjuor  are  .serum-aiiiumin,  globulin,  and  an  ovovitellin-like  sulxstance 
(Goenner). 

Bondi  foimd  pepsin,  a  diastatic  ferment,  a  fat-splitting  ferment,  and  one  like  fibrin-ferment 
in  the  licfuor  amnii.  These  facts  are  imjjortant  in  c(jnnection  with  tiie  maceration  of  fetuses  after 
they  die.  In  tlialx-ies  sugar  is  jiresent  in  the  liciuor.  Normally,  bacteria  are  not  present,  but 
un(i(>r  pathologic  conditions  they  m:iy  wander  up  the  cervix  and  through  the  membranes,  or 
through  the  nmsculature  from  adherent  adjacent  organs,  c.  cj.,  inflamed  l^ladder  and  appendix  or 
decomposing  fibroids. 

The  Sources  of  the  Lu/ni>r  Atunii. — Naturally,  the  liquor  amnii  comes  ultimately  from  the 
motlier,  but  much  discussion  has  arisen  as  to  whether  the  fetus  excretes  it,  either  as  urine  or 
through  the  cord  and  fetal  placenta,  or  whether  it  jjasses  directly  into  the  cavity  of  the  uteru.s 
from  tlu>  maternal  vessels.  Probably  both  hypotheses  arc  true.  In  favor  of  the  first  theory  have 
been  adduced — [l)  Constant  presence  of  tu'ca  in  the  li([Uor  amnii  (the  fetus  urinates  into  itj;  (2) 
the  tlemonstration  of  urine  in  the  bladder  of  new-born  cliildren;  (3)  tlie  occurrence  of  polyhy- 
dramnion  when  the  fetus  has  heart  disease,  in  unioval  twins,  and  in  fetal  monsters.  In  the 
latter,  however,  one  must  remember  that  monstrosities  are  frequently  caused  by  amnionitis, 
which  may  also  cause  the  polyhj-dramnion. 

The  theory  that  the  licjuor  amnii  is  a  transudate  from  the  maternal  vessels  is  most  plau.sible. 
(1)  When  potassium  iodid  is  given  the  mother,  it  will  appear  in  the  liquor  amnii,  but  not  in  the 
fetal  Icidney  (Haidlenj.  In  diabetes  sugar  appears  in  the  liquor  amnii.  (2j  ^^'hen  the  mother 
has  heait  disease  or  any  affection  attended  by  dropsies,  one  will  often  find  an  increase  of  the  fluid. 
(o)  I'^arly  in  [)regnancy,  and  when  the  fetus  has  been  dead  for  some  time,  there  is  relatively  too 
nuich  fluid  in  the  uvcrus.  (4)  ^^'ohlgemuth  and  Massone  experimentally  showed  that  diastase  in 
the  maternal  blood  appears  in  tlie  liquor  amnii  when  the  fetus  is  dead.  (5)  Polano  believes  the 
liquor  is  a  secretion  of  the  amniotic  epithelium,  and  since  pathologic  changes  in  the  amnion  have 
been  found  in  cases  of  hydramnion,  color  is  lent  to  this  view.  That  the  fetus  urinates  into  the 
liquor  amnii  is  improbable.  If  urea  was  excreted  in  this  fashion,  more  of  it  should  be  found,  and 
it  is  unreasonable  to  suppose  that  nature  would  have  an  individual  floating  in  and  drinking  its  own 
excreta.  Cohnstein  and  Zuntz  have  proved  that  the  arterial  pressure  in  the  kidney  is  too  low 
even  for  the  production  of  urine.  Ahlfeld  proves  almost  conclusively  that  the  fetus  does  not, 
normally,  urinate  into  the  liquor  amnii;  that  when  this  does  occur,  it  is  accidental,  and  probably 
due  to  some  more  or  less  serious  circulatory  disturbance. 

In  a  case  where  I  administered  methylene-blue  to  the  mother  before  labor  it  was  excreted  by 
the  new-born  cliild  in  the  urine  for  several  days  after  birth,  but  the  liquor  amnii  was  not  blue. 

The  Uses  of  the  Lieiuor  Amnii. — The  fluid  around  the  child  lias  most  important 
functions:  1.  First  it  is  a  food,  which  the  fetus  drinks.  This  is  proved  by — (a)  The 
finding  of  lanugo  in  the  meconium  after  birth,  and  real  swallo-\nng  motions  have 
been  determined  in  the  fetus  during  the  latter  months  of  pregnancy.  (6)  In  a  case 
of  occlusion  of  the  gullet  the  fetus  was  atrophied,  (c)  The  liciuor  amnii  contains 
albumin  con.stantly,  and  if  the  fetus  drinks  enough,  it  will  get  a  considerable  amount 
of  albumin. 

2.  It  is  a  water-cushion  taking  up  the  shocks  from  external  injury,  and  allowing 
free  motion  to  the  fetus;  this  prevents  deformities,  e.  g.,  clulj-foot.  In  cases  where 
the  liquor  is  very  scant  the  child  is  folded  compactly  together,  and  shortening  of  the 
muscles,  wry-neck,  and  various  distortions  of  the  extremities  result. 

3.  It  prevents  the  amnion  from  adhering  to  the  fetus  and  causing  deformities, 
e.  g.,  harelip,  hemicc]-)halus,  am])utations,  imperfect  closure  of  the  l)ody  cavities, 
all  examples  of  arrest  of  development  due  to  strands  of  amnion,  called  Simonart's 
bands.  It  preserves  the  cord  from  pressure  and  renders  the  movements  of  the 
child  less  painful  to  the  mother. 

4.  During  labor  it — (a)  Helps  dilate  the  passages  by  forming  a  fluid  wedge  with 
the  membranes,  and  (6),  surrounding  the  fetus  completely,  it  distriljutes,  as  all 
fluids  do,  the  compression  exerted  by  the  contracting  uterus,  equally  in  all  directions, 
and  thus  saves  any  part  of  the  fetus  from  injurious  pressure.  "WTien  the  liquor  amnii 
has  been  discharged,  the  fetus  is  exposed  to  this  pressure  and  may  succumb  to  it. 
By  the  same  action  the  placenta  is  held  against  the  uterine  wall,     (c)  It  washes  out 


54 


PHYSIOLOGY    OF   PREGNANCY 


the  vagina  for  the  passage  of  the  child,  and  by  its  shghtly  bactericidal  action,  pre- 
vents infection  of  the  child  and  the  uterine  cavity.  Unfortunately,  this  antiseptic 
action  is  weak. 


THE  FETUS  AT  DIFFERENT  PERIODS  OF  DEVELOPMENT 

At  no  time  of  life  is  the  growth  of  the  individual  as  rapid  as  it  is  during  the  period  spent  in 
utero.  From  the  fifth  week  the  fetus  doubles  its  length  five  times,  and  its  weight  is  800  times  greater 
at  term  than  it  is  at  two  months.     Fig.  76  shows  graphically  the  length  curve,  and  Fig.  77,  the  weight 


So 

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Fig.  73. — Chart  Showing  Growth  in  Length  of  Fetus  in  Uteko. 


WEEKS 


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Fig.  77. — Weight  Cfiaht  or  Fetu.s  in  Utero. 


curve,  of  the  fetus.  It  is  impossible  to  obtain  these  figures  with  scientific  accuracy,  first,  because 
the  exact  date  of  conception  cannot  he  determined  in  any  of  the  cases,  and,  second,  the  individuals 
vary  in  utero  a.s  they  do  aft  or  birth.  A  good  rule,  whic'li  for  practic^al  purposes  will  suffice  for  the 
determination  of  the  length  of  the  fetus  at  a  given  period  of  pregnancy,  is  this:  Square  the  number 


DEVELOPMENT    OF   THE    OVUM 


55 


of  tlio  month,  which  will  ^ivo  the  IciiKtli  of  the  fetus  in  continiotors  until  tho  fifth  month.  After 
the  fiftii  month  add  to  this  five  eaeh  month;  tiius  at  four  months  a  fetus  should  be  about  16  cm. 
long;  at  six  months,  30  cm.  (")X")  + "));  at  seven  months  (oX^  +  o  +  o),  and  so  on.  Tho  length  of 
the  fetus  is  the  safest  guide  in  the  determination  of  its  age.  (children  vary  both  in  length  and 
weight.  Some  babies  grow  faster  than  others,  and  too  their  growth  may  Ix;  interrupted  tempo- 
rarily (luring  j)regn:incy-      l'"rc(iuent  examinations  during  gestation  will  show  this. 

The  Fetus  at  Various  Periods. — TIk;  best  work  on  the  early  human  ovum  was  done  by 
His,  and  from  iiis  "  Atlas  der  Anatoriiie  mensclil.  I'lmbryonen,"  Lei[)/,ig,  1SS2,  the  following  pictures 
are  taken  (lugs.  TS  and  7i)).  His  distinguished  three  periods  in  the  life  of  the  child — the  ovular, 
during  the  first  two  weeks;  embryonal,  tli(?  third,  fourth,  and  fifth  weeks;  and  fetal,  from  that  on 
until  term.  TIk^  ovum  in  the  first  weeks  interests  the  practical  obstetrician  little,  because  it  can 
be  studied  only  with  a  microscoix'.  It  is  almost  impo.ssible  to  judge  the  age  of  the  little,  .shaggy, 
bladder-like  ova  that  are  expelled  in  early  abortions,  because  they  are  often  pathologic.  As  a 
general  rule,  however,  an  ovum  the  size  of  a  pigeon's  egg  is  four  weeks,  and  one  the  size  of  a  hen's 


14  days 


23  days 


27  duya 


32  daya 


34  days 


«^        GO  days 


Fig.  78. — E.\rly  Em- 
bryos (from  His) . 


Fig.  79. 


-Two  Embryos,  One  About  Eleven  Weeks,  the  Other,  Fifteen 
TO  Seventeen  Weeks. 


egg,  six  or  seven  weeks.  After  this  period  the  length  of  the  fetus  from  nape  of  neck  to  sacrum,  and 
still  later  the  total  length,  give  more  certain  conclusions. 

End  of  the  First  Lunar  Month. — An  embryo  of  this  period  is  7}  2  to  9  mm.  long,  has  indications 
of  nose,  eyes,  and  ears.  The  stumps  of  the  extremities  are  fairly  long,  and  show  rudiments  of  fingers. 
The  head  and  tail  ends  are  almost  in  contact,  separated  only  by  the  stalk  of  the  vitelhne  sac  and 
the  abdominal  pedicle.  The  visceral  arches  are  distinct;  the  foiu"  heart  ca^^ties  are  developed; 
the  intestinal  canal  is  nearly  closed,  and  first  indications  of  liver  and  kidnej-s  appear. 

End  of  Second  Month. — The  fetus  is  2}4  cm.  long;  the  branchial  arches  are  prominent  at  the 
beginning  of  this  period,  but  disappear  at  its  end.  The  ear  appears,  and,  later,  the  eyelids.  The 
extremities,  at  first  bud-like  at  the  end,  show  the  division  into  three  parts:  first,  the  arm,  forearm, 
and  hand;  then  the  thigh,  leg,  and  foot,  and  the  digits  are  more  marked.  The  tail-like  process  has 
disappeai'ed.  The  navel  begins  to  close;  the  liver  develops,  also  the  abdomen,  which  is  not  j'et 
quite  closed,  and  the  external  genitals  appear,  but  it  is  impossible  to  determine  the  sex  of  the  fetus, 
since  the  male  and  female  genitaha  are  developed  from  identical  organs  and  are  differentiated  later. 


56  PHYSIOLOGY    OF    PREGNANCY 

The  villi  in  the  decidua  serotina  grow  luxuriantly,  forming  the  future  placenta,  the  perma- 
nent fetal  maternal  relations  being  now  fully  estabhshed. 

End  of  Third  Month. — The  o^'um  is  a  little  larger  than  a  goose-egg,  and  the  fetus  7  to  9  cm. 
long,  weighing  5  gm.  at  the  beginning  and  20  gm.  at  the  end  of  the  month.  The  navel  is  closed, 
the  internal  genitals  differentiated.  The  external  genitals  are  ahke  in  the  two  sexes.  At  the 
beginning  of  the  eleventh  week  the  scrotum  closes,  and  the  sex  maj^  be  determined.  The  intestinal 
canal  is  formed  and  contains  bile  (Zweifelj.  The  bodj'  resembles  a  human  being,  though  the  head 
is  still  proportionately  extremely  large.     Centers  of  ossification  are  visible  in  many  of  the  bones. 

End  of  Fourth  Month. — The  fetus  is  10  to  17  cm.  long,  and  weighs  120  gm.  at  the  end  of  this 
period.  jNIeconium  is  present  and  is  turning  green  (Charpentier).  The  muscles  are  active,  fetal 
movements  being  occasionally  felt  by  the  mother.  The  heart-beat  is  strong  and  has  been  heard. 
The  external  organs  of  sex  can  easily  be  differentiated.  The  skin  is  bright  red,  transparent,  so 
that  all  the  vessels  are  visible.     Lanugo — fine  hair — appears  on  the  skin. 

Fifth  Month.— The  fetus  is  now  from  17  to  26  cm.  long,  and  weighs  250  to  280  gm.  (7  to  9 
ounces).  The  head  is  still  very  large,  being  the  size  of  a  hen's  egg,  but  the  abdomen  is  less  promi- 
nent. The  fetus  is  lean.  The  skin  is  still  red,  but,  owing  to  the  deposition  of  fat,  is  less  trans- 
parent. The  lanugo  is  present  all  over  the  body,  but  on  the  head  there  are  indications  of  hair. 
The  nails  can  be  distinguished.  The  eyelids  are  closed.  Such  a  fetus  may  hve  for  five  to  ten 
minutes  with  strong  heart-beat  and  attempts  at  respiration. 

Sixth  Month. — The  fetus,  at  the  end  of  the  sixth  month,  is  28  to  34  cm.  long  and  weighs 
about  Qio  gm.  {l}i  pounds).  Its  body  is  more  in  proportion,  though  still  lean,  the  amount  of  fat 
in  the  skin  being  still  small.  The  skin  is  wrinkled,  and  vernix  caseosa  begins  to  form.  This  is  the 
accmnulated,  exfoliated  epithelium  and  sebaceous  secretion.  The  eyebrows  and  lashes  are  formed; 
the  eyelids  are  separated,  and  such  an  infant  born,  may  breathe,  though  superficially,  and  live  for 
several  hours  under  favorable  conditions.  Since  its  respiratory,  digestive,  and  assimilative  organs 
are  undeveloped,  no  artificial  means  will  preserve  these  fetuses  from  congelation  and  starvation. 
Reports  of  the  rearing  of  such  infants  are  to  be  discredited. 

Seventh  Month. — Length,  35  to  38  cm.;  weight,  1000  to  1220  gm.  (around  2}4  pounds). 
The  infant  looks  like  a  dried-up  old  person,  with  red,  wrinkled  skin.  The  wrinkles  fill  out  with 
fat  and  disappear,  but  in  later  life  or  in  illness  they  develop  again  in  the  same  form  and  distribu- 
tion. One  can  often  trace  family  traits  tlii-ough  these  wrinkles.  The  eyes  are  opened;  the  tes- 
ticles sometimes  have  entered  the  scrotum.  The  child  cries  with  a  weak  whine  or  grunt,  but,  since 
the  lungs  are  not  developed,  it  can  seldom  be  kept  alive.  Rarely,  an  infant  at  seven  months  of 
gestation  is  as  far  advanced  as  another  at  eight  months,  and  can,  of  course,  survive.  Those  chil- 
dren of  the  early  part  of  tliis  period  which  the  author  has  succeeded  in  raising  have  in  later  years 
not  given  him  much  satisfaction,  having  nearly  all  become  hydrocephalic,  dwarfed,  or  paralytic. 
From  the  twenty-seventh  to  the  twenty-eighth  week  not  a  few  have  been  saved  and  are  growing 
promisingly. 

Eighth  Month. — The  cliild  is  now  43  cm.  long,  and  weighs  around  1600  gm.  (33^  to  4  pounds). 
The  papillary  membrane  has  disappeared.  The  skin,  though  still  red,  is  not  so  much  wrinkled, 
and  the  cMld  is  less  lean.  Vernix  caseosa  and  lanugo  are  still  present.  The  testicles  are  usually 
in  the  scrotum.  The  bones  of  the  head  are  soft  and  flexible;  ossification  begins  in  the  lower 
epiphysis  of  the  femur.  [Meconium  is  passed  -ndth  difficulty.  Crying  is  stronger,  but  some- 
times only  a  whimper.  Such  cliildren  may  generally  be  reared,  -s^ath  the  aid  of  maternal  milk, 
good  nursing,  and  a  proper  incubator. 

Ninth  Month. — Weight,  about  2500  gm.  (around  5H  pounds);  length,  46  to  48  cm.  The 
lanugo  begins  to  disappear  from  the  face  and  abdomen,  the  redness  fades,  the  wrinkles  smooth  out, 
the  panniculus  adiposus  develops,  the  limbs  become  rounded.  The  nails  are  at  the  tips  of  the 
fingers.  Circulatory,  respiratory,  and  digestive  organs  are  now  well  developed,  though  the  child 
requires  good  care  for  a  successful  extra-uterine  existence. 

Tenth  Month.— Weight,  3100  gm.  (7  to  7^  pounds);  length,  48  to  50  cm.  Ahlfeld  says  the 
fetus  may  lose  a  little  after  the  fortieth  week.  At  the  end  of  this  period  the  child  is  prepared  to 
cope  with  the  factors  of  an  extra-uterine  existence.     It  is  "ripe"  or  "at  full  term." 

The  Fetus  at  Term. — A  fully  developed,  ripe  fetus  presents  the  following  signs 
of  maturity:  length,  50  cm.;  weight,  3200  gm.  (7  to  73^  pounds);  the  skin  is 
white  or  pink,  a  fleshy  red  denoting  prematurity;  vernix  caseosa  is  thick  in  the 
creases  and  around  the  shoulders  and  back;  the  hair  is  several  centimeters  long; 
the  lanugo  mostly  gone;  the  finger-nails  are  firm  and  protrude  beyond  the  finger- 
tips and  to  the  tips  of  the  toes;  the  panniculus  adiposus  is  well  developed;  the  miha 
and  comedones  around  the  nose  have  usually  disappeared;  the  chest  is  prominent; 
the  mammary  glands  project;  the  navel  is  at  the  middle  of  the  l)elly,  and  two  or 
three  centimeters  Ijelow  the  middle  of  the  body  (higher  in  boys  than  in  girls) ;  the 
testicles  are  in  the  scrotum;  in  girls  the  labia  majora  cover  the  minora;  the  ear 
stands  out  from  the  head,  its  cartilage  being  well  developed;  the  bones  of  the  head 
are  hard,  the  sutures  narrow;  the  circumference^  of  tiie  head  is  equal  to  or  less  than 
that  of  the  shoulders  (Frank),  the  voice  is  loud  and  strong;  sucking  movements  are 
vigorous  and  sustained;   meconium  is  passed  early  and  often. 


DEVELOPMENT   OF   THE    OVUM 


57 


At  autopsy  one  [iuds  ot  licf  si};iis  of  matiii'ily  in  llic  advanced  ossification  of  the 
bonos,  c.  (/.,  tlic  ossification  ccnttT  in  the  lower  end  oi  the  femur  is  7  to  8  iniii.  l)r(jad, 
and  the  e(>rel)ral  convohitions  resemble  those  of  the  adult  brain,  von  Winckel 
found  the  size  of  the  liver  and  other  organs  a  guide  1o  the  age  of  the  fetus.  Tfie 
size  and  (le\'elo))nient  of  the  placenta  and  cord  are  unrelial)le  indices  of  maturit}'. 
Vascularity  of  the  decidua  at  the  border  of  the  placenta  is  usually  a  sign  of  jjre- 
maturity  of  \\w  ovum,  but  endometritis  must  b(-  excluded.  Ahlfeld  found  scratch- 
marks  on  the  anuiion  made  by  the  fetus  after  its  nails  had  grown  beyond  the  hnger- 


FiG.  so. — .Y-Ray  of  Fetus,  Eighth  Month.     Length,  45  cm.;  Weight,  3  Pounds,  S'o  Ounces. 


tips.  This  might  be  useful  in  medicolegal  cases  to  determine,  from  the  secundines, 
if  the  puerpera  had  delivered  a  viable  infant.  (See  v.  Winckel's  Handbuch  for  an 
exhaustive  consideration  of  this  subject.) 

Not  any  one  of  all  these  signs  is  absolutely  reliable.  The  most  certain  is  the 
length  of  the  fetus,  but  even  this  varies  from  48  to  52  cm.,  while  children  of  55  to 
62  cm.  have  frequently  been  delivered.  The  weight  of  the  fetus  is  especially  un- 
certain, as  a  nine  months'  pregnancy  may  produce  a  child  of  only  1700  gm.  (33^ 
pounds),  while  one  of  eight  months  may  develop  an  infant  of  3840  gm.  (8  pounds). 
Hodge  (1850)  taught  that  well-matured  children  are  sometimes  born  before  full 


58  PHYSIOLOGY    OF    PREGNANCY 

term,  and  Parvin  mentions  a  case  of  an  infant  weighing  7  pounds  delivered  after  less 
than  two  hundred  and  twenty-six  days  of  gestation. 

Some  children  at  term  or  over  term  are  small  and  puny  because  of  general  de- 
bihty  of  the  mother  or  sickness  during  pregnancy.  A  prolonged  febrile  disease,  for 
instance,  tj-phoid,  during  pregnancy  will  compromise  the  growth  of  the  fetus,  as 
also  will  chronic  diseases,  diabetes,  heart  disease,  tuberculosis,  the  various  anemias, 
and  sjTphilis.  Bright's  disease  is  particularly  unfavorable,  since  the  placenta  is 
frequentl}'  infarcted  (le  placenta  albmninurique)  and  its  nutritional  function  inter- 
fered with. 

Diseases  and  abnormal  location  of  the  placenta  restrict  the  growth  of  the  child. 
The  children  in  placenta  prsevia  are  usually  undersized.  Women  with  generally 
contracted  pelves  often  have  small  babies,  thus  giving  evidence  of  a  hereditary 
tendency  to  arrest  in  development.  La  Torre  finds  no  difference  in  size  in  the  chil- 
dren from  women  ^\'ith  contracted  pelves  and  those  with  normal  pelves,  but  his  ob- 
servations were  mainly  on  rachitic  women.  Large  muscular  women  have  large 
babies,  and  the  same  is  true,  to  an  extent,  of  the  father.  The  head  of  the  child 
bears  a  certain  relation  to  that  of  the  father  and  mother.  Fat  women  usually  have 
large  babies.  Women  of  the  better  classes  have  larger  infants  than  the  needy  poor. 
Workers  in  factories  have  small  children,  and  in  some  European  countries  pregnant 
women  are  not  allowed  to  work  in  them  during  the  latter  months,  many  being  sent 
to  maternities  to  rest  during  the  period.  Statistics  have  shown  a  distinct  improve- 
ment in  the  general  health  of  the  mothers  and  a  gain  in  the  weight  of  their  infants 
since  this  practice  was  instituted.  Cigarmakers  and  workers  in  lead  and  phosphorus, 
if  abortion  and  premature  labor  do  not  occur,  have  puny  children.  Therapeu- 
tically, we  try  to  influence  the  size  of  the  child  by  dieting  the  mother  during  the 
latter  third  of  pregnancy.  (See  Prochownik's  diet.)  White  children  are  larger 
than  colored,  American  larger  than  European,  boys  larger  than  girls— 3  to  5  ounces. 
Children  born  in  wedlock  are  heavier  than  the  illegitimate;  this  may  be  due  to  the 
attempts  to  produce  abortion  which  many  such  women  make,  to  tight  abdominal 
constriction  practised  to  hide  the  evidence  of  pregnancy,  and  to  the  lack  of  proper 
nutrition  and  care  they  often  suffer. 

The  children  increase  in  size  in  successive  pregnancies,  which  is  due  to  the  better 
development  of  the  mother  which  comes  with  years,  the  more  active  circulation  in 
the  uterus,  and  the  prolongation  of  the  later  pregnancies.  The  first  child  is  likely  to 
be  small  or  thin,  since  it  often  comes  a  few  weeks  before  term ;  the  uterus  is  tense  and 
allows  little  freedom  of  movement,  and  the  health  of  women  in  their  first  pregnancy 
is  usually  not  as  good  as  in  the  subsequent  ones.  The  children  of  later  pregnancies, 
too,  are  better  developed  mentally  than  the  first  born.  Most  great  men  were  later 
children  in  large  families;  for  instance,  Benjamin  Franklin  was  the  seventeenth; 
Napoleon,  the  eighth ;  Daniel  Webster,  the  seventh ;  Wagner,  the  seventh ;  Irving, 
the  eleventh;  Coleridge,  the  thirteenth,  child  of  their  parents.  After  the  eighth  or 
ninth  child  a  reduction  in  size  is  often  apparent,  due  to  a  decline  of  the  general 
health.  Children  from  women  after  a  long  period  of  sterility  are  smaller  than  usual, 
and  the  infants  of  young  girls  are  generally  undersized. 

If  the  child  is  carried  over  term,  which  is  not  seldom,  it  overgrows,  the  head 
hardens,  and  the  muscles  and  fat  become  firmer.  (See  the  chapter  on  Prolonged 
Pregnancy.) 

The  evidences  of  life  of  the  fetus  in  utero  form  an  interesting  study.  The  fetal 
heart  can  be  heard;  heart  and  funic  murmurs,  too;  one  can  feel  the  pulsation  of  the 
heart  through  the  abdominal  wall — all  of  which  will  be  considered  fully  under  the 
Diagnosis  of  Pregnancy.  The  fetus  moves  its  limbs  and  body  from  the  earliest 
months,  and  the  movements  are  audil)le  and  palpable  from  the  fifteenth  week. 
Oft(m  one  sees  an  extremity  move  under  the  abdominal  wall,  and  sometimes  the 
legs  kick  out  with  considerable  force.     These  movements  may  be  so  active  that  they 


DEVELOPMENT    OF   THE    OVUM  59 

(listurl)  tho  mother's  slccf)  and  n'(iiiirc  treatment,  sueli  us  a  tight  abdominal  binder 
and  a  dose  of  sodium  broniid.  'I'lie  child  has  periods  of  sleep,  of  rest,  and  of  activity. 
The  mother  may  notice  that  the  fetus  stretches  itself  after  a  period  of  quiet.  Tho 
author  has  felt  the  child  (ie.x  or  extend  its  head,  withdraw  its  hand  when  the  member 
was  touched,  and  move  out  of  a  strained  })ositi(jn  into  one  more  comfortable.  The 
infant  swallows  the  licjuor  ainnii  in  larfz;e  amounts,  lanugo  and  vernix  caseosa  having 
been  found  in  the  meconium.  These  swallowing  motions  have  never  been  diag- 
nosed. The  fetus  also  sucks  its  fingers  in  utero,  Ahlfeld  reports  a  case  where  the 
child's  thumb  was  swollen  at  ])irth,  and  it  innnediately  put  the  swollen  member  in 
its  mouth  and  sucked  it.  In  face  presentation  the  child  will  suck  the  examining 
finger.  One  of  the  most  interesting  ph(!nomena  of  intra-uterine  life  is  fetal  hiccup. 
Mermann  first  described  it,  but  Ahlfeld  has  worked  up  the  subject.  The  author 
has  very  frequently  found  it,  and  many  intelligent  women  have  remarked  and 
correctly  diagnosed  the  ])henom(>n()n.  The  movements  are  short,  ([uick  jerks  of  the 
shoulders  and  trunk,  15  to  30  a  minute,  regular,  visible,  audible,  and  palpable  to  the 
observer.  They  resemble  hiccups  perfectly  except  the  absence  of  stridor.  The 
author  has  heard  them  as  early  as  the  fifth  month  of  gestation.  They  may  continue 
fifteen  to  twenty  minutes  and  become  very  annoying  to  the  mother,  recurring  at 
more  or  less  frequent  intervals  until  delivery.  In  one  case  the  author  heard  the 
sounds  chstinctly  just  before  the  child  was  born,  and  within  a  minute  after  the 
child  was  delivered  it  was  hiccuping  so  loudly  that  it  was  heard  in  the  next  room. 
The  contraction  of  the  diaphragm  has  been  felt  by  the  hand  in  the  uterus  during  the 
operations  of  version  and  extraction,  but  it  was  impossible  to  be  sure  that  the  in- 
fant was  not  suffering  from  asphyxia  and  was  gasping  for  breath.  The  latter  ex- 
planation of  such  a  movement  is  the  first  one  to  be  thought  of  in  cases  of  this 
nature. 

Another  phenomenon,  not  so  common,  and  more  uncertain  of  diagnosis,  is  the 
respiratory  action  of  the  child  in  utero.  If  one  carefully  observes  the  umbilical 
region  of  a  thin  woman,  pregnant  near  term,  one  may  discover  fine  rising  and 
falling  movements  of  the  abdominal  wall.  They  occur  60  to  80  a  minute,  are  inter- 
mittent, and  are  most  pronounced  in  the  region  of  the  child's  chest.  Ahlfeld  has 
studied  these  motions  very  thoroughly,  and  is  convinced  that  they  are  due  to  minute 
excursions  of  the  fetal  chest,  and  he  has  succeeded  in  getting  graphic  tracings  of 
them  with  the  cardiograph,  showing  that  when  the  chest  expands,  the  abdomen  con- 
tracts. As  a  support  to  this  theory  one  may  add  the  daily  observations  of  the  new- 
born child.  Inspection  of  the  chest  will  show,  just  before  the  gasp  that  precedes  the 
first  cry,  tiny  rapid  inspirations  and  expirations.  These  are  best  observed  on  the 
apneic  child  delivered  by  cesarean  section.  The  motion  in  utero  serves  to  strengthen 
and  prepare  the  diaphragm  and  chest  muscles  for  the  function  of  respiration,  but 
it  is  not  strong  enough  to  suck  liquor  amnii  further  than  the  pharynx,  whence  it 
probabl}^  is  swallowed. 

The  Mental  State  of  the  Fetus  in  Utero. — A  child  shows,  very  shortly  after 
birth,  a  few  evidences  of  mental  action.  It  turns  its  face  toward  the  light;  it  draws 
the  foot  or  arm  away  from  an  obstructing  object.  The  special  senses  are  all  present ; 
even  if  only  a  few  hours  old  it  makes  a  wry  face  when  a  solution  of  quinin  is  placed 
on  the  tongue;   a  loud  sound  causes  it  to  start;   it  feels  pain,  and  it  sees. 

The  mental  condition  of  the  fetus  in  utero  has  been  the  subject  of  much  specula- 
tion. That  the  child  lies  in  a  continuous  "dreamless  sleep"  (Parvin)  is  not  prob- 
able. Intelligent  mothers  have  said  they  could  distinguish  periods  of  sleep,  of  rest, 
and  of  activity.  The  child  will  assume  a  more  comfortable  attitude  after  it  is  dis- 
turbed by  external  manipulation.  During  labor  it  will  wriggle  its  head  away  from 
the  examining  finger;  it  will  draw  its  hand  away  from  one's  grasp.  As  Bailly  said, 
it  is  probable  that  a  vague  and  obscure  will  intervenes  in  the  production  of  these 
movements. 


60  PHYSIOLOGY    OF    PREGNANCY 

Palpation  of  the  fetus  increases  the  rapidity  of  the  heart.     (For  further  informa- 
tion on  this  subject  see  Peterson  and  Rainey.) 

Literature 

Ahlfeld:  Lehrbuch  der  Geb.,  1903,  p.  44. — Barnes:  Principles  and  Practice  of  Obstetrics. — Barry:  "Researches  in 
Embryology,"  Phil.  Trans.  Roy.  Soc.  of  London,  1839.— Bo?idi.-  Centralbl.  f.  Gyn.,  1903,  p.  636.— BrJ/ce, 
Teacher,  and  Kerr:  The  Early  Human  Ovum,  Glasgow,  1908,  Maclehose  and  Sons.— ^Cohnstein  and  Zuntz: 
Pfliiger's  Arch.,  vol.  xxxiv,  p.  173. — Driesch:  Zeitschr.  f.  ^-issensch.  Zoologie,  vols,  liii  and  Iv,  quoted  by  Nagel, — 
Fetzer:  "Young  Human  Ovum,"  Centralbl.  f.  Gyn.,  1910,  p.  1413. — Goenner:  Winckel's  Handbuch  der  Geb., 
vol.  i,  p.  320. — Heine  and  Hofbnucr:  "Early  Human  Egg,"  Zeitschr.  f.  Geb.  u.  Gyn.,  1911,  vol.  Ixviii. — Hertwig: 
Lehrbuch  der  Entwickelungsgesohichte,  eighth  edition,  p.  49  et  seq. — Herzog:  "Early  Placentation,  etc.,  in 
Man,"  Amer.  Jour.  Anat.,  July,  1909. — Keim:  Paris  Obstetric  Soc,  1901. — La  Torre:  Du  Development  du 
Foetus  ches  les  Femmes  a  Bassin  Vicie,  Paris,  O.  Doin,  1887. — Matthews:  "Maturation,  etc.,  in  the  Echinoderm 
Egg,"  Jour,  of  Morph.,  1895. — Hermann:  Centralbl.  f.  Gyn.,  1880,  p.  377. — Parvin:  Science  and  Art  of  Ob- 
stetrics, p.  211. — Peters:  Uber  die  Einbettung  des  menschl.  Eies,  Vienna,  1899. — Peterson  and  Rainey:  Bull. 
New  York  Lying-in  Hospital,  December,  1910. — Pfannenstiel:  Handbuch  d.  Geb.,  1903,  vol.  i,  p.  218. — Prochow- 
nik:  Arch.  f.  Gyn.,  vol.  xi. — Winckel:  Handbuch  der  Geb.,  vol.  iii,  p.  568. — Wohlgemuth  and  Massone:  Arch.  f. 
Gyn.  u.  Geb.,  July,  1911,  vol.  xciv,  p.  381. 


CTTAPTET}  TTT 
THE  PHYSIOLOGY  OF  THE  FETUS 

This  is  a  now  scit'uce,  and  known  facts  arc  few,  though  many  hypotheses  have 
been  advanced  and  sui^ijorted  by  deduction  from  the  study  of  the  lower  animals. 
The  ovum  is  not  a  part  of  its  mother,  but  simply  a  parasite,  possessing  all  the  func- 
tions of  an  organized  being. 

In  the  first  (hi>'S  after  fertilization  the  ovum  ]:)robably  is  nourished  by  osmosis 
and  imbibition  of  the  fluids  surrounding  it  in  the  tube.  When  it.  reaches  the  uterus, 
the  trophoblast  is  already  developed,  and  these  cells  eat  into  the  uterine  mucosa. 
The  immense  development  of  the  decidual  cells  may  be  to  serve  as  nutriment  for  the 
o\T.mi,  and  the  same  is  gotten  and  prepared  by  the  trophoblast.  The  glands  of  the 
uteiiis  enlarge  enormously,  and  are  filled  with  secretion,  as  is  shown  by  Fig.  41. 
This  secretion  has  fat  from  degenerated  leukocytes,  and  was  called  uterine  milk  by 
the  older  writers,  and  their  view  that  it  furnished  nourishment  to  the  ovum  may 
not  be  without  foundation,  though  in  the  human  placenta  the  villi  do  not  chp  into 
the  glands.  In  earliest  fetation  the  glands  around  the  ovum  contain  blood.  Until 
the  i^lacental  circulation  is  established,  the  ovum  very  probably  is  nourished  in  the 
two  ways  indicated. 

The  Fetal  Blood. — The  blood  at  term  has  about  the  same  appearance  as  ma- 
ternal Ivlootl,  l)ut  has  less  fibrin  and  hemoglo]:)in  and  more  salts  (Preyer).  It  con- 
tains hemolysin,  which  has  also  been  proved  to  pass  through  the  placenta  from  the 
mother.  Its  blood  may  react,  as  does  its  mother's,  to  the  introduction  of  foreign 
albuininoids,  by  the  production  of  antibodies.  It  has  less  complement  than  the 
mother's  blood. 

The  nucleated  red  blood-corpuscles  have  all  disappeared  at  the  ninth  month. 
The  red  blood-corpuscles  are  more  easily  decomposed  than  the  mother's,  but 
show  increased  resistance  to  hemolysis  by  cobra  toxin.  Boys  have  more  than  girls 
(8  per  cent.).  The  fetus  has  a  relative  leukocythemia,  and  the  number  of  leukoc\i:es 
in  the  umbilical  vein  is  greater  than  in  the  arteries;  wherefore,  since  the  white  blood- 
corpuscles  cannot  pass  over  from  the  mother,  one  must  conclude  that  they  are 
made  in  the  placenta. 

The  hemorrhagic  and  icteric  tendencies  of  the  new-born  and  its  weakness 
against  infection  show  that  it  has  a  special  blood  pathology,  but  little  is  actually 
known  about  it.  Its  immunities  are  not  yet  developed,  and,  unless  it  receives  anti- 
bodies from  the  mother  via  the  milk,  it  succmnbs  easilj"  to  infections. 

The  Fetal  Circulation. — The  umbilical  vesicle  has  nutritive  properties;  it  ac- 
quires a  store  of  nutriment  from  the  mother,  and  supplies  it  to  the  growing  embryo 
through  two  sets  of  vessels — the  omphalomesenteric  arteries  and  veins.  This  is  the 
first,  or  "vitelline,"  circulation;  it  is  prominent  for  the  first  twelve  clays,  and  dis- 
appears about  the  fifth  week  (Fig.  81).  "With  the  development  of  the  chorionic  villi 
and  the  vessels  from  the  allantois  the  fetus  is  provided  with  a  new,  rather  a  more 
direct,  source  of  nourishment.  The  capillary  system  of  the  allantoic  arteries  and 
veins  rapidly  invades  the  growing  villi,  and  thus  the  osmotic  connection  between  the 
maternal  and  fetal  ]:)lood  is  soon  established.  Fig.  83  shows  the  vitelline  and  allan- 
toic circulation  existing  side  by  side.  The  fetal  blood  now  passes  from  the  primitive 
heart  through  the  primitive  aorta,  the  allantoic  arteries,  to  the  capillaries  lining  the 
periphery  of  the  ovum,  and  dipping  into  the  chorionic  villi,  returning  through  the 

61 


62 


PHYSIOLOGY    OF   PREGNANCY 


allantoic  veins  to  the  heart  through  the  ducts  of  Cuvier.  As  the  liver  develops  the 
blood  returning  from  the  chorionic  area  through  the  allantoic  veins,  now  the  um- 
bihcal  vein,  traverses  the  liver,  but  soon,  since  the  vessels  of  the  hver  cannot  accom- 
modate the  rapidly  growing  demands  of  the  developing  placental  circulation,  a  by- 
pass is  formed  from  the  umbilical  vein  under  the  liver  to  the  inferior  vena  cava. 
Thus  the  returning  blood  from  the  now  fully  differentiated  placenta  passes,  part 
through  the  liver  with  that  from  the  portal  vein,  and  part  through  the  by-pass,  the 
ductus  venosus  Arantii,  into  the  inferior  vena  cava.     The  circulation  of  the  blood 


Fio.  81. — The  Vitelline  Circulation  (from  a  specimen  loiined  by  Professor  R.  R.  Benslcy,  Chicago  University). 


in  the  fetus  before  birth  is  different  from  that  afterward,  and  at  no  part  of  the  body 
is  purely  arterial  blood  supplied.  This  is  easily  seen  in  children  delivered  by 
cesarean  section;   they  present  a  dull  blue  color,  almost  cyanotic. 

The  blood,  oxygenated  and  cl(;ansod  in  the  placenta,  provided  with  nutritive 
substances  and  water  for  the  fetus,  is  collected  by  the  branches  of  the  umbilical 
vein  and  passes  through  the  single  vein  of  large  caliber  to  the  child,  entering  its 
body  at  the  navel,  then  ascending  })ehind  the  parietal  peritoneum  to  the  liver.  Here 
the  vein  divides,  several  Ijranches  entering  the  liver  directly,  others  anastomosing 


THE    IMIYSIOLOGY    OF    TFTE    FETUS 


63 


with  the  portal  vein,  while  one  large  branch  goes  directly  into  the  vena  cava.  This 
is  the  ductus  vonosus  Arantii.  The  blood  of  the  vena  cava  ascendons  is,  of  course, 
venous,  and  iningl(>8  with  that  coininj!;  from  the  ductus  venosus,  both  proceeding  to 
the  heart,  which  is  entered  through  tlic  riglit  auricle.  Owing  to  a  peculiar  arrange- 
ment of  the  endocariliurn  a  vaKc-like  fold  is  thrown  up  near  the  opening  of  the  cava, 
— ^the  Eustachian  valve,^ — wiiich  directs  the  blood-stream  toward  the  septum  of  the 
auricles,  where  an  ()i)ening  exists — -the  foramen  ovale.  This  communication  be- 
tween the  auricles  ])erniits  the  blood  from  the  ascending  cava,  during  cardiac diast(;le, 
to  pass  directly  into  the  left  ventricle.  The  right  auricle  is  filled  by  ventjus  blood 
coming  down  from  the  superior  vena  cava,  antl  a  little  admixture  of  arterial  blood 
not  deflected  by  the  valvula  Eustachii.  This  dark  blood  flows  into  the  right  ven- 
tricle (Fig.  84).  When  the  cardiac  systole  occurs  (Fig.  So),  the  blood  (almost  ar- 
terial) in  the  left  ventricle  is  forced  into  tiie  aorta,  its  cranial  branches,  and  down  into 
the  trunk.  The  venous  blood  in  the  right  ventricle  passes  up  through  the  pul- 
monary trunk,  which  divides  into  three  branches — one  to  each  lung,  and  one  large 
division  which  anastomoses  with  the  aorta.     This  by-pass  is  called  the  ductus 


Fig.  82. — Diagram  of  the  Vitelline  Circul.\tion. 
Embryo,  20  mm.  long,  between  four  and  five  weeks'  growth.     Vitelline  circulation  completed.     Allantoic  circulation  in- 
creasing.    Atrium  dividing.     Liver  consisting  of  two  equal  lobes.     Primitive  aortse  partlj-  united. 


Botalli,  and  serves  to  relieve  the  functionless  lungs  of  the  excess  of  blood  that  the 
right  ventricle  throws  out.  One-half  of  the  blood  takes  this  short  cut  to  the  aorta. 
The  blood  in  the  arch  of  the  aorta,  therefore,  is  quite  arterial,  while  that  which  goes 
to  the  trunk  and  extremities  is  mostly  venous.  The  hypogastric — the  former  allan- 
toic— arteries,  leaving  the  external  iliacs  in  the  pelvis,  ascend  alongside  the  bladder 
and  urachus  to  the  navel,  then,  ^^^nding  spirally  around  the  mnbilical  vein  in  the 
cord,  reach  the  placenta.  Here  they  split  up  into  arterioles  and  capillaries  in  the 
villi.  The  fetal  blood  contained  in  the  placenta  is  constantlj-  undergoing  the 
changes  that  in  the  adult  occur  in  the  lungs,  the  liver,  the  blood-making  and  other 
organs  of  the  body.  The  peculiar  distribution  of  the  fresh  blood  in  the  fetus  ac- 
counts for  the  variation  in  the  gTo^\'th  of  its  organs.  The  liver,  receiving  the  blood 
coming  directly  from  the  placenta,  grows  massively,  and  is  thus  able  to  perform  its 
most  important  functions  in  fetal  life.  The  head  receives  the  blood  next  in  fresh- 
ness, while  the  trunk  and  extremities  receive  the  poorest  blood.  Late  in  pregnancy 
the  opening  of  the  vena  cava  inferior  moves  over  to  the  right  of  the  auricle,  and  the 
foramen  ovale  begins  to  diminish  in  calil:)er;  thus  the  right  auricle  receives  fresh 
blood,  and  more  blood  is  forced  into  the  lungs  and  through  the  ductus  Botalli  into 


64 


PHYSIOLOGY    OF    PREGNANCY 


the  lower  portion  of  the  body.     A  more  equable  distribution  of  nourishment  is 
effected,  and  greater  symmetry  of  the  body  results. 

After  the  birth  of  the  child  important  changes  in  the  blood-currents  occur. 
With  the  first  inspiration  the  lungs  expand.  The  pulmonary  vessels  are  dilated, 
and  blood  rushes  into  them  from  the  right  ventricle.  Since  the  lungs  now  take  all  the 
supply  from  the  pulmonary  artery,  the  by-pass  to  the  aorta,  the  ductus  arteriosus 
Botalii,  collapses  and  shrinks  up.  It  is  solidly  obliterated  in  a  few  weeks.  The 
aspiration  of  the  right  auricle  and  ventricle  draws  the  blood  from  the  umbilical  vein. 


Umbilical  vesicle 


Fig.  83. — Synchron'ou.s  Vitelline  and  Allantoic  Circulations  (schematic). 


This  and  the  influence  of  cold  air  cause  the  vein  to  collapse.  Tying  the  cord  shuts 
off  permanently  the  supply  of  blood  from  the  vein.  It  collapses,  its  walls  aggluti- 
nate, and  in  a  few  weeks  the  vein  is  obliterated,  remaining  as  a  cord-like  ligament 
for  the  liver — the  ligamentum  teres.  The  ductus  venosus  Arantii  also  collapses  and 
disappears.  The  pressure  in  the  right  auricle  ceasing,  that  of  the  left  auricle  and 
ventricle  increases,  which  results  in  the  gradual  closure  of  the  foramen  ovale.  This 
opening  sometimes  persists  for  months,  or  may  be  the  cause  of  permanent  and  fatal 
heart  disease.  Children  with  persistent  patent  foramen  ovale  are  cyanotic,  es- 
pecially when  crying  or  on  exertion,  and  are  called  "blue  babies" — morbus  cseru- 


THE    PHYSIOLOGY    OF   THE    FETUS 


65 


Fig.  S4. — ^Fetal  Circulation — Diastole. 


66 


PHYSIOLOGY   OF   PREGNANCY 


leus.  The  hypogastric  arteries  contract  and  thrombose.  This  is  due  to  the  fact 
that  the  left  ventricle,  unassisted  as  formerly  by  the  right  ventricle  via  the  ductus 
Botalli,  cannot  force  the  blood  the  long  distance  through  the  cord  to  the  placenta. 
In  addition,  exposure  to  cold  contracts  the  umbilical  arteries.     The  pulsation  in  the 


Fig.  85. — Fetal  Circulation — Systole. 


cord  cea.ses,  and  the  adult  circulation  is  established.     Normally,  no  clots  form  in 
any  of  the  temporary  fetal  vessels  except  the  hypogastric  arteries. 

Special  Physiology. — Tin;  fetus  in  utero  has  all  the  functions  of  the  infant, 
re.spiruticjii,  digestion,  assimilation,  metabolism,  heat-production  and  regulation, 
excretion,  etc.,  but,  owing  to  its  particular  environment,  these  are  all  much  modified. 
The  placenta  does  several  of  the  vital  functions  of  the  fetus  almost  entirely.     It  is 


TIIK    I'lIYSlOLOGY    OF   THE    FETUS  07 

the  luiijjjs  of  the  child;  il  ixTlonns  nearly  all  its  digcslion;  it  assimilates  foo<l;  it 
stores  up  glycogen  (liernard),  and  it  is  the  general  excretory  organ.  (The  decidua 
seems  to  possess  the  glycogenic  power — Zaretzsky.)  Its  functions  should  be  con- 
sidered a  little  more  in  detail,  though  we  will  have  to  present  much  that  is,  at  this 
time,  unfinished,  or  only  ])artly  ])rov('d. 

Respirdiinn. — Zweifel  i)roved  that  the  uml)ilical  vein  contains  oxj'genated 
blood,  and  the  arteries  venous  blood.  If  the  placenta  becomes  detached  or  the 
cord  (•omi)r('ss('d,  tlie  child  dies  from  asphyxia.  These  two  facts  prove  that  the 
fetal  blood  is  supplied  with  oxygen  in  the  i)lacenta.  The  fetus  needs  little  ox^'gcn, 
as  its  conil)Ustion  ])r(jcesses  are  slow;  it  moves  little  and  meets  with  no  resistance; 
it  has  no  perspiration  with  evaporation  from  the  skin.  It  loses  no  heat.  Since  this 
is  so,  the  fetus  tolerates  withdrawal  of  its  oxygen  supply — asphjTiia — very  well  for 
a  time.  As  jiregnancy  goes  on  this  toleration  is  lost.  It  is  believed  that  the  fetal 
blood  is  more  and  more  venous  in  tlu;  later  months  of  pregnancy.  The  ])rocess  l)y 
which  the  fetal  blood,  carried  to  the  placenta,  becomes  oxygenated  is  probably 
analogous  to  the  process  going  on  in  the  lungs.  It  is  not  by  osmosis,  becau.se  the 
oxygen  is  bound  to  the  hemoglobin.  The  vital  oxidizing  power  of  the  placental 
cells,  ]xn-haps  through  the  medium  of  a  ferment,  splits  off  the  oxygen  and  carries  it 
to  the  fetal  red  blood-corpuscles.  The  process  is  similar  to  internal  or  tissue  resi)ira- 
tion,  and  perhaps  the  fat  in  the  villi  facilitates  the  change  (Hofbauer). 

Digestion. — In  many  respects  the  vilU  of  the  placenta  resemble  the  intestinal 
villi.  In  selective  and  vital  action  they  exceed  the  latter  in  vigor  and  variety  of 
function.  The  placenta  is  a  large  gland,  and  it  prol^ably  assumes  the  functions 
which  the  adult  glands  later  perform.  The  fetus  needs  albumin,  fat,  carbohydrates, 
water,  and  salts.  Exactly  how  albumin  is  carried  over  from  the  mother's  to  the 
fetus'  blood  is  not  known.  Albumose,  but  not  peptone,  is  found  in  the  placenta. 
Verj'  probably  the  syncytial  cells  secrete  an  albumin-splitting  ferment,  the  proteid 
going  over  into  a  compound  of  lower  t\pe,  and  the  albumin  is  then  reformed  inside 
the  fetal  vessels.  Fat,  according  to  Hofbauer,  is  found  in  the  deeper  parts  of  the 
syncytium  and  in  the  vacuolated  cells  in  the  form  of  fine  droplets.  It  comes  from 
the  blood  of  the  mother,  and  in  small  amounts  from  the  glands  of  the  uterus.  In 
cows  and  dogs,  for  example,  the  connection  of  the  villi  with  the  glands  is  intimate, 
and  the  latter  play  an  important  part  in  fetal  nutrition.  Physiologists  are  not  sure 
how  fat  exists  in  the  blood,  nor  do  they  know  how  it  passes  over  to  the  fetus.  Emul- 
sified fat  does  not  pass  the  placenta.  Probably  again  here  a  fat-splitting  ferment 
(lipase)  is  in  action,  fatty  acids  and  glycerin  being  formed.  The  analogy  between 
intestinal  and  placental  villi  is  again  strengthened. 

Water  is  readily  absorbed  by  the  villi,  differences  in  the  molecular  concentra- 
tion betw^een  the  two  bloods  accomplishing  the  transfer.  Of  the  metals,  iron  is  one 
of  the  most  important,  and  the  fetus  needs  a  great  deal  of  it.  There  is  no  iron  in  the 
blood  plasma  of  the  mother,  therefore  the  red  corpuscles  must  be  used  by  the  tropho- 
blast  to  ]:)rovide  the  necessary  amount.  Probably  the  syncytium  has  a  cytotoxic  or 
hemolji:ic  action  on  the  erythrocytes,  perhaps  dependent  on  the  transformation  of 
the  lipoid  substances  in  the  covering  of  the  cells  (Overton).  The  red  blood-cor- 
puscles are  destroyed  by  the  vilU,  and  the  hemoglol)in,  by  complicated  and  not  fully 
understood  biochemical  processes,  is  umnade  and  reformed  in  the  fetal  red  blood- 
corpuscles.  Perhaps  this  destruction  of  er^ihrocytcs  accounts  for  some  of  the 
anemia  of  women  in  the  early  months  of  pregnancy.  ]\Iayer,  in  1827,  proved  that 
substances  in  solution  in  the  maternal  blood  pass  on  to  the  fetus  through  the  mem- 
brane separating  fetal  and  maternal  blood,  e.  g.,  salts,  potassium  iodid,  salicylic 
acid,  atropin,  etc.,  and  in  amount  as  they  are  dial>-zable.  Oases  pass  over,  as 
chloroform  and  carbon  dioxid;  therefore  the  danger  of  giving  too  much  chloroform. 
Ahlfeld  found  the  liquor  amnii  in  many  cases  of  cesarean  section  stained  with  me- 
conium.    Xicloux  assembled  our  knowledge  on  this  subject  up  to  1909.     Pregnant 


68  PHYSIOLOGY    OF    PREGNANCY 

women  should  avoid  large  gatherings,  or  where  large  coal-stoves  are  used,  as  the 
carbon  monoxid  may  injure  the  fetus. 

The  placenta,  then,  prepares  the  food  for  the  infant,  so  that  it  may  be  immedi- 
ately used  for  its  general  metabolism.  In  addition,  the  intact  placenta  offers  a 
barrier  to  the  passage  of  infection  to  the  fetus.  Only  if  its  walls  are  injured  will  the 
villus  allow  bacteria  to  pass.  (See  Pathology  of  Pregnancy.)  If  bacteria  do  not 
pass,  many  toxins  do,  but  antitoxins,  e.  g.,  diphtheria  and  antitetanus  serum,  do  not 
pass  over. 

As  another  source  of  nourishment,  mention  must  be  made  of  the  liquor  amnii. 
It  contains  a  slight  amount  of  albumin,  and  the  fetus  drinks  it  in  large  quantities. 
This  is  proved  by  finding  lanugo  in  the  meconium,  and  the  infant  vomiting  the  liquor 
amnii  after  birth.  The  stomach  of  the  fetus  contains  pepsin,  and  the  intestines  a 
trjTDtic  ferment;  therefore  the  function  of  digestion  could  be  carried  on.  Water  is 
probably  supplied  the  fetus  in  this  manner.  Until  the  second  month  the  fetus  is 
almost  all  water,  has  less  solids  even  than  milk.  At  the  end  of  pregnancy  the  fetus 
is  74  per  cent,  water.  The  liver  is  active,  demonstrated  by  its  preponderating  bulk 
and  the  presence  of  bile  in  the  meconium.  The  meconium  is  a  tarry,  greenish- 
black  substance,  found  in  the  colon  of  the  fetus  in  considerable  quantity  even  before 
the  seventh  month.  It  accumulates  in  the  colon  and,  therefore,  peristalsis  must 
occur  in  the  intestines.  This  has  also  been  demonstrated  experimentally.  The 
meconium  becomes  thicker  in  the  latter  weeks,  since  the  intestine  is  absorptive. 
It  is  composed  of  secretions  of  the  intestinal  canal,  the  solid  particles  swallowed 
with  the  Hquor  amnii;  lanugo,  epithelium,  vernix  caseosa,  and  bile,  and,  chemically, 
cholesterin,  bilirubin,  fat,  and  mucin. 

The  Kidneys. — These  are  active  from  the  early  months,  as  Nagel  has  shown. 
Ahlfeld  denies  that  the  liquor  amnii  contains  urine.  He  says  the  excrementitious 
matters  which  the  kidney  usually  excretes  are  taken  away  through  the  placenta. 
Still,  urea  has  been  found  in  the  liquor  amnii;  the  bladder  has  been  found  distended, 
even  so  as  to  be  a  hindrance  to  labor;  the  kidnej^s  are  there,  and,  by  analogy  with 
other  organs,  must  work.  Urine  is  often  found  in  the  bladder  of  new-born  children. 
They  sometimes  urinate  freely  during  delivery.  Probably  the  action  of  the  kidneys 
before  birth  is  not  constant  nor  considerable — rather,  exceptional.  Ahlfeld's 
arguments  are  very  plausible.  The  child  has  its  own  general  metabolism — internal 
respiration,  anabolism,  catabolism,  heat-production  all  go  on  as  in  the  adult,  but  in 
varying  degrees.  The  tissue  changes  are  very  active,  since  growth  is  so  rapid,  but 
the  child  needs  to  produce  very  little  heat,  being  so  well  protected.  Its  temperature 
is  one-half  to  three-fourths  of  a  degree  higher  than  that  of  the  mother.  The  prod- 
ucts of  the  fetal  metabolism  are  carried  to  the  placenta.  Glands  with  internal  se- 
cretion probably  functionate. 

Less  is  Icnown  of  the  excretory  functions  of  the  placenta,  but  such  a  function 
surely  exists,  since  the  fetus  has  very  little  other  outlet  for  its  waste  matters.  Some 
waste  may  accumulate  as  meconium  in  the  intestinal  canal,  and  a  little  more  may  be 
passed  as  urine  or  perspiration.  That  the  mother  can  absorb  materials  from  the 
child  is  proved  by  the  injection  of  a  salt,  as  iodid  of  potassium,  into  the  child,  and 
its  demonstration  in  the  saliva  of  the  mother.  That  substances  will  pass  from  fetus 
to  mother  was  known  to  Harvey.  Carbon  dioxid  passes  from  the  fetus  and  is  ex- 
creted by  the  mother. 

The  amount  of  actual  waste  furnished  by  the  child  cannot  be  large,  because  its 
nourishment  is  provided  in  a  condition  ready  for  immediate  assimilation  and  con- 
version into  living  protoplasm. 

The  Determination  of  Sex. — It  is  felt  that  there  must  be  a  natural  law  govern- 
ing the  production  of  males  and  females,  because  the  proportion  between  the  two  in 
nearly  all  countries  is  as  105  or  106  is  to  100.  The  males  have  a  higher  death-rate 
in  delivery  and  after,  so  that  among  adults  the  relation  is  reversed.     What  this  law 


THE    PHYSIOLOGY    OF    THE    FETUS  69 

is  no  one  knows,  l)ut  wo  have  many  llicorics,  u  review  of  which  may  be  found  in  the 
literature  indicated  below  (Cohn,  Dawson,  Morgan,  Rauber). 

Sex  may  be  determined — (1)  In  the  ovum  itself;  (2)  at  the  time  of  fertilization 
by  the  s]M'rniatozoid;  (3)  by  the  influence  of  external  factors  dui-iufz;  the  first  forma- 
tive period  of  tlu;  embryo.  All  the  theories  ))ro])osed  may  be  grouped  under  these 
headings. 

That  th(!  ovum  itself  carries  the  sex-inilividuality  is  shown — (a)  By  the  constant 
occurrence  of  one  sex  in  unioval  twins;  (6)  the  embryologic  demonstration  of  sex 
difference's  in  even  the  earliest  human  ova;  (c)  the  preponderance  of  monstrosities 
in  the  female  sex;  (d)  in  c(>rtain  worms  {Dmophihi.s  apatri-s)  one  can  distinguish 
male  and  female  ova;  (e)  the  phenomena  of  parthenogenesis  in  certain  inverte- 
brate's. There  is  no  scientific  basis  for  the  supposition  that  the  spermatozoid  has 
an>'  iiithiciice  on  the  sex  of  the  fetus,  though  recently  Wilson  and  Stevens  have 
sought  to  prove  that  in  certain  insects  the  chromosomes  present  different  arrange- 
ments in  the  spermatocytes,  and  the  resulting  spermatozoids,  therefore,  have  vary- 
ing fertilizing  power  on  the  ovum.  Regarding  the  influence  of  environment,  scien- 
tists differ.  Ploss  and  Waldeyer  claimed  that  in  the  lower  forms  of  life,  as  melons, 
cucumbers,  favorable  conditions  produce  females,  and  Fiirst  claims  that  the  larvae 
of  bees,  when  the  nourishment  is  insuflficient,  result  in  hermaphrodites.  On  the 
other  hand,  Pfliiger,  Schultze,  and  Heapes  (quoted  by  Ahlfeld,  loc.  cit.)  have  been 
unable  to  mocUfy  the  sex  of  frogs,  mice,  and  rabbits  by  altering  their  environment. 

Many  conditions  have  been  assumed  as  causative  of  sex  distinction,  and  at- 
tempts have  been  made  to  influence  nature,  ])ased  on  these,  usually  false,  assump- 
tions. Hippocrates  and  Galen  believed  that  boys  came  from  the  right  ovary,  girls 
from  the  left,  and  Henke,  in  1786,  advised  coition  on  the  corresponding  side  when 
a  child  of  that  sex  was  desired.  Hofacker  and  Sadler  believed  that  the  father,  if 
older,  would  produce  more  males.  Other  statistics  prove  the  reverse.  It  is  a  fact 
that  old  primiparffi  have  a  preponderance  of  lioys.  Women  with  contracted  pelves 
have  more  boys,  perhaps  because  they  are  usually  older  when  they  marr}-. 

Impregnation  of  an  ovum  before  menstruation  is  said  to  produce  females;  after- 
ward, males  (Thury).     It  may  be  true  of  animals,  but  is  not  in  the  human. 

Janke  claimed  the  weaker  party  in  the  sexual  act  produced  the  opposite  sex, 
and  advised  that  either  the  man  or  the  woman  be  at  the  height  of  sexual  potency, 
depending  on  the  sex  desired.  Diising,  from  the  study  of  10,500,000  births,  finds 
more  boys  are  conceived  in  winter  than  in  summer,  and  Ploss  found  that  women  in 
high  altitudes  give  birth  to  more  sons  than  those  on  the  plains. 

Schenk  believed  that  the  sex  of  the  offspring  depended  on  the  nutrition  of  the 
mother;  if  her  metabolism  is  so  affected  by  conditions  during  pregnancy  that  sugar 
appears  in  the  urine,  the  product  of  conception  wnll  be  female;  if  the  patient  is  kept 
on  a  diet  that  will  prevent  sugar,  or  reduce  the  carbohydrates  in  the  urine,  the  child 
will  be  a  boy.     Experience  has  proved  the  utter  fallacy  of  this  theory. 

Nature  still  holds  the  secret  of  sex  production,  and  it  is  not  desirable,  even  if 
it  were  possible,  for  man  to  interfere  in  the  matter. 

Literature 

Bernard:  Ribemont,  Dessaigneset  Le  Page,  1S73,  p.  103. — Cohn:  Die  willkiirliche  Bestimmung  des  Geschlechts,  Wurz- 
burg,  1S9S. — Dawson:  Causation  of  Sex,  1909. — Foster  and  Balfour:  Embryology,  1J>7.5. — Hoibauir:  Biologic 
der  inenschl.  Plazenta,  Vienna,  1905. — v.  Lenhossek:  Das  Problem  der  Geschleclits-Bestimminden  Ursachon, 
Jena,  1903. — -Liepman:  Zeitschr.  f.  Geb.  u.  Gyn.,  1905. — Meyer  and  Overton:  Vierteljahresschr.  der  Xaturforsch- 
crges  in  Ziiricli,  1S99. — Morgan:  Popular  Science  Monthly,  December,  1903.  Full  literature  on  Causation  of 
Sex. — A'icloux:  L'Obstctrique,  November,  1909,  p.  840. — Preyer:  Speoielle  Phys.  der  Embryo,  Leipzig,  1885. 
Complete  literature. — Rauber:  Der  L'berschuss  von  Knabengeburten  und  seine  biologische  Bedeutung,  Leipzig, 
1900. — Strassman:  "Das  Leben  vor  der  Geburt,"  Volkmann's  klin.  Vort.,  X.  F.,  No.  353. — Sterens:  Publica- 
tions of  the  Carnegie  Institute,  1906. — Wilson:  "Studies  on  Chromosomes,"  Jour.  Exper.  Zoologj',  1906,  vol. 
iii. — Zaretzsky:   L'Obstetrique,  May,  1911.     Gives  full  literature. 


CHAPTER  IV 
CHANGES  DUE  TO  PREGNANCY 

LOCAL  CHANGES 

The  rapidly  growing  ovum  makes  many  demands  on  the  maternal  organism. 
It  requires  a  great  deal  of  room  for  its  development,  and  a  free  blood-supply  for 
its  nourishment;  then,  too,  the  parturient  canal  must  be  prepared,  and  the  means 
proA'ided  for  the  expulsion  of  the  completed  child.  These  are  the  local  requirements : 
there  are,  in  addition,  demands  on  the  organs  of  general  metabolism — the  liver, 
the  kidneys,  the  ductless  glands,  the  nervous  system,  etc.,  and,  unless  the  proper 
balance  is  maintained,  either  mother  or  child  or  both  will  suffer.  To  meet  these 
requirements  of  the  growing  fetus  the  whole  body  of  the  mother  undergoes  certain 
changes,  which  for  the  purpose  of  study  are  divided  into  local  and  general. 


^^-^\M\^%'. 


« 


^  • 


t** 


\,\^'  * 


Fig.  S6. — Muscle  of  Non-pregnant  Uterus. 


Local  Changes. — Naturally  the  uterus  is  most  markedly  altered.  The  normal 
uterus  of  a  nulligravida  is  a  pear-shaped  organ,  63^2  cm.  long,  2}^  cm.  thick,  and 
4  cm.  wide,  weighing  42  gm.  In  multipara  the  uterus  is  73^2  cm.  long,  5  cm.  wide, 
and  3  cm.  thick,  weighing  65  gm.  It  is  made  up  of  hard,  unstriped  muscle,  covered 
in  part  by  the  peritoneum,  moored  to  the  pelvis  by  eight  so-called  ligaments,  and 
attached  to  the  pelvic  floor  by  means  of  the  vagina. 

During  the  first  half  of  pregnancy  the  uterus  enlarges  as  the  result  of  a  hyper- 
plasia of  its  muscular  substance.     This  is  a  true  eccentric  growth,  is  much  more 

70 


CHANGES  DUE  TO  PREGNANCY  71 

rapid  than  is  sufficient  to  acconiniodatc  the  growing  ovum,  and  is  not  due  to  expan- 
sion by  the  growing  ovum,  as  the  same  changes  occur  in  the  uterus  even  when  the 
ovum  develops  outside  of  it.  There  are  hypertrophy  and  also  hyperplasia  of  the 
cells.  The  wall  of  ihe  uterus,  which  was  8  nmi.  before  pregnancy,  grows  to  })e  25 
mm.  thick  by  the  fourth  month.  After  this  the  decidua  reflexa  comes  to  lie  on  and 
fuse  with  the  decidua  vera,  and  the  development  of  the  uterus  is  coequal  with  that 
of  the  ovum.     At  no  time  in  pregnancy  docs  the  ovum  actively  distend  the  uterus. 


0 


> 

<% 

s 

« 

m 


K 

Fig.  S7. — Muscle  of  Pregnant  Uterus.  Cross-  and  Long  Sections. 
Removed  at  time  of  a  cesarean  section. 

In  cases  of  twins  and  polyhydramnion  there  may  be  pathologic  distention  of  the 
uterus.  At  the  end  of  pregnancy  the  uterine  wall  varies  from  4  to  7  mm.  in  thick- 
ness, and  it  is  remarkable  Avhat  muscular  power  this  thin-walled  organ  may  develop. 
The  muscle-fiber  of  the  non-pregnant  uterus  is  spindle  shaped,  and  about  50 /x 
long.  That  of  the  full-term  pregnant  uterus  is  enormously  enlarged  (200  to  600 /i) 
and  presents  fine  longitudinal  filirillations  (Figs.  84,  86,  and  87).  The  muscle-fibers 
of  the  cervix  also  undergo  hypertrophy,  but  not  as  much  as  those  of  the  fundus. 


72 


PHYSIOLOGY    OF   PREGNANCY 


Rarely  cross-striated  muscle-fibers  have  been  found  in  the  uterus,  a  phenomenon 
that  may  indicate  metaplasia. 

The  fibro-elastic  tissue  of  the  uterus  is  of  great  importance  in  view  of  the 
functions  of  the  organ  and  its  resistance  to  distention  and  the  stress  of  labor. 
Diihrssen  and  others  have  shown  that  the  fundus  is  less  rich  in  elastic  tissue  than 
the  cer\ax,  that  the  fibers  are  most  numerous  in  the  outer  layers  of  the  uterus  and 
around  the  vessels,  from  which  they  probably  arise.     Fieux  states  that  the  muscula- 


Tube 


Round  ligament 
Ovarian  ligament 


Uterosacral  ligaments 
Fig.  88. — Schema  of  the  Outek  Layer  of  Uterine  Muscle-Fibers. 


ture  of  the  cervix  has  disappeared  before  term,  to  be  regenerated  after  labor,  so 
that  at  the  end  of  pregnancy  the  cervix  is  composed  entirely  of  connective  tissue. 
No  one  has  confirmed  this  view. 

The  uterine  connective,  tissue  becomes  augmented,  softer,  and  slightly  fibril- 
lated,  permitting  free  motion  between  the  muscle-bundles  and  layers.  How  much 
hyperplasia  exists  is  under  question. 

The  arrangement  of  the  muscle-fibers  has  been  the  object  of  an  immense  amount 


Tube 


Round  ligament 

Ovarian  ligament 


k Uterosacral  ligaments 

Fio.  S9. — Sche.ma  oi-  the  Inner  Layer  of  Uterine  Fibers. 


of  study,  and  it  is  not  yet  fully  understood.  Bayer  gives  a  full  history  of  the 
subject,  and  his  d(^scription,  with  those  of  Helie  and  Chenantais,  will  1)c  followed. 
In  general  three  layers  may  be  distinguished:  an  outer  thin,  an  inner,  also  thin,  and 
the  middle,  very  thick  and  vascular.  These  layers  are  distinguishable  only  during 
pregnancy.  At  cesarean  sections  one  observes  them,  and  it  is  possible  to  unite 
them  inflividually  V)y  suture.  Since  the  uterus  is  the  result  of  the  fusion  of  the  two 
Miillcrian  ducts,  we  would  expect  the  tubes  to  play  a  role  in  the  distribution  of  the 


CHANGES  DUE  TO  PREGNANCY  73 

uterine  muscular  fibers,  and  this  is  borne  out  by  various  dissections.     The  uterine 
liRanients  also  determine  the  direction  of  the  muscular  bundles  (Ivanoff). 

The  outer  layer  of  the  uterus  covers  the  fundus  down  to  the  point  where  the 


Fig.  90. — Dissectio.v  of  Uterine  Muscle.     Fundus  (from  Ilclic  and  Chenantais). 

peritoneum  is  loosely  attached,  and  is  composed  of  the  longitudinal  fibers  of  the 
tubes  (Fig.  88).  It  is  hood-like,  but  does  not  cover  the  sides  of  the  uterus,  where 
the  lilood-vessels  enter.  The  fil)ers  are  more  or  less  longitudinal,  and  interlace  in 
the  middle,  some  crossing  to  the  opposite  side.     The  imier  layer  of  the  longitudinal 


Fig.  91. — Dissection  of  Uterine  Muscle.     Inner  Layer  (from  HcHp  and  Chenantais). 

fibers  of  the  tube  is  continued  under  the  endometrium,  and  forms  the  looped  bundles 
of  muscle  around  the  tubal  ostia  and  around  the  internal  os.  The  powerful  middle 
layer  is  composed  of  the  circular  fi]:)ers  of  the  tul)e  and  the  radiating  fibers  from  the 
sacro-uterine  ligaments,  the  round  and   the  ovarian  ligaments  (Fig.  89).     These 


74 


PHYSIOLOGY    OF    PREGNANCY 


ligaments,  during  the  development  of  the  uterus  in  pregnancy,  exert  a  marked 
effect  on  the  direction  of  its  growth,  and  during  labor  have  a  decided  influence  in 
the  mechanism  of  the  process. 

As  a  res.ult  of  tlie  crossing  and  recrossing  of  the  various  muscular  lamellae 
and  bundles,  a  most  complicated  netAvork  results,  and  through  this  network  the 
blood-vessels  of  the  uterus  pursue  their  course.  It  is  easily  seen  that  when  the 
muscle  contracts,  these  vessels  will  be  twisted,  bent,  and  closed.  This  is  what 
normally  occurs  in  the  third  stage  of  labor  after  the  child  is  expelled.  The  lamellar 
structure  of  the  uterus  is  necessary  to  permit  the  distention  of  the  uterus  and  its 
accommodation  to  the  growing  ovum. 

The  muscle-fibers  of  the  cervix  pursue  simpler  courses.  At  the  isthmus  the 
circular  layers  are  prominent,  especially  at  the  insertion  of  the  retractor  fibers  in 
the  rear,  i.  e.,  the  uterosacral  ligaments.     The  plicae  palmatae  are  made  up  of  longi- 


FiG.  92. — Middle  Layer  of  Uterine  Fibers  (from  Helie  and  Chenantais). 


tudinal  fibers.  Externally  the  cervix  shows  a  layer  of  longitudinal  and  oblique 
fibers  which  spread  out  into  the  bladder  through  the  vesi co-uterine  ligaments 
and  into  the  bases  of  the  broad  ligaments.  The  portio  vaginalis  presents  an  inner, 
submucous,  circular  layer,  derived  from  the  vagina,  an  outer,  longitudinal,  from  the 
same,  and  a  middle  layer,  vascular  and  not  pronounced,  from  the  similar  layer  of 
the  fundus  compounded  with  the  ligaments  entering  the  cervix.  Reynolds,  in 
1911,  showed  the  clinical  importance  of  these  hgaments. 

The  blood-supply  of  the  uterus  must  be  very  liberal  to  render  possible  the 
immense  cliangcs  in  the  organ.  The  vessels  undergo  hypertrophy  and  probably 
hyperplasia  also.  The  arterial  supply  of  the  uterus  is  derived  mainly  from  the 
uterine,  a  branch  of  the  hypogastric,  the  ovarian  or  spermatic,  a  branch  of  the 
aorta,  and  the  funicular,  a  branch  of  the  vesical,  which  passes  up  the  round  liga- 
ment and  joins  the  ovarian  at  the  fundus  uteri.  The  uterine  artery,  arriving  at 
the  side  of  the  uterus  at  the  level  of  the  cervix,  gives  off  a  large  branch  which  goes 


CHANGES  DUE  TO  PREGNANCY 


75 


clown  on  the  vagina  (artoria  corvicovaf>;inalis),  tlic  main  trunk  ascending  in  tlie 
broad  ligament  closely  at  the  side  of  the  uterus.  At  the  level  of  tiie  internal  os 
it  begins  to  give  off  branches  which  cross  through  the  substance  of  the  uterus,  to 
anastomose  with  those  of  the  other  side.  The  trunk,  which  is  sometimes  called  the 
puerperal  artery,  rises,  giving  off  branches  all  the  way,  and  unites  with  the  si)er- 
matic  or  oxarian  artery.  These  vessels  are  wonderfully  twisted,  even  to  the 
smallest  branches,  and  their  anastomoses  are  frequent  and  full  (Fig.  93).  (See 
also  Redlich  in  literature.) 

The  veins  are  mucii  more  developed  than  the  arteries,  and  in  general  follow 
their  course.  They  penetrate  all  the  layers  of  the  uterus,  especially  the  middle, 
anastomose  very  fi'eelN',  and  empty  into  the  plexuses  at  the  sides  of  the  uterus  in  the 


Fig.  93. — Injected  Puerperal  Uterus  (Nagel). 


ovarian  and  broad  ligaments.  The  former  empties  into  the  renal  vein  or  the  cava, 
the  latter  into  the  hypogastric  vein,  and  thence  into  the  internal  iliac.  The  uterine 
veins  have  no  valves. 

Microscopically,  both  arteries  and  veins,  particularly  the  veins,  midergo 
interesting  changes  in  the  uterine  wall.  They  lose  their  outer  coats,  and  come  to 
lie  on  the  muscle-ljundles,  with  only  an  intima  or  with  very  little  tunica  mecUa, 
really  forming  large  blood-spaces  called  sinuses.  The  uterus  thus  seems  to  form 
part  of  the  vascular  system,  and,  as  a  matter  of  fact,  it  follows  vasomotor  impulses, 
for  instance,  the  action  of  ergot  and  adrenalin  and  of  nervous  shocks. 

The  lymphatics  of  the  uterus  enlarge  and  multiply  during  pregnancy,  so  that 
the  full-term  organ  is  well  honeycombed  by  them.     They  Ijegin  as  large  spaces 


76 


PHYSIOLOGY    OF   PREGNANCY 


under  the  endometrium  and  under  the  serosa,  following  the  course  of  the  muscle- 
bundles  and  blood-vessels;  they  anastomose  freel}^  under  the  serosa,  communicat- 
ing by  stomata  with  the  peritoneal  cavity,  and  empty  into  the  vessels  of  the  broad 
hgament.  The  lymphatics  of  the  corpus  uteri  empty  into  the  lumbar  glands; 
those  of  the  cervix  into  the  pelvic  glands;  those  which  accompany  the  round  liga- 
ment into  the  upper  set  of  deep  inguinal  glands;  those  of  the  lower  vagina  and 
\'ulva  go  to  the  deep  and  superficial  inguinal  glands,  and  through  these  to  the 
glands  around  the  external  iliac  arteries.     The  large  size  and  great  number  of  the 


Solar  ganglion 

Superior  renal  ganglion 
Inferior  renal  ganglion 


Lumbar  ganglia  f, 

■    •  V 


■1   Superior  and  inferior  genital 
Spermatic  plexus 


Right  cer- 
vical gan- 
glion 


Fig.  94. — The  Nerves  of  the  Uterus. 
Combined  from  Frankenhauser  and  Bumm. 


lymphatics  in  and  around  the  uterus  must  be  noted,  also  the  distribution  of  the 
various  streams  of  lymph,  as  this  is  important  in  the  consideration  of  puerperal 
fever. 

The  nervous  supply  of  the  uterus  is  very  rich,  and  comes  from  both  sympa- 
thetic and  cerebrospinal  systems.  Motor  fibers  are  derived  from  the  sympathetic, 
passing  down  from  the  aortic  plexus;  they  are  reinforced  by  fibers  from  the  solar, 
renal,  and  genital  ganglia,  forming  a  large  plexus  above  the  promontory  of  the  sacrum, 
near  the  bifurcation  of  the  aorta,  and  called  the  great  uterine  plexus.  From  here 
the  fibers  pass  on  either  side  of  the  rectum  through  the  hypogastric  plexuses  to  the 


CHANGES    DUE   TO    PREGNANCY 


77 


sidos  of  the  uterus,  but  nuiiuly  In  tlu-  ^i'^'^^^  cervical  Kun<j;liou  and  thus  into  the 
uterus.  { 'erel)rospiiial  fil)(>rs  eoinins  from  thepneumosastric,  phrenic,  and  splanchnic 
nerves  follow   the  same  course.     Their  function  is  unknown.     The  close  nervous 


Uard 


Fig.  95. — Uterus  at  Eight  Weeks. 
Note  enlargement  of  one  half. 


i 


Dc'ciilua  vora 
Internal  os 


External  os 


Fig.  96. — Uterus  at  Five  Weeks. 
From  Professor  laggard's  collection. 


connection  between  the  uterus  and  the  stomach  and  heart  may  explain  the  reflex 
phenomena  intercurrent  between  these  organs.  Sensory  fibers  come  from  the 
spinal  cord  through  the  sacral  nerves,  being  also  distributed  via  the  great  cervical 


78 


PHYSIOLOGY    OF    PREGNANCY 


ganglion.  That  the  sensory  fibers  come  from  the  spinal  cord  in  this  way  is  shown 
bj"  the  clinical  observation  of  painless  labors  in  paraplegic  women,  and  rendering 
the  labor  painless  by  the  injection  of  cocain  into  the  spinal  canal.  The  region 
supplied  by  the  cauda  is  made  anesthetic.  The  great  cervical  ganglion  (Franken- 
hauser)  is  a  triangular  mass  of  ganglion-cells  and  nerve-fibers  lying  at  the  side  of 
the  cervix  and  upper  vagina,  Yi  inch  wide  and  ^  inch  long.  During  pregnancy  it 
grows  to  be  2  inches  long  and  13^2  inches  wide.  Another  ganglion  exists  on  the 
posterior  wall  of  the  cervix. 

The  nerve-centers  are  less  well  known.  One  is  believed  to  exist  in  the  cortex, 
one  in  the  medulla,  in  the  cerebellum,  and  in  the  lumbar  enlargement  of  the  cord, 
because  irritation  at  these  points  causes  uterine  contractions.  There  is  an  indepen- 
dent nerve-center  in  the  uterus,  because  the  organ  acts  even  when  removed  from  the 
body.     Cases  of  paraplegia  are  on  record  where  labor  was  normal  or  even  pre- 


Reflexa  with  pla- 
centa 


Fig.  97. — Utbbus  at  Twelve  Weeks. 
Northwestern  University  Medical  School  Museum. 


cipitate.  The  author  delivered  a  paraplegic  with  forceps  after  the  head  was  visible 
because  of  failure  of  the  abdominal  muscles  to  contract.  This  local  center  is  sup- 
posed to  be  the  great  cervical  ganglion,  but  there  exist  ganglionic  cells  in  the  uterine 
muscle,  and  they  form  occasional  small  plexuses  around  the  blood-vessels  (Bar). 

Changes  in  the  Shape  of  the  Uterus. — Within  two  weeks  after  conception  the 
shape  of  the  uterus  begins  to  change.  This  is  first  appreciable  in  the  antero- 
posterior diameter  of  th(;  corpus.  The  ovum  softens  and  distends  that  part  of  the 
uterus  in  which  it  is  situated.  As  this  is  usually  the  anterior  wall,  we  find  a  bulging 
here  on  one  or  the  other  side  of  the  median  line,  making  the  affected  side  larger, 
thicker,  and  softer,  while  the  other  is  smaller,  thinner,  and  harder,  there  being  a 
groove  between.  These  findings  are  useful  in  the  diagnosis  of  pregnancy.  The 
cervix  softens,  especially  the  supravaginal  portion,  its  acquired  compressibility 
giving  Hegar's  sign  of  pregnancy.     The  junction  of  the  tubes  with  the  uterus  also 


CHANGES  DUE  TO  PREGNANCY 


79 


softens.  I'hcsc  coiidit ions  arc  lir()U<i;lit  al)()ut  cspcr-ially  hy  imhiljition  of  the  uterine 
wall  and  the  moval)ilil,\  of  lli(>  outer  lamella  of  the  uterine  muscle  on  the  middle 
coat.  After  the  second  month  one  finds  the  uterus  enlarged  laterallj%  and  in  the 
third  month  the  fundus  has  assumed  nearly  a  spheric  form.  The  consistence  of  the 
uterus  at  this  time  is  spongy,  elastic,  and  soft,  like  l)read  dough,  and  one  often 
notices  the  organ  harden  under  the  examining  hand — tliat  is,  it  contracts. 

The  cervix  softens  and  enlarges  up  to  the  fourth  month,  when  it  resembles  a 
large  nipple  hanging  from  the  globular  corpus.  Normally,  the  mucous  membrane 
of  the  cervix  is  not  altered  into  decidua,  and  it  produces  a  thick,  tenacious  mucus, 
which  fills  the  canal,  closing  the  uterine  cavity  from  the  vagina.  This  mucous 
plug  is  constantly  renewed  from  above  and  prevents  ascending  infection.  After 
the  fifth  month  the  uterus  enlarges  in  the  direction  of  the  fundus,  the  spheric  form 


Fig. 


OS. — Uterus  About  Six  Months. 
Author's  collection. 


becoming  ovoid  or  elliptic.  The  location  of  the  tu]:)al  insertion  and  of  the  round 
ligaments  shows  this  change,  at  the  fifth  month  lieing  near  the  vault  of  the  uterus, 
at  the  ninth  month  being  4  to  G  inches  lower.  During  the  last  weeks  of  pregnancy 
the  lower  part  of  the  uterus  is  developed  to  acconnnodate  one  pole  of  the  infant, 
the  so-called  lower  uterine  segment  being  formed.  This  completes  the  ovoid  or 
--  elliptic  formation  of  the  uterus  (Figs.  98,  99,  100,  101,  102). 

The  virgin  uterus  is  shaped  like  a  flattened  pear,  and  has  a  capacity  of  2  c.c. 
or  less;  the  full-term  uterus  resembles  an  immense  gourd,  and  has  a  capacity  of 
4000  to  5000  c.c. 

The  configuration  of  the  uterus  is  affected  liy  the  organs  in  the  belly,  the  posi- 
tion and  attitude  of  the  fetus,  the  amount  of  liquor  amnii,  the  location  of  the  pla- 
centa, the  attitude  of  the  mother,  uterine  neoplasms,  adhesions,  etc.     The  spinal 


80 


PHYSIOLOGY    OF   PREGNANCY 


column  presses  into  the  uterus  from  behind;  the  intestines  leave  facets  on  its  walls. 
Since  the  anterior  wall  is  supported  solely  by  the  abdominal  muscles,  it  bulges 
forward  convexly.  The  fetus  lacks  out  the  non-resistant  muscle,  as  may  be  observed 
during  any  abdominal  examination.  In  shoulder  presentation  the  uterine  ovoid 
is  transverse.  A  large  quantity  of  liquor  amnii  makes  the  uterus  spheric  and  tense. 
The  placenta  develops  that  part  of  the  uterus  to  which  it  is  attached,  and,  from  the 
location  and  course  of  the  round  ligaments,  we  make  deductions  as  to  the  seat  of 
the  placenta  (Palm).  If  the  round  ligaments  run  on  the  anterior  surface  of  the 
uterus,  the  placenta  is  located  on  the  posterior  wall;  if  they  are  far  to  the  side, 
the  placenta  is  located  anteriorly  (Figs.  102  and  103). 

"We  find,  at  term,  uteri  of  various  shapes — ovoid  and  elliptic,  cordate  and 
asymmetric  (Figs.  104,  105,  106,  107,  108).  Occasionally  the  fundus  presents  a 
shallow  gToove  (Fig.  106),  the  uterus  having  an  indication  of  horns — uterus  arcuatus. 


Fig.  99. — Uterus  near  Term. 
From  Professor  Jaggard's  collection.     Note  primary  brow  presentation. 


Sometimes  one  horn  is  developed  more  than  the  other  (Fig.  107).  The  uterus  at 
term,  in  80  per  cent,  of  cases,  is  deviated  to  the  right  side  of  the  abdomen,  and  it 
is  also  twisted  on  itself  from  left  to  right.  This  dextroversion  and  torsion,  which 
are  also  found  in  the  virgin  state,  are  due  to  the  mode  of  formation  of  the  uterus 
from  the  Miillerian  ducts — in  the  fetus  the  left  duct  lies  anterior  to  the  right; 
second,  the  location  of  the  mesenteric  attachment  of  the  sigmoid  on  the  left  side 
of  the  spinal  column;  third,  congenital  asymmetry  of  growth,  which  is  noticeable 
even  in  vegetable  life — for  instance,  trees  and  shrubs;  fourth,  the  full  rectum; 
fifth,  the  general  habit  of  lying  on  the  right  side — the  uterus  falling  over  from  the 
left.  This  dextroversion  of  the  uterus  is  of  considerable  clinical  importance.  In 
abdominal  examinations  the  left  tube  and  ovary  may  be  felt  nearer  the  middle  line, 
and  the  round  ligament  also  is  more  prominent  on  the  left  side.  During  the 
operation  of  cesarean  section  it  is  necessary  to  bring  the  uterus  to  the  middle  line 
before  making  the  incision  for  the  delivery  of  the  child. 


CHANGES    DUE   TO    PREGNANCY 


81 


For  the  first  three  months  of  pregnancy  the  uterus  is  entirely  a  pelvic  organ.    As 

itcnlargesit  becoinos  aiitevertcd  and  aiitcflexcfj  and  licsonthnhladdcr.     Thefundus 


Fig.  100. — Uterus  at  Successive  Mo.n'ths. 


Fig.  101. — Same  From  Side. 


Fig.  102. — Course  of  Round  Ligaments  when  Pl.\- 
CENT.\  Lies  on  Posterior  Wall. 

The  sign  is  usually  but  not  invariably  reliable 


Fig.   103. — S.vme  on  Anterior  Wall. 


is  readily  felt  through  the  anterior  fornix.     The  cervix  is  directed  forward  (Fig.  110). 
As  the  pregnancy  develops  the  uterus  rises  up  in  the  alxlomen,  coming  to  lie  against 
its  anterior  wall.     In  primiparae  the  uterus  is  molded  against  the  spinal  column  more 
6 


82 


PHYSIOLOGY    OF   PREGNANCY 


than  in  miiltiparee,  because  in  the  latter  the  abdominal  muscles  are  usually  not  so 
strong  and  rigid.  The  intestines  are  forced  upward  and  usually  to  the  left.  No 
intestine  normally  is  found  between  the  uterus  and  the  abdominal  wall.  A  hernia 
is  sometimes  emptied  of  gut  during  pregnancy.     The  colon  retains  its  position. 


Fig.  104. — Ovoid  Uteeus. 


Fig.  105. — Elliptic  Utekus. 


The  fundus  uteri  at  term  is  about  the  level  of  the  second  lumbar  vertebra.  It 
exerts  no  direct  pressure  on  the  Iddneys,  liver,  or  stomach,  and  is,  therefore,  not 
answerable  for  certain  troubles  of  these  organs  ascribed  to  it,  as  nephritis,  icterus, 
intercostal  neuralgia,  hyperemesis.  In  the  latter  three  months  the  lower  pole  of 
the  uterus  lies  on  the  ureters  as  they  cross  the  brim  of  the  pelvis.     Undoubtedly, 


Fig.  IOC. — Uterus  Abcuatus. 


Fig.  107. — Asymmetric  Development. 


the  ureters  are  sometimes  occluded  by  the  growing  uterus,  but  it  is  not  by  its 
weight,  because  the  specific  gravity  of  the  organ  is  the  same  as  that  of  the  intestinal 
ma.ss.  Probably  the  ureters  are  bent  or  twisted  during  the  changing  of  the  rela- 
tions of  the  pelvic  viscera. 

The  bladder  during  early  pregnancy  is  a  pelvic  organ.     In  the  last  month, 


CHANGES    DUE   TO    PREGNANCY 


83 


pari  passu  with  tho  (lovelopnu'iit  of  the  lower  uterine  segment,  the  bladder  is  drawn 
up  from  l)ehin(l  tlie  pubis  into  tlw  ubdonieii,  <i;enerally  to  the  right.  During  labor 
the  uterus  draws  away  from  the  l)la(lder,  but  the  latter,  when  filled,  may  reach 
above  the  navel.  The  urethra  is  stretched  only  when  the  bladder  is  overfillerl,  or 
during  lal)or  when  it  is  out  of  tiie  true  pelvis.  Often  the  bladder  is  saddle  shajjcd, 
extending  on  each  side  of  the  ])elvis.  It  may  als(j  be  asymmetric,  with  the  larger 
part  on  the  right. 

The  axis  of  the  utei'us  \aries  in  its  i-elation  to  that  of  the  axis  of  the  pelvic 
ink^t.  In  primi])ara',  standing,  the  two  axes  sometimes  c(jrrespond  (Fig.  111).  In 
nuiltipara>  tiie  lax  alxlominal  wall  allows  the  uterus  to  fall  forward.  If  the  recti 
abdominis  are  widely  separate(l,  the  fundus  falls  between  them,  resulting  in  "pen- 
dulous abdomen,"  or  "rupture,"  as  the  women  term  it  (Fig.  113).     When  the  woman 


Fig.  lOS.- 


-Uterus  with  Transveese  Presentation 
OF  Fetus. 


Fig.   109. — Ovoid  Uterus  from  Side. 
Shows  flexion  over  spinal  column. 


lies  in  the  horizontal  position,  the  uterine  axis  sinks  behind  that  of  the  inlet  (Fig. 
112). 

Up  to  the  seventh  month  the  growth  of  the  uterus  is  fairly  uniform,  and  we 
may  draw  qualified  conclusions  as  to  the  duration  of  pregnancy  from  the  height 
of  the  fundus  above  the  pubis.  If  the  fundus  reaches  one-third  the  way  to  the 
navel,  the  pregnancy  is  of  four  months;  if  two-thirds,  five  months;  at  the  navel, 
six  months;  one-third  the  distance  to  the  ensiform,  seven  months;  two-thirds, 
eight  months;  at  the  ensiform,  nine  months.  Now  the  uterus  sinks  do^^^l  and 
forward,  the  process  being  called  "lightening,"  and  reaches  the  level  it  had  at  the 
eighth  month.  Naturally,  the  accuracy  of  these  decisions  is  not  great,  being  dis- 
turbed by  the  inconstancy  of  the  location  of  the  navel,  the  elasticity  of  the  l^elly-wall, 
and  so  many  intra-abdominal  conditions,  the  amount  of  liquor  amnii,  the  size  of 
the  child,  its  position,  etc.  Toward  the  end  of  the  last  trimester  the  shape  of  the 
uterus  alters.  It  becomes  longer,  which  is  due  to  the  head  passing  into  the  newly 
formed  lower  uterine  segment,  a  change  less  observable  in  pluripara-  until  actual 
labor  begins.     The  formation  of  the  lower  uterine  segment  is  caused  bv  several 


84  PHYSIOLOGY    OF   PREGNANCY 

factors,  and  maj'  be  part  of  the  process  of  lightening — the  weight  of  the  child,  the 
intermittent  uterine  contractions,  the  action  of  the  round  ligaments,  the  tightness 
of  the  abdominal  wall,  and  this  is  the  reason  that  lightening  is  more  likely  to  be 
found  in  primipartB. 

The  uterus,  owing  to  absorption  of  some  of  the  liquor  amnii,  conforms  a  little 
more  to  the  shape  of  the  child  and  flattens  at  the  fundus. 


Fig.  110. — UxERca  at  End  of  Third  Month. 
Shows  long  cervix,  sharp  anteflexion,  and  how  the  fundus  sags  heavily  on  bladder. 

Lightening. — Two  to  three  weeks  Ijcfore  labor  the  uterus  sinks  downward 
and  forward.  The  women  call  this  "settling"  or  "dropping";  the  technical  term 
is  "lightening."  It  is  due  to  the  gradual  sinking  of  the  child's  head  into  the  true 
pelvis,  and  occurs  only  in  primipara?  with  normal  pelves,  or  multiparas  with  normal 
pelves  and  well-preserved  abdominal  muscles.  Lightening  may  be  simulated  by 
the  sudden  weakening  of  the  abdominal  wall,  Avhich  sometimes  occurs  late  in  preg- 


CHANGES  DUE  TO  PREGNANCY 


85 


nancy,  unci  by  the  aljscjrpliun  of  the  hquor  annui.  Jiuth  of  these  conditions  produce 
the  changes  in  the  contour  of  the  belly,  relieve  the  distress  in  breathing,  and  show 
other  syiuptoins  attendaiit  on  true  li<i;hteiunfj;.     The  (iiffercntial  diagnosis  is  easily 


\ 


i  J 

Fig.  111. — Shows  Relation  of  Utekine  Axis  to  Axis  of  Inlet  in  the  Erect  Posture  (Primipara). 

made  ])y  fintling  that  the  head  has  not  engaged  and  that  the  changes  in  the  cervix 
about  to  be  described  have  not  taken  place.  When  the  uterus  sinks,  the  intestines 
and  stomach  have  more  room,  the  epigastrium  is  free,  the  diaphragm  regains  more 


Fig.  112. — Same  Primipara,  Lting  Flat. 
Shows  crossing  of  axes. 


nearly  its  usual  level,  the  waist-line  sinks  so  that  the  woman  can  fit  her  skirts  better. 
On  the  other  hand,  the  head  presses  upon  the  bladder  and  rectum,  producing  symp- 
toms from  these  organs;  walking  is  rendered  more  difficult,  and  many  pains  of  a 
neuralgic  nature  and  much  distress  referred  to  the  pelvis  are  complained  of. 


86 


PHYSIOLOGY   OF   PREGNANCY 


On  internal  examination  one  finds  the  vault  of  the  pelvis  filled  by  the  head,  and 

the  cervix,  which  before  was  a  prominent  protu- 
berance on  the  lower  uterine  segment  (Fig.  116), 
now  has  been  flattened  out  against  the  head 
so  that  it  can  hardly  be  recognized  as  apart 
from  the  vagina.  Often  too  the  vagina  is  folded 
on  itself  like  a  loose  cuff,  and  this  might  be  mis- 
taken for  the  dilated  os  or  a  stricture  (Fig.  118). 
Sometimes  lightening  occurs  suddenly,  at- 
tended by  more  or  less  regular  labor-pains. 
The  patient  summons  the  physician,  but  labor 
does  not  occur,  and  sometimes  does  not  come  on 
for  two  weeks.  These  cases  are  not  to  be  con- 
founded with  protracted  gestation  and  post- 
poned labor  {q.  v.).  Lightening  may  occur  as 
early  as  the  seventh  month,  and  the  head  may 
recede  and  enter  again,  or  later  be  prevented 
from  engaging  by  having  overgrown  the  size 
of  the  inlet  in  the  mean  time.  As  a  rule,  how- 
ever, the  phenomenon  indicates  that  that  head 
is  not  too  large  to  go  through  that  particular 
pelvis,  and,  therefore,  is  alw^ays  a  welcome  sign. 
If  the  head  remains  very  low  in  the  pelvis  for 
several  weeks,  it  may  be  molded  to  the  pelvic 
floor,  and  be  flattened  on  the  posterior  parietal 
bone,  a  deformity  more  or  less  permanent. 

The  Cervix  and  Lower  Uterine  Segment. — 

The  unimpregnated  uterus  has  two  parts — the 

corpus,  or  body,  and  the  cervix.     Some  authors 

distinguish  a  third  portion — an  "isthmus,"  at  the  junction  of  the  two,  and  many 

points  are  in  favor  of  the  view  that  such  a  zone  exists.     The  cervix  is  about  as  long  as 


Fig.  113. 


-MuLTiPABA  Standing. 
Abdomen. 


Pendulous 


Fig.  114. — Silhouktte  of  a  Primipaka  befobe 
Lightening. 


Fig.  115. — S.\.me  after  Lightening. 


CHANGES  DUE  TO  PREGNANCY 


87 


the  body, and  the  insertion  of  thcwi^^ina  makes  three  nioroor  loss  sliarp divisions  (Fig. 
119).  The  anterior  wall  of  the  vagina  is  inserted  1  tol3^  cm.  from  the  external  os;  the 
posterior  wall  about  3  cm.  above  the  external  os;  and  the  cervix  extends  about  1  cm. 
above  th(!  latter  i)()int.  That  portion  of  the  cervix  lying  entirely  in  the  vagina  is  called 
the  vaginal  portion — sometimes  siinjily  "portio";  that  which  lies  behind  in  the  vagina 
and  in  front  against  the  bladder,  the  median  portion  ;  and  that  which  lies  above  the 
vaginal  insertion,  the  supravaginal  portion.  If  one  examines  the  cervix  of  a  preg- 
nant woman  at  successive  weeks,  marked  changes  in  consistence,  form,  and  position 
will  be  noticed.     Within  a  few  weeks  after  conception  the  tip  of  the  cervix  begins 


External  os 


Fia.  116. — Head  and  Cervix  Before  Engagement. 


to  soften,  and  this  increases  upward  toward  the  corpus  and  from  without  inward. 
The  softening  is  caused  Ijy  imbilMtion  of  the  tissues  and  increased  vascularity,  both 
hemic  and  lymphatic.  The  anteflexion  of  the  uterus  being  increased,  the  cer\'ix 
points  forward,  and  the  uterus,  as  a  whole,  sinks  lower  in  the  pelvis.  This  is 
especially  noticeable  if  the  woman  wears  tight  corsets.  The  cervical  canal  in  the 
first  three  months  runs  from  below  and  forward,  behind  and  upward  (Fig.  110). 
When  the  uterus  rises  up  into  the  abdomen,  the  cervical  canal  takes  a  more  vertical 
direction,  the  angle  of  the  point  of  anteflexion  becoming  obtuse.  The  softening 
now  pervades  the  whole  cervix  and  paracervical  tissues.  The  canal  is  closed  by 
a  tough  mucous  plug,  which  hinders  the  ascent  of  infection.     In  multiparse  as 


88 


PHYSIOLOGY    OF   PREGNANCY 


early  as  the  fifth  month  the  external  os  is  often  patulous,  and  will  admit  the  finger 
one-half  inch.  This  is  especiallj^  true  if  the  cervix  has  been  lacerated  and  not 
repaired. 

In  the  seventh  month  the  succulence  which  affected  the  cervix  has  pervaded 
the  whole  pelvis,  and  the  outlines  of  the  former  are  hard  to  distinguish.  The  cervix 
has  taken  a  position  higher  and  further  back  in  the  pelvic  cavity.  The  external  os 
always  admits  the  finger  in  multiparse,  and  occasionally  in  primiparse.  The  cer- 
vical canal  is  directed  backward,  but  exceptions  are  not  uncommon.     The  author 


Bladder 


ric 


117. — Effect  on  Cervix  of  Engagement  of  Head. 
Sometimes  the  canal  is  directed  backward. 


has  found  it  sometimes  points  forward  and  upward.  The  internal  os  is  usually 
closed  both  in  primiparse  and  in  multiparse,  though  it  occasionally  admits  the  tip 
of  the  finger  in  the  latter.  The  cervix  begins  now  to  flatten  out  against  the  fetal 
head,  seemingly  to  be  taken  up  and  used  as  part  of  the  uterine  cavity.  This  is  the 
impression  one  receives  from  the  examining  finger,  but  frozen  sections  prove 
that  it  is  not  always  the  case. 

In  the  ninth  month  the  softening  and  succulence  of  the  cervix  and  neighboring 
tissues  are  greatest,  since  the  venous  congestion  is  at  its  height  and  the  uterine  con- 
tractions of  pregnancy  force  a  great  deal  of  serum  into  the  tissues.     Sometimes 


CHANGES    DUE   TO    PREGNANCY 


89 


ovon  the  (■(lucal('(l  linger  cxixTicnccs  difricully  in  outlining  tlic  stnifturfs.     The 
iiiiliil)itiitii  III'  I  lie  cpil  lii'liiiiii  often  leads  to  erosions,  and  catarrhal  affect icjii.s  of  the 


Fig.  lis. — Foi.DixG  of  the  Vagina  (b)  Dcring  the  Pkocess  of  Lightening,  SmrLATiNG  the  External  Os  (a). 


Fig.  1 19. — The  Three  Clinical  Divisions  of  the  Cervix. 
Supravaginal  portion;    6,  median  portion;    c,  vaginal  portion.     The  "isthmus"  would  be  right  above  the  line  at  a. 

cervix  are  much  aggravated.     Hence  the  gravidse  frequently  have  leukorrhea. 
If  the  patient  previously  had  cervicitis  with  erosions,  the  condition  may  become 


90 


PHYSIOLOGY    OF    PREGNANCY 


SO  marked  as  to  require  treatment,  because  of  hemorrhage,  profuse  and  irritating 
discharge,  etc.     The  changes  in  the  chrection  of  the  cervical  canal  have  been 


Fig.  120. — Cervix  as  Most  Commonly  Located. 


described  under  the  heading  of  Lightening  (p.  84).  The  external  os,  even  in 
primipara?,  now  usually  admits  the  index-finger,  and  in  most  of  the  cases  the  internal 
OS  vsdll  also  allow  the  finger  to  pass.     This  is  especially  true  of  multiparas  in  whom  two 


Fig.   12L — Cervix  in  Hollow  of  Sacrum. 


or  even  three  fingers  may  be  inscirtcd.  The  shape  and  size  of  the  external  os  are 
much  affected  by  previous  laceration  or  scar  formation.  One  will  find  many 
individual  differences.     The  author  has  found  the  cervical  canal  in  an  old  primipara 


CHANGES  DUE  TO  PREGNANCY 


91 


enlarged  iit  the  1  hirtv-third  week  so  that  the  external  os  admitted  the  middle 
finger  and  the  internal  os  was  the  size  of  a  nickel.  While  the  extreme  softening  and 
the  enlargement  of  the  cervical  canal  indicate  that  labor  is  near,  still,  in  view  of 
what  has  l)een  said,  absolute  reliance  may  not  be  placed  on  these  signs.  In  the 
last  week  or  ten  days  the  uterine  contractions  (jften  bring  about  a  true  effacement 
of  the  cervix,  and  use  it  to  form  the  lower  portion  of  the  uterine  cavity,  thus  antici- 
pating part  of  the  first  stage  of  labor.  This  is  called  "insensible  labor"  by  the 
French,  and  is  a  welcome  finding  to  the  olistetrician,  as  it  facilitates  all  operative 
manceuvers  shoukl  hasty  delivery  be  necessary.  A  cervix  that  remains  long  and 
tightly  closed  up  until  labor  begins  is  not  normal. 

The  location  of  the  cervix  at  full  term  varies.  Rarely  one  finds  it  anteriorly 
or  at  one  side;  most  often  it  is  in  the  middle  of  the  pelvis  (Fig.  120),  and  many 
times  it  is  l)ack  in  the  hollow  of  the  sacrum  (Fig.  121).  If  it  is  high  up  near  the 
sacrum  and  hard  to  reach  with  the  finger,  the  condition  is  pathologic.     In  cases  of 


Fig.  122. — Cervix  near  Pubis 


antefixed  uteri,  the  cervix  may  be  located  above  the  promontory  in  the  alxlominal 
cavity. 

The  relation  of  the  cervix  to  the  lower  uterine  segment  has  been  the  subject 
of  conflicting  theories  since  1746.  Mauriceau  and  Levret  taught  that  from  the 
sixth  month  the  upper  portion  of  the  cervix  was  unfolded  or  effaced,  drawn  up,  and 
used  to  form  part  of  the  uterine  cavity,  until  at  term  only  a  small  part  of  the  cervix 
was  left.  Stoltz,  in  1826,  denied  this,  claiming  that  the  cervix  remained  closed 
until  near  the  advent  of  labor.  Both  opinions  were  based  on  the  results  of  vaginal 
exploration.  Bandl,  in  1876,  as  the  result  of  examination  of  many  uteri,  reaffirmed 
the  old  theory,  while  Schroder,  Ruge,  Leopold,  and  very  many  others  have  sought 
to  prove  that  the  cervix  does  not,  during  pregnancy,  form  part  of  the  uterine  cavity. 
Bayer  has  done  the  most  work  on  the  subject,  and  his  conclusions  are  slowly  gaining 
more  and  more  acceptance.  They  are  supported  by  the  latest  and  best  frozen 
section  by  Bumm  and  Blumreich.  If  one  examines  a  gravida  in  the  last  month  of 
pregnancy,  one  will  often  find  conditions  as  indicated  in  Fig.   123.     The  finger 


92 


PHYSIOLOGY    OF    PREGNANCY 


passes  along  the  cervical  canal,  meets  a  ring  at  Os  I,  generally  termed  the  internal 
OS,  and,  if  this  point  does  not  offer  resistance,  enters  the  cavity  of  the  uterus,  finds 
the  membrane  but  lightly  adherent  to  the  lower  pole  of  the  same,  and  about  an 
inch  from  the  internal  os,  at  the  level  of  the  pelvic  inlet,  encounters  a  slight  ridge, 
C.R.,  above  which  the  hard,  muscular  uterus  is  felt.  The  portion  from  Os  I  to 
C.R.  has  been  called  the  lower  uterine  segment,  and  its  origin  has  been  much  dis- 
cussed— its  existence  even  been  questioned.  The  old  theory,  supported  by  Mauri- 
ceau,  Bandl,  Bayer,  et  al.,  was  that  the  lower  uterine  segment  was  the  expanded 
upper  portion  of  the  cervix.  The  newer  theory,  supported  by  Stoltz,  Schroder, 
Hofmeier,  et  al.,  w^as  that  the  lower  uterine  segment  came  from  the  uterus  itself, 
its  lower  portion  being  thus  differentiated.  Both  theories  have  this  in  common, 
that  there  is  such  a  zone  as  the  lower  uterine  segment,  and  that  it  is  different  in 
structure  and  formation  from  the  fundus  uteri.  Braune  and  Bumm  claim  that  it  is 
formed  during  labor,  the  cervix  and  uterus  remaining  unchanged  until  pains  begin. 


Oil 


Fig.  123. — The  Cervix  and  Lower  Uterine  Segment  at  the  End  op  Pregnancy. 
Os  E,  Os  externum;    Os  I,  os  internum;    C.R.,  contraction  ring. 


As  Bandl  remarks,  it  is  hardly  to  be  thought  that  so  mighty  an  alteration  could  be 
wrought  in  the  small  cervix  in  the  few  hours  of  labor.  Aschoff  describes  a  portion 
of  the  uterus — an  isthmus — between  the  corpus  and  cervix,  partaking  of  the  char- 
acter of  both,  and  claims  that  this  forms  the  lower  uterine  segment.  The  literature 
on  this  subject  is  immense,  and  on  reading  it  one  is  struck  with  the  lack  of  uni- 
formity in  nomenclature,  in  the  lack  of  anatomic  basis  for  the  various  divisions  of 
the  cervix  and  corpus  uteri  graviditatis,  and  with  the  superficiality  of  many  of  the 
examinations  of  the  specimens. 

The  OS  internum  of  the  non-pregnant  uterus  is  easily  determined;  not  so  that 
of  the  pregnant  organ.  Not  the  sharp  edge  of  the  mucous  membrane  of  the  cervix 
at  the  so-called  internal  os ;  not  the  firm  attachment  of  the  peritoneum  to  the  uter- 
ine muscle;  not  ithe  location  of  the  circular  vein;  not  the  formation  of  decidua; 
not  the  mucin  reaction  of  the  cervical  glands — distinguishes  cervix  from  corpus,  or 
lower  uterine  segment  from  cervix,  .The  most  certain  difference  is  the  distrilDution 


CHANGES    DUE   TO    PREGNANCY 


93 


of  the  musclo-fibcrH,  and  Buyer  luis  shown  (hut  these  aher  Iheir  position  in  fiuito 
characteristic  fashion  in  the  hitter  weeks  of  pre<i;iiaiicy. 

It  is  probal)le,  in  some  eases,  multiparte  notably,  thai  the  muc(;us  nicinlM'ane 
and  a  few  hiyers  of  iiius(  h — mostly  circular — of  tlu;  cervix  remain  michanged  until 
very  near  the  atlvent  of  labor  ])ains.  T\\\s  gives  the  sensation  of  a  long  canal  and 
of  a  closed  internal  os,  a  condition  well  known  to  Bandl.  It  is  just  as  probable  that 
the  Older  layers  of  cervical  muscle  are  drawn  up  and  expanded  during  the  latter 
months  of  pregnancy,  to  form  part  of  the  uterine  cavity — the  so-called  lower 
uterine  segment.     The  upper  boundary  of  this  zone  is  the  "contraction  ring,"  or 


Fig.  124. — Closed  Cervix  in  a  Primipara  After  Pains  had  Begun.     Condition  Pathologic  (Bayer). 


the  lower  edge  of  the  contracting  muscle  of  the  corpus;  the  lower  boundary  is  the 
so-called  internal  os  of  the  cervix,  the  edge  of  the  cervical  mucous  membrane.  This 
zone  is  sometimes  covered  with  decidua,  but  the  membranes  are  loosely  attached  to 
it,  showing  its  late  formation.  It  has  little,  if  any,  contractile  power.  The  mov- 
ability  of  the  muscular  layers  on  each  other  permits  the  employment  of  cervical 
fibers  for  the  formation  of  the  lower  uterine  segment.  It  is  probable,  too,  that 
sometimes,  oftener  in  primipara3,  the  cervical  mucous  membrane  is  also  drawn  up 
into  the  lower  uterine  segment.  In  this  case  one  j&nds  portions  of  the  plica  palmatse 
spread  out  in  the  lower  uterine  segment,  and  one  may  even  find  the  mucous  mem- 


94  PHYSIOLOGY    OF   PREGNANCY 

brane  changed  into  decidua.  It  is  certain  that  sometimes  the  cervix  remains  un- 
changed, except  to  soften  and  hypertrophy,  and  tightly  closed  until  the  advent  of 
hard  labor.  These  cases  are,  according  to  Bayer,  pathologic,  and  the  author  agrees 
with  him  (Fig.  123). 

That  the  changes  in  the  cervix  during  pregnancy  are  not  constant  and  typical 
will  not  surprise  him  who  remembers  the  variously  sized  and  shaped  cervices  he 
meets  in  the  routine  of  gynecologic  examinations,  and  one  must  agree  with  Bayer 
that  sometimes  the  cervix  unfolds  in  pregnancy  and  sometimes  it  does  not. 

During  labor  the  differentiation  in  the  uterus  becomes  marked  and  unquestion- 
able. The  corpus  contracts  strongly,  the  lower  uterine  segment  feebly,  the  cervix 
not  at  all ;  thus  two  zones  are  formed — an  upper,  contracting,  and  a  lower,  dilating. 
In  the  consideration  of  the  mechanism  of  labor  this  subject  will  again  come  up. 

Changes  in  the  Physiology  of  the  Uterus. — During  pregnancy  the  uterus  ac- 
quires no  new  functions;  those  it  has,  however,  are  much  developed.  Menstrua- 
tion normally  ceases  during  pregnancy. 

The  sensibility  varies  in  different  women.  Unless  diseased,  the  organ  is  not 
tender.  In  neurotic  patients  the  lightest  palpation,  even  the  fetal  movements, 
evoke  pain.     In  labor  the  uterus  is  more  sensitive. 

Irritability  is  that  property  which  makes  the  uterus  respond  to  external  stimu- 
lation by  contracting.  Pregnancy  develops  this  quality,  but  it  also  varies  in  differ- 
ent women.  In  some  the  ordinary  abdominal  examination  evokes  contractions; 
in  others  most  powerful  external  and  internal  stimuli  produce  little,  if  any,  effect. 
This  is  best  observed  when  we  try  to  bring  on  labor. 

The  dilatability  of  the  uterus  increases  very  much  during  pregnancy,  and  even 
when  the  uterus  seems  well  filled  by  the  ovum  it  can  still  stretch  to  hold  a  con- 
siderable amount  of  extra  fluid.  This  is  shown  by  the  enormous  acute  distention  in 
polyhydramnion  and  in  the  accumulation  of  large  quantities  of  blood  in  cases  of 
abruptio  placentae. 

Contractility  increases  as  pregnancy  advances.  Acting  on  impulses  coming 
through  the  nervous  system,  the  uterus  contracts  and  relaxes.  We  note  this  power 
in  the  unimpregnated  uterus  when  it  expels  clots,  membranes,  or  fibroids.  As  early 
as  the  fifth  week  of  gestation  the  contractions  of  the  uterus  are  perceptible  to  the 
examining  finger.  These  are  painless,  last  twenty  to  thirty  seconds,  sometimes  a 
few  minutes,  and  may  be  observed  to  recur  at  irregular  intervals  up  to  the  advent  of 
labor,  when  they  become  regular,  painful,  and  more  powerful.  The  contractions 
are  involuntary,  but  are  sometimes  affected  by  the  nervous  condition  of  the  woman. 
They  may  continue  postmortem  for  a  brief  period. 

Retractility  is  a  function  of  the  uterine  muscle  not  fully  understood.  It  is 
that  power  which  enal^les  the  uterine  wall  to  close  down  on  its  diminishing  cavity. 
This  is  brought  about  by  a  microscopic  felting  together  of  the  muscle-fibers  and  a 
superimposition  of  the  muscular  lamellae.  This  power  is  manifested  only  in  parturi- 
tion. A  retracted  uterus  cannot  be  completely  expanded  without  danger  to  its 
structure.  The  property  of  retractility  lies  either  in  the  muscle  itself,  or  it  is  evoked 
through  the  nervous  mechanism — probably  the  latter,  since  it  seems  to  be  affected 
by  the  same  influences  as  contractility. 

Elasticity  is  the  ability  of  the  uterine  wall  to  return  to  a  condition  of  rest  after 
being  distended.     It  must  be  sharply  differentiated  from  retractility. 

The  round  ligaments  are  part  of  the  uterine  muscle,  and  hypertrophy  with  it. 
Late  in  pregnancy  they  may  l)e  as  thick  as  the  little  finger,  and,  owing  to  the  high 
location  of  the  fundus,  they  run  vertically.  When  the  placenta  is  situated  on  the 
posterior  wall,  the  round  ligaments  are  felt  converging  toward  the  fundus  on  the 
anterior  wall  of  the  uterus,  and  when  the  anterior  wall  is  occupied  ])y  the  placenta, 
the  ligaments  are  pushed  to  the  sides.  The  round  ligaments  contract  synchro- 
nously with  the  uterus,  and  serve  to  moor  the  latter  organ  to  the  pelvis  during  labor. 


CHANGES  DUE  TO  PREGNANCY 


95 


la  pregnancy  no  such  action  is  ohscrvahlc  cxcopt  in  pathologic  cases — as  retrover- 
sion. 

The  uterosacral  ligaments  normally  vary  much  in  their  development  and  in 
the  place  of  insertion  on  the  uterus.  They  too  are  part  of  the  uterine  musculature 
and  hypertrophy  in  pregnancy.  The  part  played  by  these  ligaments  as  suspensors 
of  the  uterus  has  l)een  much  exaggerated.  Normally,  they  are  relaxed  and  are  put 
on  the  stretch  only  when  the  uterus  is  drawn  or  forced  down  or  up.  If  the  disi)lace- 
ment  is  kept  up,  they  stretch  and  tear.  During  labor,  however,  they  contract  with 
the  uterus,  assisting  to  hold  it  in  the  proper  axis  of  the  pelvis,  and  they  aid  in  the 
dilatation  of  the  lower  uterine  segment  and  cervix. 

The  broad  ligaments  arr  also  strengthened  by  the  addition  of  nniscular  fibers, 
particularly  around  the  arteries  and  veins.     The  two  peritoneal  layers  are  separated 


/      1/ 


•I 


i     ' 


)= 


Fig.  12.5. — Showing  Wrinkling  of  UTERris  at  Placental  Site. 
Specimen  kindly  loaned  by  Professor  Piscatek,  of  Vienna. 


by  the  development  of  the  uterus,  so  that  a  much  larger  portion  of  this  organ  is  un- 
covered at  the  sides. 

The  pelvic  connective  tissue  loses  its  fat;  the  unstriped  muscle-fibers  develop 
more  abundantly  in  it;  the  lymph-spaces  are  larger;  there  is  a  serous  imbibition  of 
all  the  tissues,  and  the  whole  pelvis  is  congested  and  more  succulent.  Immense 
veins  develop  in  and  around  the  vagina  and  cervix,  sometimes  to  a  pathologic  ex- 
tent. The  sides  of  the  uterus  may  bulge  with  soft  venous  swellings.  During  lal^or 
these  may  burst,  forming  hematomata,  and  after  labor  they  may  thrombose  and 
give  rise  to  emboli. 

The  peritoneum  grows  with  the  uterus,  a  true  hyperplasia  occurring.  In 
pathologic  cases  the  peritoneum  may  not  grow,  and  tears  result.  After  delivery 
the  peritoneum  lies  wrinjcled  in  more  or  less  typical  directions  on  the  contracted 


96  PHYSIOLOGY    OF    PREGNANCY 

uterus,  corresponding  to  the  course  of  the  muscle-fibers  (Fig.  125).  Walker,  in 
1887.  and  Schmorl  call  attention  to  decidua-like  growths  on  the  peritoneum  of 
Douglas'  culdesac,  the  posterior  wall  of  the  uterus,  the  tubes,  ovaries,  and  omentum. 
The  author  has  found  them  on  the  anterior  abdominal  wall  in  cases  of  cesarean 
section.  They  may  be  2  to  3  mm.  thick,  are  just  under  the  endothelium,  raising  it 
up,  resembling  miliary  tubercles,  and  may  be  pedunculated.  They  are  derived 
from  the  connective  tissue,  and  may  be  cystic  or  even  calcareous.  One  finds  these 
structures  from  the  third  to  the  tenth  month,  and  the  remains  persist  for  several 
weeks  after  delivery. 

The  tubes,  which  ordinarily  vary  in  length  from  5  to  19  cm.,  are  stretched  out 
in  pregnancy,  hanging  almost  perpendicularly  at  the  sides  of  the  uterus.  There  is 
no  hypertrophy  of  the  muscle-fibers,  but  much  increased  vascularity  and  succulence. 
A  moderate  decidual  change  of  the  mucous  membrane  has  been  observed  even  with 
intra-uterine  pregnancy.  The  uterine  end  is  usually  closed,  but  the  fimbriated  end 
is  open.  The  patulousness  of  the  tubes  is  closely  associated  with  the  question  of 
the  possibility  of  superfecundation. 

The  ovaries  are  enlarged,  especially  the  one  containing  the  corpus  luteum. 
In  the  early  months  the  corpus  luteum  may  be  palpated — of  course,  only  in  favor- 
able cases.  In  the  later  months  one  may  feel  the  ovary  through  the  abdominal 
wall  hanging  on  the  side  of  the  uterus.  The  right  one  is  less  easily  felt.  They  are 
alwaj's  quite  tender.  The  microscopic  changes  in  the  ovary  are  edema,  vasculariza- 
tion, decidua-like  formations  under  the  tunica  albuginea.  Ovulation  does  not  in- 
variably cease  during  pregnancy,  as  was  formerly  taught. 

The  vagina  increases  in  length  and  capacity  by  a  real  eccentric  hypertrophy. 
It  becomes  more  distensible,  the  elastic  fibers  increasing  in  amount,  and  th.e  tissues 
becoming  infiltrated  with  serum.  The  rugae  deepen,  the  papillae  swell,  so  that 
sometimes  they  are  palpable  as  small  granules.  In  pathologic  cases  a  vaginitis 
granulosa  may  develop,  and  in  cases  of  gonorrhea  the  surface  may  feel  like  a  nutmeg- 
grater.  The  veins  enlarge,  the  venules  also,  giving  the  surface  a  deep  wine  color 
(diagnostic  of  pregnane}^,  and  this  engorgement  is  attended  by  pronounced  secre- 
tion or  leukorrhea. 

The  upper  portion  of  the  vagina  enlarges  as  pregnancy  advances,  so  that  in  the 
later  months  it  is  usually  possible  to  touch  the  sides  of  the  pelvis  with  the  stretched 
fingers  or  a  dilating  pelvimeter.  When  the  uterus  ascends,  the  vagina  is  drawn  up ; 
when  the  head  enters  the  pelvis  in  the  last  month  of  pregnancy,  the  vagina  is  pushed 
down  and  often  thrown  into  the  circular  folds,  which  may  simulate  the  dilating 
cervix  (Fig.  118).  The  anterior  vaginal  wall  and  thickened  urethrovaginal  sejDtum 
may  prolapse  through  the  patulous  vulva.  Similar  changes  are  seen  on  the  vulva — 
softening,  dark  coloration,  varices,  pigmentation,  thickening,  enlargement,  in- 
creased secretion  of  all  its  glands. 

The  pelvic  floor  takes  part  in  the  general  imbibition  of  the  pelvis.  The  levator 
ani  becomes  less  rigid,  more  distensible.  The  fat  in  the  ischiorectal  fossa  is  partly 
absorbed  by  the  end  of  pregnancy,  but  the  infiltration  with  serum  causes  a  pro- 
nounced swelling  and  sagging  of  the  perineum.  This  sagging  of  the  perineum  below 
a  line  drawn  from  the  under  surface  of  the  pubis  to  the  tip  of  the  sacrum  is  called 
'pelvic  floor  projection  (Fig.  126).  Other  conditions  cause  an  increase  of  pelvic  floor 
projection,  such  as  pelvic  tumors,  marked  intra-a1)dominal  pressure,  but  in  preg- 
nancy it  is  most  manifest,  and  in  cases  of  incarceration  of  the  gravid  uterus  one  meets 
the  greatest  depression  of  the  tissues.  The  pelvic  floor  projection  during  labor  will 
be  considered  later. 

The  bladder  is  much  concerned  in  the  changes  wrought  by  pregnancy.  In  the 
early  montlis  llie  fundus  uteri  lies  upon  it,  but  with  no  greater  Aveight  than  the  in- 
testines. A  certain  amount  of  traction  is  exerted  by  the  retroposed  cervix  on  the 
neck  of  the  Vjladder,  and  this,  with  the  congestion  of  the  parts,  explains  the  fre- 


CHANGES  DUE  TO  PREGNANCY 


97 


quent  urination  complained  of  by  tlic  women  at  this  j)eii(j(l.  Cystoscopically,  the 
indentation  made  by  tiie  fundus  uteri  is  easily  discov<'red;  the  eolor  of  the  interior 
is  darker,  and  one  experienced  in  the  use  of  the  inslrunient  may  suspect  tlie  preg- 


FiG.  126. — Pelvic  Floor  Projection  (adapted  from  Hart  and  Barbour). 
Red  indicates  the  parts  before  pregnancy. 


nancy  from  the  appearance  of  the  congested  and  newly  vascularized  bladder  mucosa. 
Varicose  veins  in  the  loase  of  the  l^ladder  are  sometimes  found.  In  the  later  months 
they  may  give  rise  to  hemorrhage.  Even  after  the  uterus  has  risen  into  the  abdo- 
men the  bladder  remains  a  pelvic  organ,  unless  distended,  when  it  is  flattened  out 

7 


98  PHYSIOLOGY   OF    PREGNANCY 

against  the  abdominal  wall.  In  these  cases  the  bladder  assumes  a  saddle  shape, 
extending  up  to  either  side  of  the  uterus — more  toward  the  right.  This  is  determin- 
able by  the  cystoscope  or  by  illuminating  the  filled  bladder  and  observing  the  abdo- 
men in  a  dark  room.  The  area  of  redness  on  the  belly-wall  shows  the  outline  of 
the  bladder.  With  the  development  of  the  lower  uterine  segment  the  attachment 
of  the  bladder  to  the  uterus  is  loosened  and  the  bladder  is  stripped  off  the  wall 
of  the  latter.  In  labor  the  uterus  retracts  still  further  away  from  the  bladder — 
sometimes  so  far  that  the  latter  comes  to  lie  on  the  vagina.  These  facts  were  de- 
termined clinically  in  cases  of  extraperitoneal  cesarean  section.  During  the  latter 
part  of  the  first  stage  of  labor  the  peritoneum  of  the  anterior  culdesac  may  be  partly 
stripped  off  the  bladder.  When  the  head  enters  the  pelvis  in  the  last  month,  it 
may  ]3ress  directly  on  the  bladder  or  distort  its  base,  thus  giving  rise  to  the  fre- 
quent urination  so  often  noted.  Perhaps  the  diminished  capacity  of  the  organ 
is  also  causative.  The  bladder,  flattened  between  the  head  and  pelvis,  bulges  out 
at  either  side,  especially  the  right,  when  filling. 

The  ureters  are  enlarged  early  in  pregnancy.  Thickening  is  one  of  the  diag- 
nostic signs.  They  are  displaced  to  the  side  of  the  pelvis,  and  may  be  felt  on  bi- 
manual examination  as  two  cord-like,  tender  structures,  coursing  between  the  cervix 
and  pelvic  wall.  Late  in  pregnancy  they  may  be  felt  lying  against  the  lower  uterine 
segment  and  the  fetal  head.  Halbertsma  claimed  that  the  ureters  frequently  suffer 
compression  during  the  later  months  of  pregnancy,  and  that  eclampsia  is  due  to  the 
damming  back  of  the  urine.  At  no  time  can  the  uterus  directly  compress  the  ureters, 
and,  further,  the  weight  of  the  uterus  is  not  greater  than  that  of  the  intestinal  mass. 
The  entrj^  of  the  fetal  head  into  the  pelvis  in  the  last  month  distorts  the  course  of 
the  ureter  or  kinks  or  stretches  it,  and  this  may  interfere  with  the  passage  of  urine. 
Cystoscopically,  the  ureteral  openings  in  the  bladder  appear  elevated,  thickened, 
and  deeply  congested. 

The  pelvic  girdle  is  affected  by  the  changes  of  pregnancy.  The  author  has 
determined  an  actual  increase  of  the  size  of  the  pelvic  cavity.  Measurements  taken 
of  contracted  pelves  before  conception,  and  just  before  labor,  will  often  show  this, 
and  women  in  whom  labor  was  predicted  as  impossible  may  have  spontaneous  or 
easy  operative  deliveries.  The  constitution  of  the  pelvic  bones  during  pregnancy 
is  altered  similarly  to  the  pathologic  osteomalacia.  Occasionally  there  is  an  irreg- 
ular deposit  of  extra  bone  under  the  periosteum — the  puerperal  osteophytes  of 
Rokitansky. 

The  pelvic  articulations  undergo  marked  changes.  Hippocrates  knew  that 
they  softened  and  became  looser,  and  he  believed  that  parturition  was  difficult  if 
this  relaxation  did  not  occur.  Perhaps  part  of  the  enlargement  of  the  pelvic  circle 
above  mentioned  is  due  to  the  thickening  of  the  cartilages  of  the  joints.  Normally, 
and  in  man,  there  is  a  slight  movability  of  the  pelvic  joints,  but  in  pregnancy  this  is 
increased  and  during  labor  it  is  greatest.  The  tissues  of  the  joint  imbibe  fluid,  the 
capsule  thickens,  the  vascularity  is  increased,  and  there  is  an  augmentation  of 
synovia.  It  is  to  be  noted  that  these  changes  are  most  marked  in  women  with 
varicose  veins  of  the  pelvis.  The  pubic,  sacrococcygeal,  and  sacro-iliac  joints  are 
affected  in  the  order  named.  In  guinea-pigs  these  changes  are  part  of  the  preg- 
nancy and  parturition,  and  may  be  so  pronounced  that  the  bones  of  the  pubis  may 
separate  so  far  as  to  allow  the  animal's  legs  to  lie  alongside  the  body  on  the  table. 
In  cows  the  "sinking  of  the  rump"  informs  the  veterinarian  that  delivery  is  at  hand. 
In  women  an  actual  enlargement  of  the  pelvis  in  labor  occurs  only  in  very  slight 
degree,  but  the  softening  of  the  joints  allows  free  motion  of  the  bones  and  thus  a 
certain  configuration,  which  facilitates  the  delivery. 

Many  women  in  the  later  months  of  })regnancy  complain  of  pain  in  the  pelvic 
joints,  a  waddling  gait,  and  difficult}^  in  walking.  Examination  will  usually  show 
tenderness  over  the  pubes,  and  riding  of  the  two  bones  on  each  other  when  the  pelvis 


CHANGES   DUE   TO    PREGNANCY 


99 


is  stnHigl}'  rocked  from  side  io  side,  or  even  a  {groove  showiii}^  a  larger  degree  of 
separation.     (See  Relaxation  and  Rupture  of  the  Pelvic  Joints.) 

T\h)  abdominal  wall  distends  as  the  pregnancy  advanc(?s,  and  grows  thinner, 
especially  around  the  navel.  lOxperiinents  by  Kraus  have  shown  that  the  tension  is 
in  the  direction  of  radii  from  tlu;  navel.  In  i)rimipara)  tlu;  abdominal  walls  are 
tenser  and  sag  less  than  in  women  wlio  have  borne  children.  Sometimes  the  linea 
alba  gives  way  to  the  strain,  the  recti  muscles  separate,  and  the  pnignant  uterus 
falls  forward  between  them,  covered  only  by  a  thin  layer  of  skin  and  peritoneum. 
This  is  called  "ruptun^"  by  the  laity.  The  belly  becomes  pendulous, — "venire  en 
hesace," — and  not  seldom  the  condition  gives  rise  to  dystocia.  Any  tendency  to 
hernia  is  aggravated  by  pregnancy,  bul ,  during  t  lie  pc^riod  the  uterus  usually  pushes 
up  and  keeps  away  the 
gut  and  omentum  from 
the  hernial  openings — 
that  is,  unless  these  are 
adherent  to  the  sac. 

In  90  per  cent. 
(Crede),  and  in  practi- 
cally all  cases  of  the 
author,  the  skin  shows 
smooth,  silvery,  or 
pearly  white  or  violet 
broad  lines,  called  striae 
or  lineae  albicantes  gravi- 
darum. The  lines  are 
curved,  irregular,  some- 
times confluent,  and 
show  a  fine  transverse 
fibrillation.  They  are  ar- 
ranged more  or  less  con- 
centrically, but  some- 
times radially  around 
the  navel,  especially  on 
the  lower  abdomen.  Near 
Poupart's  ligament  they 
are  always  broader  and 
deeper  in  color.  One  finds 
them  on  the  nates,  the 

thighs,  more  on  the  anterior  aspect,  but  sometimes  on  the  posterior  too,  and  as  far 
down  as  the  loiees.  The  breasts  also  show  them,  arranged  radially  to  the  nipple. 
Blonds  are  more  affected  than  brunets,  primiparne  more  than  multiparse,  fat 
women  more  than  lean,  large  women  more  than  small.  The  number  depends  also 
on  the  degree  of  abdominal  distention,  but  there  are  other  factors  in  the  causation 
than  mere  abdominal  distention,  because  in  cases  of  immense  abdominal  enlarge- 
ment due  to  ovarian  tumors  or  ascites  the  stripe  are  not  constant.  Formerly  they 
were  considered  positive  proof  of  preexisting  pregnancy,  but  this  is  not  true,  since 
they  occur  in  the  following  conditions:  rapid  accumulation  of  fat  at  any  period,  as 
at  puberty;  they  are  found  in  men  (6  per  cent.);  dropsy  and  ascites;  abdominal 
tumors;  unusually  rapid  growth  of  the  long  bones  may  develop  them  at  the  epi- 
physes; after  typhoid  fever.  If  the  linear  are  marked  and  with  t>^Dical  distribution, 
the  presumption  of  previous  pregnancy  is  strong,  l^ut  never  certain.  The  author 
has  seen  striae  on  the  breasts  of  a  virgin.  New  striae  may  appear  among  the  old. 
The  author  has  observed  lineae  gravidarum  in  the  sixth  month.  Histologically,  one 
finds  the  connective  tissue  of  the  cutis  and  subcutis  stretched,  sometimes  torn,  and 


Fig.   127. — Stri.b  Gr.\vid.\.rum. 
From  a  photograph,  Chicago  Lying-in  Hospital. 


100 


PHYSIOLOGY    OF   PREGNANCY 


the  former  rhomboid  arrangement  of  the  fibers  changed  to  a  more  parallel  disposi- 
tion of  the  strands  across  the  striae.  The  elastic  fibers  are  always  torn,  and  the  re- 
tracted ends  found  at  the  edge  of  the  striae.  The  lymph-spaces  are  compressed  and 
arranged  parallel.  Perhaps  this  explains  the  tendency  of  the  lineae  to  become  drop- 
sical. The  papillae  are  flattened,  sometimes  completely,  and  are  also  arranged  in 
transverse  rows.  The  epidermis  is  thinned.  In  brunets  and  colored  women  there 
is  a  tendency  to  pigmentation  of  the  striae.  Stratz  says  that  savage  women  do  not 
have  striae,  and  advises  massage  with  oil  as  a  preventive. 

The  Physics  of  the  Abdomen, — The  pressure  in  the  belly  varies  very  little  from 
that  outside,  and  depends  on  the  tonicity  of  the  abdominal  walls.  In  the  relaxed 
horizontal  position  the  abdominal  walls  support  a  pressure  equal  only  to  the  weight 
of  the  viscera,  which,  being  practically  semifluid,  seek  the  lowest  portions  of  the 
cavity.  In  this  position  there  is  a  slight  increase  of  intra-abdominal  pressure  with 
inspiration,  and  a  slight  decrease  during  expiration. 

In  the  erect  position  there  is  a  slight  increase  of  intra-abdominal  pressure  be- 
cause the  muscles  are  on  tension,  and 
this  is  augmented  by  inspiration, 
forced  expiration,  as  by  exercise,  ex- 
pulsive efforts,  defecation,  vomiting, 
parturition.  The  development  of 
tumors  in  the  belly,  as  fibroids,  cysts, 
pregnancy,  increases  intra-abdom- 
inal pressure.  In  addition  the  lower 
portions  of  the  abdomen,  in  the  erect 
position,  sustain  the  weight  of  the 
superimposed  column  of  viscera. 
Therefore  intra-abdominal  pressure 
is  not  the  same  at  all  points.  The 
changes  in  the  pressure  brought 
about  by  respiration  are  transmitted 
throughout  the  abdomen,  and  are 
evident  on  the  perineum  and  organs 
resting  on  the  pelvic  floor,  uterus,  and 
bladder.  The  organs  in  the  belly 
are  not  held  in  position  by  atmos- 
pheric pressure.  They  are  fastened 
to  the  firm  parietes  by  ligaments 
and  floated  on  each  other,  getting  indirect  support  from  the  abdominal  muscles 
and  pelvic  floor.  In  the  knee-chest  position  the  weight  of  the  liver  and  intestines 
falling  toward  the  chest  produces  a  negative  pressure  in  the  abdomen.  If,  now, 
the  belly,  vagina,  rectum,  and  bladder  are  opened,  air  rushes  in  and  distends  them. 
We  use  this  position  therapeutically. 

The  Breasts. — In  the  embryo  of  six  weeks  there  is  found  a  line  of  cells  running 
from  the  axilla  to  the  groin,  and  called  the  linea  or  crista  lactea.  From  the  chest 
portion  of  this  the  breasts  develop.  Accessory  breasts  and  supernumerary  nipples 
are  almost  always  found  in  this  line  on  either  side,  and  indicate  a  tendency  to  revert 
to  a  lower  order  in  human  development. 

An  ingi'owth  of  epithelial  cells,  which  later  become  tubulated,  marks  the  site 
of  the  mamma.  In  the  fetus  at  five  months  the  gland  consists  simply  of  a  collection 
of  ducts  which  open  at  one  spot — the  future  nipple.  This  spot  is  depressed;  thus 
an  inverted  nipple  in  the  adult  is  simply  one  retarded  in  development.  Even  at 
seven  months  th(;  ducts  are  l)ranched,  and  at  term  they  divide  two  or  three  times. 
These  primitive  ducts  represent  the  future  lobules.     Hardly  any  acinous  structure 


Fig.  128. — Bkunet's  Breast. 
Shows  primary  and  secondary  areolae. 


CHANGE.S  DUE  TO  PREGNANCY 


101 


exists  at  birth,  hut  the  tu))ulcs  an-  (■a|)al)lo  of  secreting  milk  and  colostrum  which 
do  not  differ  in  comjxjsition  from  those  of  tlie  mother.  The  growth  of  tlie  gland  is 
very  slow  until  ])ul)erty.  Then  acini  deveh^i)  in  the  primitive  tubules,  each  of 
which  becomes  a  tubuloracemose  gland,  and  thus  the  breast  comes  to  be  made  up 
of  distinct  lobules  embedded  in  a  fat  cushion.  Each  lobe  empties  on  the  surface 
of  the  n(nv  i)rominent  ni])])le  by  a  duct.  Before  opening  on  the  nipple  each  duct 
dilates  a  little — the  sinus  lactiferus.  There  are  lo  to  20  ducts.  The  nipple  is  a 
muscular  organ,  and  is  covered  by  delicate  pigmented  skin,  is  finite  vascular,  and  at 
the  base  is  surrounded  l)y  unstriped  muscle-fibers  which  unite  with  those  of  the 
nipple  itself  and  thus  produce  the  erection  of  the  same.  For  a  varying  distance 
around  the  nipjile  the  skin  is  very  delicate,  more  or  less  pigmented,  and  raised  from 
the  fascia  covering  the  mammarv  gland  bv  soft  connective  tissue  and  fat.     This  is 


Fig.    129. — Variously    Shaped    Breasts 
(Primipar^). 


Fig.   130. — ^"ARIOL•SLY  Shaped  Breasts  (Mt"LTiP.\K.i:). 


the  areola.  Embedded  in  this  areola  lie  tiny  milk-glands,  each  opening  on  the  sur- 
face b}'  a  microscopic  duct,  jNIontgomery's  tuliercles.  Sebaceous  and  sweat-glands 
are  also  found. 

With  the  advent  of  pregnancy  the  glands  take  on  renewed  growth,  and  as  earlj^ 
as  the  second  month  a  change  may  be  noted.  The  breasts  increase  in  size  and  sensi- 
liility;  the  hard,  tense  feel  of  the  virgin  gland  is  lost;  it  softens  and  sags.  The 
lobules  become  more  marked,  due  to  enlargement,  development  of  acini  in  the 
periphery,  and  softening  of  the  connective  tissue  and  fat  around  them.  The 
acinous  formation  on  the  tubules  in  the  center  of  the  gland  is  especially  marked 
during  pregnancy,  there  being  both  h}'perplasia  and  hypertrophy.  The  veins  en- 
large and  are  seen  as  bluish  streaks,  especially  at  the  periphery,  and  here  striae  often 
(67  per  cent.)  develop.  Hypertrophy  of  the  lymph-system  is  also  a  feature.  The 
nipple  becomes  more  erectile,  and,  with,  the  areola,  becomes  more  deeply  pigmented. 


102 


PHYSIOLOGY    OF   PREGNANCY 


The  base  of  the  areola  becomes  puff}',  raising  the  surface  above  that  of  the  rest  of 
the  gland,  and  the  milk-glands  of  Montgomery  enlarge  prominently.  Occasionally 
a  droplet  of  secretion  may  be  expressed  from  them.  Around  the  primary  areola, 
especially  in  brunets,  a  secondary  areola,  less  pigmented,  sometimes  develops.  It 
resembles  "dust}'  paper  sprinkled  with  drops  of  water."  The  clear  spots  are  due 
to  lack  of  pigment  around  the  openings  of  sweat  and  sebaceous  glands.  From  the 
early  months — and  the  time  varies — a  little  clear,  sticky  fluid  may  be  expressed  from 
the  nipple.  Later  this  is  mixed  with  yellow  material.  It  is  called  colostrum. 
Often  it  oozes  out  and  dries  into  branny  scales  on  the  nipple.  Unless  cleaned  ofT, 
these  sometimes  decompose  and  give  rise  to  sore  nipples,  even  in  pregnancy. 

The  shape  of  the  breast  varies  much  in  women,  and  also  at  different  periods  of 
life.     In  young,  non-pregnant  women  they  sometimes  are  hemispheric  and  promi- 
nent.    In  old  women  and  in  the  later  months  of 
pregnancy  they  are  pendulous.     In  some  colored 
races  they  are  like  long  sacs,  and  they  may  be 
thrown  over  the  shoulder,  for  a  child,  carried  on 
the  back,  to  nurse  from.     Some  breasts  are  large, 
others  small,  which  depends  on  the  amount  of 
gland  tissue  and  fat,  of  which  there  is  sometimes 
more  of  one  than  of  the  other.     The  right  breast 
is  sometimes  larger  than  the  left,  and  vice  versa. 
The   mammary   glands  may   be   considered 
modified  skin-glands,  with  a  fetal  origin  similar 
/  ___^_^  to  the  sebaceous  glands  (Basch).     Sometimes  we 

,vi5<^^'  ^.  ^^^  V' :  .  ^^^^  supernumerary  glands  and  nipples  above  and 

below  the  normal  one.  This  is  called  polymastia, 
and  is  rare.  Accessory  glands  and  nipples  are  usu- 
ally found  in  a  line  running  from  the  axilla  onto  the 
abdomen — the  crista  lactea  already  referred  to; 
this  and  embryologic  studies  indicate  that  man 
had  at  one  time  a  line  of  glands  similarly  to  some 
of  the  lower  animals.  Up  in  the  axilla  there  is 
often  an  aberrant  piece  of  the  mammary  gland, 
which  sometimes  swells  and  becomes  painful  when 
lactation  starts.  It  is  often  mistaken  for  a  lymph- 
gland.     It  may  enlarge  outside  of  pregnancy.    . 

When  the  child  is  delivered  and  lactation  be- 
gins, the  breasts  reach  their  highest  development, 
but  we  will  leave  the  consideration  of  this  until 
we  discuss  the  changes  of  the  puerperium.  Star- 
ling believes  that  the  growth  of  the  mammae 
during  pregnancy  is  due  to  the  action  of  a 
"mamma  hormone,"  developed  in  the  growing 
fetus,  carried  to  the  breasts  by  the  blood,  and  there  acting  specifically  on  the 
gland-cells.  In  the  Blazek  united  twins,  though  only  one  was  pregnant,  in  both  the 
breasts  were  enlarged  and  secreted  milk.  The  breasts  possess  an  internal  secretion. 
It  may  have  some  relation  to  the  inauguration  of  labor.  Extracts  of  the  mamma 
have  been  employed  therapeutically. 


Fio.  131.- 


-FtTNCTIONATING  BkEAST,  MOSTLY 
DiAGBAilMATIC. 


Literature 

Bandl:  Uber  das  ^■f;^haIten  des  L'terus  und  Cervix,  Stuttgart,  1870;  ibid.,  tjber  Ruptura  Uteri,  Vienna,  1875. — Bar: 
La  Pratifjue  des  Accouchements,  1907,  p.  37. — Basch:  Arch.  f.  Gynak.,  vol.  xliv.  Gives  literature. — Bayer: 
Freund'.sGynakol.  Klinik,  Stuttgart,  1885,  p.  369;  ibid.,  Arch.  f.  Gynak.,  vol.  liv.,  p.  70. — Bummand  Blumreich: 
Ein  neuer  Gefrierdurchschnitt  einer  Gebarenden,  Wiesbaden,  1907. — Fieux:  Annales  de  Gyn.,  June,  1903,  p. 
407. — Frnrikcnhduser:  Die  Xer\'en  der  Gebiirmutter,  1807. — Krause  and  Fehenreich:  Arch.  f.  Gyniik.  vol.  xv. — 
Ivanow:  \an&\as  de  Gyn.,  June,  1911,  p.  327,  Musculature  dc  I'ute. — Palm:  Zeitschr.  f.  Geb.  u.  Gyn.,  vol.  xxv. 


CHANGES  DUE  TO  PREGNANCY  103 

p.  .317. — Hiilliili:  RontKcn  .\tlus  of  .VrterieH  of  UtcruH,  Vt-it  &  Co.,  LoipziK,  I'.lll. — liMertr  and  Lalievre:  ".Struc- 
tunlu  iiiii.sclc  uli'riii,"  I,'ObHtctri(|iic,  October,  1000,  p.  7:^.5;  also  March,  1011, — Rei/noUln:  .Surgerj',  Cyn.,  and 
ObHtctric.H,  .Inly,  1011. — Srhmorl:  .Monatssclir.  f.  0<.-burt.>(h.,  1807,  vol.  v.  p.  -16. —  Walker:  Arch.  f.  path.  Anat., 
vol.  cx.'cvii. —  iVuUke:   Ziogler'f)  IJeitriiKe,  1000,  vol.  xxvii,  p.  .'571. 


GENERAL  CHANGES  IN  THE  MATERNAL  ORGANS 

Mauriccau  called  pregnancy  a  disease  of  nine  monllis'  duration,  anrl  there  is 
much  truth  in  tlie  statement.  Clenerally,  the  pregnant  state  and  labor  are  looked 
upon  as  i)hysiolofi;i(',  and  in  perfectly  healthy  women  they  may  be  so.  Xo  other 
function  of  the  body  is  attended  by  such  dangerous  possiV^ilities  or  is  so  easily  de- 
ranged, so  that  one  must  always  bear  in  mind  how  close  to  the  borderland  of 
pathology  the  obstetric  case  continuously  runs.     (See  Introduction.) 

Pregnant  women  ought  to  feel  as  well  as  during  the  non-pregnant  state.  In  a 
large  percentage  of  the  cases  they  do,  or  even  feel  better,  but  often  this  is  not  so. 
They  are  more  irritable;  their  character  changes;  they  are  less  trustworthy;  they 
are  less  tidy;  they  have  various  aches  and  pains — neuralgia,  toothache,  headache — 
and  innumerable  symptoms,  which  the  doctor  is  called  upon  to  alleviate  during  the 
nine  months.  Sometimes  severe  mental  disturbances  arise.  Every  organ,  every 
tissue  of  the  body,  feels  the  stimulus  of  pregnancy.  The  whole  metabolism  is 
changed  to  meet  the  new  demands  on  the  system,  and  it  has  been  well  said  that 
"Gestation  tests  the  integrity  of  every  structure  of  the  body"  (R.  Barnes).  If 
there  is  any  latent  disease  in  the  woman,  pregnancy  will  bring  it  to  the  surface. 
This  fact  w^arns  the  accoucheur  to  study  w^ell  the  constitution  of  his  patient  and  to 
watch  carefully  all  w^eak  points  in  the  organism. 

The  Blood. — Investigators  are  not  agreed  on  the  changes  Avhich  the  blood 
undergoes  during  pregnancy,  and  it  is  because  the  blood  reacts  differentl}'  to  the 
stimulus  of  pregnancy  in  different  women.  Kiwisch  described  the  condition  of  the 
blood  in  early  pregnancy  as  a  "serous  plethora,"  or  hydremia.  From  external  ap- 
pearances many  women,  especially  those  generally  ill  nourished  or  living  in  poor 
circumstances,  suffer  from  a  condition  of  chloranemia. 

While  in  the  first  few  months  there  may  be  a  slight  reduction  in  the  reds  and 
increase  of  the  whites,  the  system  soon  reacts  to  the  necessities  imposed  l^y  preg- 
nancy, and  there  is  an  increase  of  the  reds,  also  of  the  whites,  the  latter  out  of  pro- 
portion to  the  reds — the  "physiologic  leukoc}i:osis  of  pregnancy"  of  Virchow. 
Blumenthal  found  a  leukocytosis  in  the  latter  months  of  pregnane}-.  There  is  often 
an  increase  of  the  neutrophile  polynuclears  and  also  of  the  myelocytes,  the  latter 
indicating  the  part  taken  b}^  the  bone-marrow.  During  labor  there  is  a  marked 
leukocytosis,  especially  of  the  polynuclear  neutrophiles,  values  as  high  as  34,200 
being  obtained,  and  the  eosinophiles  disappear.  The  leukocytosis  was  more  marked 
in  cases  of  oljstructed  labor.  In  the  main  these  findings  are  confirmed  by  the  recent 
work  of  Dietrich,  1911.  The  leukocytosis  is  more  marked  in  primiparse.  Of  the 
many  theories  as  to  its  cause,  that  of  Dietrich  seems  most  plausible,  that  it  is  a 
reaction  against  the  toxins  of  pregnancy. 

The  number  of  reds  at  first  remains  normal  or  is  slightly  increased,  and  there  is 
a  corresponding  increase  of  the  hemoglobin.  Later  the  reds  and  hemoglobin  are 
augmented.  The  alkalinity  of  the  blood  is  slighth"  diminished,  but  the  freezing- 
point  remains  the  same  as  in  the  non-pregnant  state  —0.55  to  —0.59.  The 
amount  of  fibrin  and  fibrinogen  increases  from  the  sixth  month  of  pregnancy,  and 
may  be  one-third  greater  than  usual.  This  increase  of  fibrin  is  probal)ly  a  conserva- 
tive act  of  nature  to  prevent  dangerous  loss  of  blood  during  labor.  Perhaps  the 
h3^3erinosis  causes  the  thromboses  sometimes  observed  in  the  veins  of  the  leg  and 
pelvis  even  before  labor.  When  such  thromboses  give  rise  to  emboh,  sudden  death 
may  result.  Rebaudi  says  that  the  blood-platelets  increase  up  to  the  time  of  labor, 
being  1,500,000  per  c.mm.,  then  rapidly  decrease  to  600,000.     Their  agglutinating 


104  PHYSIOLOGY   OF   PREGNANCY 

properties  increase  with  the  nuinber,  therefore  the  coagulating  power  of  blood  is 
greatest  just  before  labor. 

The  total  quantity  of  blood  is  augmented,  especially  in  the  last  months,  a  true 
plethora  existing  (Spiegelberg  and  Gsheidlen),  a  fact  recently  (1911)  again  proved 
by  Zuntz.  The  need  for  more  blood  must  be  admitted;  the  addition  of  the  fetus 
and  the  fetal  circulation,  the  development  of  the  uterine  arteries  and  veins,  the  en- 
largement of  the  veins  of  the  lower  extremities,  which  are  sometimes  so  great  that 
the}'  appear  to  be  veritable  caverns.  It  would  seem  that  they  act  as  reservoirs  and 
provide  for  the  loss  of  blood  at  labor.  Often  the  loss  of  a  quart  at  this  time  creates 
no  symptoms.  The  distended  veins  collapse  after  delivery.  Chauffard,  in  1911, 
found  an  increase  of  the  cholesterin  in  the  blood,  and  at  the  seventh  month  a  true 
cholesterinemia.  Aschoff  believes  this  may  explain  the  formation  of  gall-stones. 
Lipoids  in  the  blood  are  increased.  The  resistance  of  the  reds  to  hemolysis  by 
colDratoxin  is  diminished  (von  Graff,  1912).  The  Wassermann  reaction  becomes 
less  conclusive  during  pregnancy. 

The  blood-making  organs  show  marked  activity.  The  spleen  grows  from  140 
to  180  gm.  The  lumbar  glands  enlarge,  also  the  lymphoid  structures  of  the  endo- 
metrium. The  lymph-glands  all  over  the  body  are  frequently  enlarged  in  preg- 
nancy (Meyer).  The  thyroid  becomes  more  vascular,  often  hypertrophies.  The 
enlargement  is  noticed  after  the  sixth  month,  and  may  disappear  only  partly  after 
delivery.  Lange  claimed  that  the  thyroid  has  an  influence  on  pregnancy  and  espe- 
cial bearing  on  toxemia  and  eclampsia. 

The  ovary  activates  the  thyroid,  sometimes  to  the  point  of  producing  symptoms 
of  Basedow's  disease.  The  parathyroids  are  also  affected.  Compte,  in  1899,  first 
showed  that  the  hypophysis  cerebri  hypertrophied  during  pregnancy,  a  fact  con- 
firmed by  Kohn  in  1910.  An  extract  of  the  pituitary  body,  administered  hypo- 
dermically,  stimulates  uterine  contractions.  Some  of  the  symptoms  and  changes 
in  pregnancy  are  acromegalic  in  nature,  e.  g.,  bones,  features,  hair,  larynx.  The 
interaction  of  the  internal  secretions  of  the  various  glands  is  not  at  all  well  under- 
stood, but  its  study  offers  a  promising  field  of  investigation.  Neu  (1911)  claims 
that  ''adrenalinemia"  exists  in  pregnancy. 

In  the  marrow  of  bones  decided  changes  have  been  noted.  Great  congestion 
and  even  a  transformation  of  fat  marrow  to  blood-forming  marrow  have  been  found. 
On  the  inside  of  the  skull,  along  the  middle  meningeal  artery  and  longitudinal  sinus, 
on  the  pelvic  bones,  and  occasionally  elsewhere,  one  may  find  thin  deposits  of  reddish 
bone  tissue.  They  are  1  to  2  mm.  thick,  and  each  pregnancy  brings  a  new  layer. 
Rokitansky  called  them  ''puerperal  osteophytes,"  and  believed  they  had  some  work 
to  perform  in  the  blood  making  during  pregnancy.  They  occur  only  in  one-half  of 
the  cases  of  pregnancy  that  go  to  autopsy,  and  are  not  characteristic  because  they 
have  been  found  also  in  syphilis,  tuberculosis,  and  chronic  hydrocephalus. 

The  Circulatory  System. — The  changes  here  are  marked,  the  whole  cardio- 
vascular system  being  affected,  though  not  in  the  same  degree  as  was  formerly 
believed.  Larchcr,  in  1857,  described  an  eccentric  hypertrophy  of  the  heart,  es- 
pecially of  the  left  ventricle,  Blot  and  other  French  authors  agreeing  with  him.  A 
mass  of  literature  has  accumulated  on  the  subject.  Later  investigations  (Miiller 
and  Dreysel)  considering  the  weight  of  the  Iwdy  with  that  of  the  heart  have  shown 
that  there  is  only  a  slight  if  any  enlargement,  and  that  it  is  proportionate  to  the 
general  increase  of  the  body.  The  arguments  for  accepting  the  theory  of  hyper- 
trophy are,  first,  the  physiologic  need  for  more  work  by  the  heart;  the  increased 
amount  of  blood  to  be  moved;  the  increased  viscosity  of  the  blood;  the  addition  of 
the  large  area  of  V)lood-vessels  of  the  placental  circulation,  and  the  dilated  and  new 
])lood-vessels  of  the  uterus;  the  increased  abdominal  tension;  second,  the  results  of 
postmortem  measurements,  the  majority  of  authors  finding  some  increase  in  weight; 
third,  the  clinical  findings.     There  is  an  increase  in  the  area  of  cardiac  dulness,  but 


CHANGES  DUE  TO  PREGNANCY 


105 


Gcrliunlt  claiius  this  is  due  to  the  elevation  of  tlie  diuphra{i;in  and  rosultiiifi;  leveling 
of  the  heart.  RontKen-ray  examination  of  the  chest  in  pregnancy  (Kraus)  shows 
two  types — on(>  with  Njng  thorax,  a  convex  diaphragm,  and  undisturbed  hr'art, 
another  with  short  thorax,  raised  and  flattened  diaphragui,  and  heart  placed  hori- 
zontally. The  heart  in  all  cases  is  pressed  against  the  anterior  chest-wall,  displacing 
the  lungs;   thus  the  area  of  cardiac  dulness  is  enlarged. 

Many  pregnant  women  have  high  arterial  tension,  or  a  larger  or  more;  frefiuent 
pulse-])eat,  l)ut  there  is  nothing  in  the  pulse  of  pregnant  women  that  is  characteristic 
or  different  from  other  w(jmen  (\'ejas).  Once  in  four  cases  one  hears  a  systolic 
nuu-iuur  over  the  hasc  of  the  heart,  not  transmitted  far,  and  not  always  accompanied 


/ 


Fig.   132. — Varicose  Veins  of  Vulva. 
Drawn  from  a  photograph. 


by  accentuation  of  the  second  pulmonary  sound.  It  is  usually  hemic  in  origin,  but 
may  be  due  to  displacement  of  the  heart,  and  almost  always  disappears  shortly  after 
delivery.  One  must  be  slow  to  diagnose  heart  lesions  in  pregnancy,  but  it  is  gen- 
erally admitted  that  the  heart  is  peculiarly  liable  to  disease  during  gestation,  and 
that  existing  disorders  are  aggravated. 

A  frequent  complaint  l^y  pregnant  women  is  of  fainting  spells.  There  are  also 
attacks  of  palpitation  with  a  sense  of  suffocation.  These  phenomena  are  usually 
due  to  a  disturbed  nervous  system,  hysteria,  tight  lacing,  a  full  stomach,  constipa- 
tion, or  the  toxemia  of  pregnancy. 

Pregnant  women  have  a  marked  tendency  to  develop  varicose  veins  of  the 
lower  half  of  the  body.     Nearly  every  one  has  at  least  one  or  more  phlebectasise. 


106  PHYSIOLOGY    OF   PREGNANCY 

In  20  per  cent,  of  the  cases  the  varicosities  are  marked.  The  usual  sites  are  the 
legs,  the  vulva,  the  mons,  the  pelvis,  the  rectum,  the  anus,  the  vagina,  the  abdomen, 
the  buttocks,  in  the  order  named.  One  or  more  or  all  the  parts  may  be  involved. 
One  leg,  usually  the  right,  may  exceed  the  other  in  the  size  and  number  of  the  vari- 
cosities. The  surface  veins  are  most  affected.  Of  causes,  several  are  given;  in- 
creased venous  congestion  below  the  chaphragm,  caused  by  the  greater  intra- 
abdominal tension  of  pregnancy;  obstruction  in  the  vena  ihaca  communis,  due  to  the 
rush  of  blood  from  the  enl  arged  vena  hypogastrica;  disturbed  vasomotor  conditions; 
increase  in  the  total  amount  of  blood,  and  enlargement  of  the  veins  to  accommodate 
it;  congenital  anomaly  of  veins  brought  out  by  pregnancy ;  a  toxic  alteration  of  the 
vein-wall.  Predisposing  causes  are :  Thin-walled  veins,  heart  disease,  tight  girdles 
and  garters,  constipation,  carrying  heavy  loads,  frequent  pregnancies.  The  state 
of  pregnancy  undoubtedly  has  mainly  to  do  with  the  development  of  varices,  be- 
cause increased  abdominal  tension  may  exist  without  their  occurrence,  as  in  large 
ovarian  tumors,  ascites,  etc.  Parvin  tells  of  a  patient  who  knew  she  was  pregnant 
as  early  as  four  weeks  by  the  development  of  varicosities  in  the  legs.  Compression 
of  the  cava  by  the  uterus  does  not  cause  stasis  in  the  veins  below,  because  the  specific 
gravity  of  the  uterus  is  about  the  same  as  that  of  the  intestinal  mass.  After  the 
head  has  passed  into  the  pelvis  it  may  compress  the  internal  iliac  and  hypogastric 
veins,  but  one  does  not  often  observe  much  difference  from  this  unless  there  have 
been  marked  varicosities  previously. 

Edema  is  often  associated  with  varices  of  the  legs  and  has  the  same  causes.  It 
may  occur  alone,  and  may  have  other  causes.  Three  kinds  may  be  distinguished — 
the  mechanical,  due  to  the  obstructed  venous  circulation  in  the  abdomen,  which 
disappears  when  the  patient  rests  in  the  horizontal  position;  a  general  puffiness 
affecting  the  hands  and  face,  as  well  as  the  legs,  without  urinary  findings,  commoner 
in  hydremic  patients,  and  which  disappears  rapidly  after  labor;  a  true  anasarca, 
due  to  toxemia  or  nephritis,  and  always  significant  as  a  precursor  of  eclampsia. 
Possibly  the  latter  two  forms  are  allied.  The  edema  of  the  legs  may  be  enormous ; 
the  labia  majora  may  be  so  infiltrated  as  to  be  translucent  and  as  large  as  the  fist; 
the  sodden  abdominal  wall  may  hang  down  like  a  bag. 

The  lungs  are  displaced  by  the  growing  uterus.  They  retract  to  the  sides,  ex- 
posing more  of  the  heart.  The  thorax  is  lifted  up,  is  expanded  laterally,  and  shghtly 
diminished  anteroposteriorly.  Part  of  this  change  is  permanent.  The  diaphragm 
is  pushed  up,  but  in  fat  subjects  its  upper  curve  is  not  convex,  but  flattened  or  even 
slightly  depressed  by  the  heart.  These  changes  are  more  marked  in  primiparse  than 
in  multipara,  because  of  the  lax  abdominal  wall  in  the  latter.  The  respiration  is  more 
costal  than  abdominal,  because  of  the  restricted  excursion  of  the  diaphragm.  The  vital 
capacity  is  not  decreased,  but  the  respiration  is  more  frequent — 24  to  26  a  minute. 
]More  CO2  is  excreted.  (See  Vejas,  loc.  cit.)  When  lightening  occurs  at  the  end  of 
pregnancy,  the  chest  is  relieved.  Changes  which  some  rhinologists  consider  char- 
acteristic of  pregnancy  have  been  described  as  occurring  in  the  nose  and  throat. 
The  turbinates  are  turgid,  even  to  closure  of  the  nares  or  apposition  against  the 
septum.  Perhaps  these  findings  will  explain  the  deafness  and  ringing  in  the  ears 
some  pregnant  women  have,  or  even  some  of  the  so-called  neuroses  (Freund). 
There  seems  to  be  an  interrelation  between  the  nasal  cavities  and  the  genitalia 
(Fliess).  The  larynx  is  somewhat  congested,  especially  the  false  vocal  cords,  and 
there  is  some  slight  cellular  infiltration  of  the  tissue  (Hofbauer).  Brickner  believes 
otosclerosis  is  pffuliarly  unfavorably  affected  by  pregnancy. 

The  Digestive  Tract. — One  of  the  first  symptoms  of  pregnancy  is  the  nausea 
and  vomiting — the  so-called  "morning  sickness."  It  may  be  present  as  early  as 
the  second  week,  but  usually  appears  about  the  fifth,  and  persists  until  the  twelfth 
week,  though  occasionally  it  continues  until  term.  The  patient  is  sick  at  the  stom- 
ach on  rising  or  after  breakfast,  and  vomits  the  meal  or  only  sour  mucus,  being  free 


CHANGES  DUE  TO  PREGNANCY  107 

from  nausfa  tlio  rost  of  llic  day.  The  IccliiiK  is  similar  to  soa-sicknoss,  and  it  is 
aftKi"''^'^'^t<'<l  l)y  sudden  niolioii.  The  xoinitin^  iiuiy  recur  at  tho  end  of  pregnancy, 
after  "liji;hteniii^-,"  due  to  the  displacement  (jf  the  stomach  and  intestines,  but 
at  this  time  th(>  vomiting  may  also  be  due  to  toxemia,  and  mean  that  eclampsia 
threatens.  Should  the  nausea  and  xomiting  persist  the  greater  part  of  the  day,  the 
case  becomes  i)athologic.  This  will  be  considered  under  the  subject  Hj7)eremesis 
CIravidarum,  ]).  343.  Morning  sickness  occurs  in  om^-third  of  pregnant  women. 
Its  cause  is  obscure;  perluii)s  it  is  a  reflex  from  the  uterus,  or  it  may  l;e  toxemic. 
Primiparaj  are  oftener  affected  than  multiparae.  It  occurs  oftener  in  the  higher 
classes  of  society  and  in  the  neurotic. 

The  salivary  secn^tion  is  increased,  and  when  the  ex]:)ectoration  is  froth}^,  it  is 
called  "cotton  spitting."  In  some  cases  the  i)atient  is  actually  salivated;  then  the 
case  is  ])athologic  and  needs  treatment.  The  teeth  easily  decay,  due  to  the  altera- 
tion of  the  secretions  of  the  mouth,  dentists  say,  but  perhaps,  too,  because  of  the 
demand  of  the  fetus  for  more  calcareous  salts,  or  the  teeth  partake  of  the  general 
changes  exhibited  ])y  the  bony  system.  Loosening  of  the  teeth  may  occur.  Gin- 
givitis to  a  mild  degree  is  also  observed,  but  this  Ijorders  on  the  pathologic.  The 
taste  is  sometimes  perverted,  the  gravida  having  a  desire  for  unnatural  things,  as 
chalk,  slate-pencils,  sand,  salt,  etc.  This  symptom  is  called  "pica,"  and  may  be- 
come morbid,  as  in  the  case  of  a  woman  who  craved  a  bite  of  her  husband's  arm,  and 
actually  took  it.  It  was  considered  dangerous  to  the  fetus  or  mother  to  oppose 
these  "cravings"  of  pregnant  women,  and  all  sorts  of  devices  were  employed  to  ap- 
pease them.  The  appetite  is  usually  increased  unless  nausea  occurs;  even  then, 
after  the  vomiting,  the  ]-)atient  is  hungrj^  Some  women  have  a  voracious  appetite 
in  pregnancy,  and  often  satisfy  it  to  their  detriment,  in  the  belief,  fostered  by  many, 
that  they  are  eating  for  two.     Again,  anorexia  is  present  or  the  appetite  is  fickle. 

The  stomach  is  displaced  in  the  later  months  of  gestation,  being  forced  upward, 
backward,  and  to  the  left.  The  wall  is  congested,  and  pours  out  abundant  watery 
secretion.  The  hydrochloric  acid  is  increased,  causing  frequent  "heartburn." 
Digestion  is  usually  more  active,  and  varies  with  the  appetite. 

The  liver  is  forced  upward,  backward,  and  to  the  right  in  the  late  months. 
Liver  dulness,  therefore,  must  be  corrected  in  this  period.  Tarnier,  in  1857,  de- 
scribed a  fatty  infiltration  around  the  intralobular  veins,  but  this  is  not  constant, 
and  prol)ably  does  not  occur  in  normal  pregnancy.  The  glycogen  in  the  liver  is 
decreased.  There  is  more  bile  present,  and  dilatation  of  the  bile-passages,  also 
ectasis  of  the  central  veins.  Multinuclear  cells,  presumably  from  the  placenta, 
even  portions  of  villi,  are  sometimes  found  as  emboli  in  the  liver  vessels.  The  dis- 
turbance of  the  functions  of  the  liver  noted  by  some  authors  is  pathologic,  and  will 
be  considered  under  proper  headings. 

The  intestines  are  also  affected  by  pregnancy.  Constipation  is  almost  the  rule, 
being  due  to  the  displacement  of  the  bowels,  abnormal  innervation,  general  inac- 
tivity of  the  gra\'ida,  interference  by  the  uterine  tumor  A\-ith  bearing-do-v^ai  efforts 
in  defecation.  Hemorrhoids  are  common,  from  the  constipation  and  the  increase 
of  venous  pr(^ssur(>  1)el()w  the  diaphragm. 

General  Metabolism. — The  body  weight  increases  in  the  last  three  months, 
according  to  Hecker  and  Gassner:  seventh  month,  2400  gm.;  eighth  month,  1690 
gm. ;  ninth  month,  1540  gm.  This  varies  in  relation  to  the  size  of  the  person, 
multiparte  showing  larger  gains  than  primipara-.  The  increase  in  weight  is  due  to — 
(1)  The  fetus  and  secundines;  (2)  increased  assimilation;  (3)  storing  up  of  fat  and 
albumin;  (4)  accumulation  of  water,  especially  in  the  lower  extremities;  (5)  increase 
of  the  amount  of  blood.  A  store  of  potential  energj^  is  laid  up  for  conversion  into 
heat  and  force  dvu'ing  lal^or,  and  milk  during  lactation.  The  hips  round  off  and 
become  broad;  the  lireasts  have  more  fat.  A  gravida  gains  one-thirteenth  of  her 
bod}'  weight  during  pregnancy.     If  the  fetus  dies,  this  gain  does  not  occur  or  the 


108  PHYSIOLOGY   OF   PREGNANCY 

patient  ma}'  lose  weight,  and  tliis  fact  may  be  used  in  the  diagnosis  of  the  death  of 
the  infant. 

The  metabohsm  in  pregnancy  has  been  studied  by  von  Winckel,  Miotti,  and 
Hahl,  but  Uttle  is  definitely  known.  The  nitrogen  output  is  decreased,  albumin 
being  stored  up.  Fat  and  iron  are  also  stored  up.  Carbohydrates  are  rapidly 
transformed,  and  before  labor  carbonic  acid  is  excreted  in  large  amounts. 

]\Iost  women  feel  better  during  pregnancy  than  at  other  times,  but  in  some, 
especially  the  anemic  and  the  neurotic,  a  condition  of  asthenia  develops  in  the  early 
months.  Later  the  nutrition  is  better,  and  the  woman  may  enjoy  a  permanent 
improvement  in  health  from  the  stimulus  of  pregnancy.  On  the  other  hand,  some 
women  suffer  a  permanent  neurasthenia  from  the  strain  of  reproduction. 

The  Urine. — The  quantity  is  usually  increased  about  one-fourth.  This  poly- 
uria exjDlains  in  part  the  frequent  urination  of  pregnant  women.  The  specific 
gravity  is  low,  total  solids  and  urea  output  being  the  same  as  or  slightly  less  than  in 
the  non-pregnant  state.  The  sulphates  and  phosphates  do  not  change;  the  chlorids 
decrease  in  the  last  months.  Albumin  is  found  in  one-third  of  the  cases  of  preg- 
nancy, if  one  uses  the  finest  tests,  as  acetic  acid  and  ferrocyanid  of  potash.  The 
frequency  and  amount  increase  until  labor,  when  fully  50  per  cent,  of  cases  show 
albuminuria.  These  figures  are  from  the  "HandbuchderGeburtshilfe,"  vol.  i,  p.  391. 
If  one  uses  the  hot  and  cold  nitric-acid  tests,  which,  for  practical  purposes,  are  suffi- 
cient, one  will  find  albumin  in  only  3  to  5  per  cent,  of  gravidse  and  30  per  cent,  of 
parturients.  Jaeger  found  albumin  in  70  per  cent,  of  pregTiant  women,  and  believes 
it  to  be  frequently  of  lordotic  origin,  or  due  to  a  latent  bacterial  influence.  Many 
times  the  albumin  comes  from  the  urinary  tract  or  from  the  external  genitals.  Renal 
albuminuria,  in  the  experience  of  the  author,  is  rare  in  pregnancy,  and  should  always 
be  looked  on  with  suspicion.  Mild  catarrhs  of  the  bladder,  pyelitis,  and  ureteritis 
are  not  uncommon  in  pregnant  women.  The  highly  congested,  edematous  bladder 
may  permit  the  escape  of  albumin  into  the  urine.  The  role  of  the  ''kidney  of  preg- 
nancy" in  the  production  of  albuminuria  will  be  discussed  under  Toxemia  and 
Eclampsia,  in  the  Pathology  of  Pregnancy,  since  the  author  believes  the  phenomenon 
is  not  normal. 

Sugar  is  occasionally  found  in  the  urine  during  gestation,  and  is  of  two  kinds — 
lactose  and  dextrose.  Lactosuria  occurs  in  16  per  cent,  of  gravidse  (Ney),  is  more 
pronounced  near  labor,  most  pronounced  in  the  first  week  of  the  puerperium  (77 
per  cent.),  and  disappears  after  lactation  is  discontinued,  though  it  may  be  tem- 
porarily augmented  by  the  weaning  process.  It  is  due  to  absorption  of  milk-sugar 
from  the  functionating  breasts,  and  is  not  an  unfavorable  sign,  unless  it  is  large  in 
amount  and  attended  by  signs  of  disturbed  nutrition.  (See  Literature.)  True 
glycosuria,  on  the  other  hand,  is  more  significant,  though  some  authors  describe  a 
"physiologic  diabetes  of  pregnancy."  Alimentary  glycosuria  is  more  likely  to 
occur  during  gestation,  because  of  the  decreased  glycogenic  function  of  the  liver  or 
the  diminished  assimilating  power  for  sugar,  and  one  finds  0.01  per  cent,  of  grape- 
sugar  occasionally,  as  one  does  in  men,  but  with  the  ordinary  tests  employed  by  the 
practitioner  sugar  is  not  regularly  found  in  normal  gravidas.  Its  occurrence  is 
always  a  matter  of  grave  concern.  (See  Diabetes  in  Pregnancy,  p.  502.)  Acetone 
in  the  minute  quantities  usually  found  in  women  is  also  determinable  during  preg- 
nancy. It  is  increased  in  amount  during  hard  la])or,  during  the  first  days  of  the 
puerperium,  febrile  conditions,  toxemia  and  eclampsia,  syphilis,  ectopic  gestation, 
and  death  of  the  fetus,  but  is  not  pathognomonic  of  this.  Peptone,  according  to 
Fischel,  occurs  in  25  per  cent,  of  gravidse  and  96  per  cent,  of  puerperse.  It  probably 
comes  from  the  absorption  of  the  fatty  degenerated  uterine  tissue  during  involution, 
and  has  no  proved  bearing  on  the  metabolism  of  the  fetus,  the  lochial  discharge,  or 
the  fermentation  processes  of  the  intestine.  It  occurs  in  sepsis,  acute  yellow  atrophy 
of  the  liver,  toxemia,  and  eclampsia.     Bar  claims  that  the  urine  shows  increased 


CHANGES  DUE  TO  PREGNANCY 


109 


excretion  of  liinc,  and  diaws  this  into  relation   \villi   llic  lione  changes  of  jjreg- 
nancy. 

The  Bones. — Refereneo  has  heen  made  to  tlie  tliin,  i^orous,  soft  hony  deposits 
on  the  inner  surface  of  the-  cranium — the  puerperal  osteophytes.  Their  function  is 
unknown;  probably  they  have  to  do  with  the  blood  changes  of  pregnancy,  but  it 
has  been  suggested  that  they  have  a  relation  to  the  bony  formation  of  the  fetus. 


% 


I- 


Fig.   133.  Fig.    134. 

Figs.  133  and  134. — Statics  of  the  Xox-pregx.\xt  .\xd  Pregxaxt  Wom.^x. 

■■^rrcw  indicates  direction  of  tendency  to  fall  as  abdominal  tumor  develops.     Second  figure  shows  effect  of  the  adaptatioiu 


The  bones  in  pregnancy  show  increased  vascularity,  especially  the  red  marrow, 
and  to  a  certain  extent  reseml)le  the  changes  found  in  osteomalacia.  Indeed,  a 
physiologic  osteomalacia  of  pregnancy  has  been  described  (Hanau).  Fractures 
unite  well  in  pregnancy,  contrary  to  an  old  notion.  The  joints  of  the  pelvis  soften, 
as  has  been  mentioned  (p.  98).  In  several  cases  of  young  women  the  author  has 
observed  a  rapid  growth  of  the  pelvic  bones  during  pregnancy,  increasing  materially 
the  capacity  of  the  pelvis. 


no 


PHYSIOLOGY    OF   PREGNANCY 


The  spinal  column  is  straightened,  the  uterine  tumor,  prominent  in  front, 
changes  the  line  of  direction  of  the  woman's  person.  This  line  of  direction  tends  to 
fall  anterior  to  her  base  of  support.  Therefore  she  throws  her  shoulders  back  and 
straightens  her  neck  and  head.  The  curve  in  the  small  of  the  back  is  exaggerated 
(Figs.  133  and  134),  the  pelvis  being  rotated  slightly  on  the  femora.  These  changes  in 
the  skeletal  dynamics  give  the  patient  a  peculiar  attitude  and  gait  or  strut,  which 
Shakspere  called  the  "pride  of  pregnancy."  With  marked  softening  of  the  pelvic 
joints,  however,  the  patient  has  a  waddling  gait,  because  the  innominates  move  on 
each  other.  In  cases  of  pendulous  abdomen  and  with  twins  the  changes  in  the 
attitude  of  the  gravida  are  exaggerated.     (See  La  Pointe.) 

The  skin  is  much  affected  by  pregnancy.  Pigment  is  deposited  in  more  or  less 
typical  regions — the  nipples,  the  vulva,  the  linea  alba,  the  navel,  the  face.     The 


Fig.  135. — The  Mask  of  Pregnancy. 
Photograph  of  case  at  the  Chicago  Lying-in  Hospital. 


pigmentation  of  the  linea  alba  changing  it  to  a  linea  nigra,  of  the  nipples  already 
considered  and  of  the  face  is  most  common.  The  forehead,  cheek,  and  nose  are 
covered  with  brown  stains  which  cannot  be  wiped  off.  They,  when  marked,  ap- 
pear like  a  mask,  and  the  condition  has  been  called  "the  mask  of  pregnancy"  (Fig. 
135).  This  deposit  of  pigment  in  the  rete  cutis  occurs  oftener  in  nervous  women 
or  those  suffering  from  uterine  disease.  Occurring  outside  of  pregnancy,  it  is  called 
chloasma  uterinum.  Brunets  are  more  affected  than  blonds.  Women  of  careless 
personal  habits  are  more  prone  to  manifest  this  sign,  lack  of  attention  to  skin  and 
bowels  being  a  factor.  Th(^  actual  cause  of  the  deposits  is  unknown — slow  circula- 
tion in  the  capillaries,  especially  at  the  junction  of  the  embryonal  folds,  hypertrophy 
of  the  suprarenals,  active  destruction  of  the  red  blood-corpuscles,  abnormal  iron 
metabolism,  hepatic  disturbances,  and  neurotic  influences  having  all  been  invoked. 


CHANGES  DUE  TO  PREGNANCY  111 

Acc()nliii<;'  to  Sainucly,  the  pijiiiiciitut ion  is  due  to  the  action  of  a  ferment,  tyro- 
sinase, on  the  tyrosin  in  tlie  hlood  during  exposure  to  sunlif^ht.  lioth  the  BUizek 
twins  were  pigmented,  though  only  one  was  pregnant.  A  pecuHar  darkening  of 
the  eyelids  has  also  been  noted  in  pregnancy.  It  may  be  due  to  congestion  or  pig- 
ment. This  pigmentation  disappears  mostly  after  labor,  and  especially  when  the 
menses  are  estahlisiied,  but  some  of  it  may  persist  for  years.  The  vasomotor  con- 
trol of  the  cutaneous  vessels  is  disturbed  during  pregnancy;  thus  one  is  abh;  to  pro- 
duce red  lines  by  simply  drawing  the  finger  over  the  surface. 

The  sweat  and  sebaceous  glands  increase  in  activity,  requiring  more  care  of  the 
patient  to  prevent  odors.  In  imtidy  women  pityriasis  versicolor  is  more  likely  to 
develop.  The  hair  takes  on  increased  growth;  sometimes  a  fine  lanugo  appears 
on  the  face  and  chest.  This  falls  out  later.  The  nails  are  thinner.  The  suljcuta- 
neous  fat  becomes  thicker,  the  finer  features  of  the  face  coarser;  the  complexion  in 
the  early  months  is  sallow,  in  the  later  months  florid.  Diseases  of  the  skin  are  very 
common  durini!;  ]")r(>u;nancy. 

The  Nervous  System. — Pregnant  women  are  more  impressionable,  subject  to 
varying  moods,  are  hyperexcitable,  and  sometimes  a  change  in  their  character  occurs, 
a  quiet,  sweet-tempered  person  Ijecoming  querulous  and  irritable,  or  vice  versa.  The 
author  has  only  seldom  observed  such  changes  in  an}'  degree.  In  olden  times  preg- 
nant women  were  considered  morally  irresponsiljle,  and  the  condition  was  advanced 
in  extenuation  of  crime.  They  are  not  reliable  witnesses,  perception  being  not  so 
acute  and  interpretation  false.  A  tendency  to  melancholia  occasionally  develops, 
and  real  ps>'choses  are  not  uncommon,  especially  if  there  is  a  family  taint.  These 
symptoms  may  be  the  expression  of  a  toxemia,  as  also  may  be  neuralgias  (espe- 
cially facial,  sciatic,  and  dental),  the  tingling  and  numbness  in  the  extremities, 
headache,  and  disturbances  of  the  special  senses — hemeralopia,  amaurosis,  tinnitus. 
The  exaggerated  reflex  excitability  of  the  nervous  system  is  manifested  by  marked 
skin  and  tendon  reflexes,  even  ankle-clonus,  and  by  visceral  reflexes,  vomiting, 
indigestion.  In  the  early  months  a  tendency  to  sleep,  especially  after  meals,  is 
often  noticed,  and  some  women  use  this  sjmiptom  to  diagnose  the  pregnancy. 
Hysteric  women  suffer  an  exaggeration  of  their  symptoms,  and  in  them  accesses 
of  grand  hysteria  are  more  common. 

A  sort  of  fainting  spell  is  a  frequent  complaint  of  pregnant  women.  It  is  ac- 
companied by  palpitation  or  fluttering  of  the  heart,  sometimes  with  pallor,  and 
occasionally  by  slight  loss  of  consciousness,  resembling  petit  mal.  Unless  due 
to  organic  cardiac  disease,  the  symptom,  though  annoying,  is  not  dangerous. 

Literature 

Aschoff:  Wicn.  med.  Woch.,  April  13,  1911. — Blumenthal:  Beitrage  z.  Geb.  u.  Gyn.,  vol.  xi,  H.  iii,  p.  4S9. — Brickner: 
Surg.,  Gyn.,  and  Obstet.,  July,  1911.— Chauffard:  L'Obstetrique,  May,  1911.— Z>!e<ric/i.-  Arch.  f.  Gyn.,  1911. 
vol.  xciv  ,2,  p.  394.  Gives  literature. — Fischel:  Arch.  f.  Gyn.,  vol.  xxiv,  p.  3. — Freund:  Monatsschr,  f.  Geb. 
u.  Gyn.,  vol.  xx,  H.  3. — Hahl:  Arch.  f.  Gyn.,  vol.  Ixxv. — Hanau:  Fortschritte  der  Med.,  1S92,  No.  7. — Hofhauer: 
Cent.  f.  Gyn.,  190S,  p.  1196. — Jaeger:  Zeitschr.  f.  Geb.  u.  Gyn.  1911,  vol.  lx\-iii. — Kohn:  Munch,  med.  Woch., 
1910,  p.  1485. — La  Pointe  and  Thomas:  L'Obstetrique,  December,  1911,  p.  1148. — Lange:  Zeitschr.  f.  Geb. 
u.  Gyn.,  vol.  xi,  p.  34. — Miotti:  Annali  di  Ost.  e  Ginec,  Milan,  No.  ix,  p.  733. — ^[uller  and  Dreysel:  Herzhy- 
pertrophie  bei  Schwangeren  und  Wochnorinnen,  Munich,  1901. — Xey,  J.:  Arch.  f.  Gjti.,  vol.  xx^-,  p.  239. — 
Rebaudi:  Anicr.  Jour.  Obstet.,  October,  1907,  p.  477. — Vijns:  Volkmann's  Sammlung  klinische  Vortrage,  N.  F. 
Gyn.  6.5. — von  Grnff:  Arch.  f.  Gyn.,  1912,  vol.  xcv.  Zunlz:  Cent.  f.  Gyn.,  October,  1911,  No.  39. — "  Lactosuria," 
V.  Noorden's  Handb.  der  Path,  des  StofFwechsels,  vol.'ii,  p.  238;  Hofraeister  u.  Kaltenbach,  Zeitschr.  f.  physiol. 
Chem.,  vol.  ii,  p.  360;  F.  J.  McCann,  Lancet,  April  24,  1897,  p.  1174. 


CHAPTER  V 
THE  LENGTH  OF  PREGNANCY 

It  is  impossible  to  determine  tlie  time  of  conception,  as  was  shown  on  p.  2Q, 
even  when  the  date  of  the  fruitful  coition  is  certain.  Labor  occurs  often  as  the 
result  of  some  trauma — a  fright  or  any  chsturbance  of  the  woman's  ordinary  course 
of  life.  Since  the  beginning  and  the  end  of  pregnancy  are  indeterminable,  of  course 
we  camiot  estimate  the  exact  length  of  the  period.  As  a  datum  for  the  reckoning 
the  menses  are  absolutely  unreliable,  since  a  woman  may  menstruate  during  the 
first  months  of  pregnancy,  in  which  case  it  would  seem  that  she  bore  a  fully  de- 
veloped infant  after  a  short  gestation,  and,  on  the  other  hand,  a  woman  may  con- 
ceive during  a  period  of  amenorrhea,  thus  giving  the  impression  that  pregnancy  was 
prolonged  to  ten  or  even  eleven  calendar  months.  This  will  explain  those  cases, 
referred  to  in  most  text-books,  of  pregnancy  lasting  three  hundred  and  eighty  to 
four  hundred  days.     (See  Parvin,  Obstetrics,  p.  210.) 

The  most  reliable  datum  from  which  to  estimate  the  beginning  is  the  date  of 
fruitful  coition,  and,  reckoning  from  this  day,  pregnancy  has  been  found  to  vary 
from  two  hundred  and  twenty  to  three  hundred  and  thirty  days,  the  average  being 
two  hundred  and  seventy  days.  In  cows  the  average  length  of  pregnancy  is  two 
hundred  and  eighty-five  clays,  but  a  fully  developed  calf  may  be  delivered  any  time 
from  two  hundred  and  forty-one  to  three  hundred  and  twenty-one  days  after  the 
cow  was  covered  (Ahlfeld).  From  time  immemorial  women  have  reckoned  two 
hundred  and  eighty  da,ys,  ten  lunar  months,  or  nine  calendar  months,  from  the  first 
day  of  the  last  period  as  the  length  of  normal  gestation,  and  for  practical  purposes 
this  may  be  accepted,  because  in  the  majority  of  cases  it  holds  true,  but  one  must 
remember  and  admit  the  exceptions.  No  doubt  some  children  require  a  longer 
time  in  the  uterus  for  full  development  than  others.  Some  seeds  in  favorable  soil 
grow  faster  than  others.  The  writer  has  delivered  children  that  were  carried  eight 
months  that  were  as  fully  matured  as  full-term  infants,  and  also  in  one  case,  figuring 
as  accurately  as  is  ever  possible,  he  delivered  a  child  weighing  three  and  one-half 
pounds  which  was  fully  three  weeks  over  term. 

The  German  law  recognizes  the  legitimacy  of  a  child  born  three  hundred  and 
two  days  after  the  death  of  the  husband;  the  French  law,  three  hundred,  and  in 
America,  while  there  is  no  legal  limit,  three  hundred  and  seventeen  days  was  judi- 
cially allowed  (Schatz).  The  reader  desiring  authorities  in  medicolegal  cases  of 
this  kind  should  consult  v.  Winckel  {loc.  cit.). 

Without  doubt  pregnancy  may  be  prolonged  and  an  overgrown  child  delivered. 
Von  Winckel  found  that  in  2.2  per  cent,  of  children  weighing  more  than  4000  gm. 
(8^  pounds)  the  pregnancy  had  lasted  more  than  three  hundred  and  two  days. 
CiuUa  found  that  in  1  case  of  200  the  pregnancy  lasted  more  than  three  hundred  and 
twenty  days.  Children  that  are  carried  over  term  may  be  larger  in  all  dimensions, 
or  they  may  grow  longer  and  harder  (Bossi).  The  cranial  bones  ossify,  the  bi- 
parietal  diameter  increases,  the  body  becomes  firmer  and  less  pliable;  thus  in  both 
instances  delivery  is  rendered  difficult  and  more  dangerous  to  mother  and  child. 
Children  that  are  being  carried  over  time  not  seldom  die  before  labor.  A  careful 
autopsy  performed  in  a  case  of  this  kind  showed  no  pathologic  changes  except  granu- 
lar degeneration  of  the  epithelium  of  the  kidneys.  In  some  instances  labor  pains 
come  on  at  the  computed  term  of  pregnancv,  but  they  subside  and  a  period  of  three 

112" 


THE  LENGTH  OF  PREGNANCY  113 

or  four  weeks  elapses  until  actual  delivery  occurs.  The  author  considers  it  inad- 
visable to  allow  a  woman  to  continue  far  beyond  the  normal  date  of  term,  and,  in 
the  interest  of  both  child  and  mother,  induces  labor  in  such  cases.  "Missed 
labor"  is  a  term  introduced  by  Oldham  to  describe  cases  where  pains  come 
on  when  expected,  but  cease,  th(>  child  dies,  and  is  carried  in  the  uterus  a  greater  or 
shorter  time,  as,  in  one  casse,  eleven  months.  A  dead  ovum  carried  in  the  uterus  is 
not  pregnancy.  Various  factors  may  influence  the  length  of  gestation,  as  the  age  of 
the  woman,  the  s(\\  of  the  child,  etc.  Young  women  are  likely  to  have  a  shorter 
gestation;  older  women,  longer.  Women  who  have  been  sterile  for  3'ears  and  old 
primiparae  are  likely  to  go  over  term.  Women  who  have  delayed  puberty,  dys- 
menorrhea, who  have  long  hard  rigid  cervices,  are  also  likely  to  have  delayed  labor. 
Primipani?,  except  old  ones,  not  seldom  fall  into  labor  a  few  weeks  before  the  date 
set,  the  tense  abdominal  wall  forcing  the  head  into  the  pelvis  against  the  cervix, 
which  evokes  pains.  Subsecjuent  children  are  carried  longer,  until  the  sixth  or 
eighth,  when  the  uterus,  because  of  lack  of  tonus  or  of  pathologic  changes,  expels  the 
product  of  conception  as  soon  as  it  is  ripe.  Males  are  said  to  be  carried  longer  than 
females.  While  this  is  true  in  animals,  the  author  cannot  confirm  it  from  his  own 
experience.  Women  who  are  active  in  the  last  months  of  pregnancy  are  less  likely 
to  go  over  term  than  the  lazy  ones,  who  take  no  exercise.  One  notices  this  in  hos- 
pital practice.  There  is  a  popular  notion  that  a  gravida  should  exercise  much  dur- 
ing gestation  or  "the  baby  will  be  grown  to  her  side,"  meaning  that  she  will  have  a 
difficult  labor  from  overgrowth  of  the  infant.  In  summer  women  are  likely  to  give 
birth  earlier  than  in  winter.  Heredity  seems  to  play  a  role.  De  la  Motte  reports 
the  case  of  a  woman  who  had  two  children  at  the  seventh  month.  These  girls  grew 
up,  married,  and  had  children  at  seven  months.  Retzius  describes  an  instance  of  a 
mother  and  her  two  daughters  in  all  of  whom  pregnancy  was  much  prolonged. 

Precocious  and  Late  Pregnancy. — The  earliest  authentic  pregnane^'  is  reported 
by  Bodd.  The  girl  was  eight  years  and  ten  months  old,  and  delivered  a  child  weigh- 
ing 3500  gm.  (about  7^2  pounds),  which  had  hair  on  the  pubis.  Pregnancy  in  girls 
of  twelve  to  fifteen  is  not  rare,  and  experience  shows  that  most  of  the  children  live 
and  that  labor  is  not  always  difficult.  The  pelvis  develops  rapidly  during  preg- 
nancy, and  the  child  is  usually  small,  with  a  soft  head,  which  accounts  for  the  un- 
expected safety  of  these  precocious  labors.  The  latest  pregnancy  on  record  is  the 
one  reported  by  Kennedy.  The  woman  was  sixty-two  years  old,  and  this  was  her 
twenty-second  labor.  The  author  delivered  a  woman  of  fifty-two  years  safely  of  a 
living  infant  w^eighing  over  seven  pounds.  In  some  of  the  cases  reported  (Strass- 
man)  menstruation  had  been  absent  for  years. 

Literature 

Ahlfeld:  Lohrb.  dcs  Geb.,  1903,  p.  94. — BodfJ:  L'Abeille  Medical,  1882. — Bossi:  Gynakologishor  Rundschau,  Vienna, 
vol.  i,  Xo.  1. — Ciulla:  Zeitschr.  f.  Geb.  u.  Gyn.,  1910,  vol.  Ixvii,  H.  2.  Literature.- — Kennedy:  Trans.  Obstet. 
Soc,  Edinburgh,  1882,  vol.  \'ii. — iJe^zius;  Ribemont,  Dessaignes,  and  Le  Page:  Precis  d'  Obstetrique,  p.  196. — 
Schatz,  P.:  Arch.  f.  GjTiiik.,  1908,  vol.  Ixxxiv,  H.  21. —^trassman:  Handb.  d.  Geb.,  vol.  i,  p.  95. — v.  Winckel:  Volk- 
mann's  klin.  Vortriige,  N.  F.,  1901,  p.  293;  Handb.  d.  Geb.,  vol.  i,  p.  652. 


SECTION  II 

PHYSIOLOGY  OF  LABOR 


CHAPTER  VI 
DEFINITION— CAUSES— CLINICAL  COURSE 

Labor  is  a  function  of  the  female  organism  by  which  the  product  of  conception 
is  expelled  from  the  uterus  through  the  vagina  into  the  outside  world,  the  regressive 
metamorphosis  of  the  genitals  started,  and  the  secretion  of  milk  inaugurated.  There 
are  three  essential  points  in  the  definition,  which  excludes  the  extraction  of  the  fetus 
by  any  other  passage,  as  in  cesarean  section.  Synonyms  for  labor  are  delivery, 
parturition,  travail,  childbirth,  accouchement,  confinement. 

Abortion  is  the  interruption  of  pregnancy  before  the  fetus  is  viable,  i.  e.,  capable 
of  extra-uterine  existence,  which  is  after  the  twenty-sixth  week. 

Premature  labor  is  the  interruption  of  pregnancy  after  the  fetus  is  viable,  but 
before  term,  i.  e.,  the  normal  end  of  gestation. 

Miscarriage  is  an  expression  used  by  the  laity  to  signify  the  occurrence  of  a 
premature  interruption  of  the  pregnancy  at  any  time. 

Labor  should  be  a  normal  function  of  the  human  female.  It  is  so  intricate, 
however,  that  a  great  many  irregularities  may  mark  its  course.  The  unhygienic 
surroundings  in  which  women  live,  prior  diseases,  the  tendency  to  laziness,  the  evils 
of  dress,  of  living,  occupation,  heredity,  chronic  endometritis,  salpingitis,  the  evolu- 
tion of  the  head,  i.  e.,  increased  size  of  the  child's  cranium,  due  to  the  increased 
mental  capacities  of  the  race,  all  tend  to  produce  conditions  which  influence  the 
course  of  labor  and  may  make  it  absolutely  impossible  in  a  given  case,  or  fraught 
with  great,  even  fatal,  clanger. 

We,  therefore,  must  divide  cases  into  two  groups : 

1.  Normal  labor,  or  eutocia. 

2.  Abnormal  (pathologic)  labor,  or  dystocia. 

As  a  matter  of  fact,  a  really  normal  labor  without  the  slightest  irregularity  is 
rare;  almost  alwaj's  there  is  some  small  point  that  is  peculiar,  although  it  may  not 
affect  the  course  of  the  labor,  and  the  case  may  end  favorably  for  mother  and  child. 
In  general  we  call  those  cases  normal  where  we  do  not  have  to  interfere — where  the 
woman  expels  the  child  and  placenta  herself,  and  she  and  the  child  live.  Strictly 
speaking,  however,  unless  the  woman's  condition  is  exactly  as  good  as  it  was  before 
conception  and  the  child  perfectly  well  and  uninjured,  the  labor  may  not  be  called 
normal.  Such  cases  as  these  are  excessively  rare.  The  boundaries  between  eutocia 
and  dystocia  are  very  narrow,  and  depend  largely  on  the  individual  views  of  the 
obstetrician.  Certain  complications  are  classed  by  some  under  eutocia,  while  by 
others  they  are  called  distinctly  pathologic.  For  example,  I  consider  the  vomiting 
of  pregnancy,  the  kidney  of  pregnancy,  breech  and  face  presentation,  rupture  of 
the  urogenital  septum,  to  be  pathologic  conditions,  while  many  authors  hold  them 
to  be  normal. 

In  the  study  of  the  phenomena  of  parturition  four  factors  must  be  considered: 
(1)  The  powers,  by  which  the  expulsion  of  the  ovum  is  accomplished;    (2)  the  pas- 

114 


DEFINITION — CAUSES — CLINICAL  COURSE  115 

sages,  which  roprcsont  tlic  road  tiiul  llie  rcsistancps  met;  (3)  the  'paaaemjers,  the  cliild 
and  its  adnexa^  (phiccnta,  etc.);  and  (4)  external  coniplicalion.s  which  may  (hsturb 
the  course  of  the  function.  Tiic  hist-naincd  factor  is  the  pathohj^i'-  one,  and  will 
be  omitted  for  the  jjreseiit.  The  other  tiu-ee  factors  make  up  the  study  of  the 
mechanism  of  lahor. 

The  Causes  of  Labor. — W'liat  l)rinp;s  on  hi])or?  Why  should  the  uterus  which 
has  carried  the  oN'um  for  so  many  months,  suddenly  violently  expel  it?  Nature 
certainly  reco<;nizes  the  risht  moment  for  the  exi)ulsion,  since  it  is  almost  always 
accomplished  at  a  time  when  the  child  is  best  able  to  carry  on  extra-uterine  existence, 
and  before  it  has  become  too  large  to  pass  safely  through  the  parturient  canal. 
What  the  cause  is  that  sets  the  uterus  in  action  has  been  the  subj(>ct  of  much  specula- 
tion and  investigation,  but  nature  still  hides  the  secret.  We  v/ish  to  know  it,  be- 
cause often  it  is  necessary  to  bring  on  labor  ourselves,  and  experience  has  shown  that 
it  is  wise  to  follow  nature's  methods  in  accomplishing  things.  The  many  theories 
can  only  be  touched  upon. 

1.  The  ovum  is  prepared  for  separation  by  the  degeneration  of  the  decidua  in  the  later 
months  of  pregnancy,  and  the  disappearance  of  the  placental  septsp,  thus  loosening  the  attachment 
of  the  latter  to  the  uterine  wall.  The  ovum,  then,  according  to  Simpson,  Huve,  and  Scanzoni, 
becomes  a  foreign  body.  The  placenta  does  not  loosen  its  Hving  attachment  to  the  uterine  wall 
until  the  child  is  delivered,  therefore  this  theory  is  untenable. 

2.  Thrombosis  in  the  placental  vessels  causing  increase  of  the  carbon  dioxid  content  of  the 
uterine  blood  has  been  advanced  by  Leopold.  The  thrombosis  is  not  constant,  and  it  too  must  be 
explained. 

3.  Bro^^Tl-S6quard  proved  that  an  increase  of  carbon  dioxid  in  the  blood  will  evoke  uterine 
contractions.  Lack  of  oxygen  will  do  the  same.  The  increased  venosity  of  the  fetal  blood,  which 
normally  occurs  in  the  later  months,  due  to  the  narrowing  of  the  ductus  Arantii  and  ductus  liotalli, 
has  also  been  suggested  as  provocative  of  uterine  action — all  not  proved,  but  they  indicate  chemic 
lines  of  stutly  instead  of  mechanical. 

4.  Products  of  altered  metabolic  activity  of  the  mother  or  from  the  child,  accumulating  in 
the  maternal  blood,  may  evoke  the  pains,  either  by  way  of  the  uterine  innervation  or  indirectly 
through  the  vasomotor  system.  SchaefTcr  beheves  that  the  sjmcytium  has  an  influence  in  limiting 
the  passage  of  poisons  from  the  fetus  to  the  mother.  Late  in  pregnancy  the  action  of  the  SAoicytium 
is  insufficient.  Others  have  referred  to  the  possibility  of  fetal  poisons  stimulating  the  uterine 
muscle.  Williams  found  that  just  before  labor  there  was  diminished  nitrogen  output  in  the  urine, 
with  marked  diuresis,  confirming  the  suspicion  that  metabohc  changes  are  involved  in  the  causation 
of  labor.  It  is  possible  that,  by  working  this  field,  the  active  factor  may  be  discovered.  We  know 
that  diphtheria  antitoxin  sometimes  brings  on  abortion. 

5.  Mauriceau  believed  that  the  excessive  distention  of  the  uterine  wall  resulted  in  labor. 
The  uterine  wah  Is  not  distended  at  term,  therefore  only  in  pathologic  cases,  as  t\\-ins, — polyhy- 
dramnion, — could  such  a  force  act. 

6.  The  increased  irritability  of  the  uterus  is  generally  acknowledged  to  be  an  important 
factor.  'We  know  that  the  uterus  contracts  from  the  beginning  of  pregnane}',  and  also  that  the 
contractions  become  stronger  and  more  easily  elicited  toward  the  end.  This  marked  irritability 
is  due  to  the  great  increase  in  the  development  of  the  muscular  fibers  and  the  nerves  and  cells  of 
the  cervical  ganglion.  When  the  end  of  pregnancy  is  near,  some  slight  accident  may  make  the 
contractions  stronger,  and  each  contraction  stimulates  the  succeeding  one  until  regularity  is 
estabhshed. 

7.  The  influence  of  the  periodicity  of  menstruation  cannot  be  denied,  though  why  the  final 
effort  of  the  uterus  shoidd  come  at  the  completion  of  the  ten  menstrual  cj'cles  is  not  understood. 
It  is  not  believed  that  the  ovaries  have  anything  to  do  with  it,  since  labor  can  occur  \\-itiiout  them. 
The  same  is  true  of  the  corpus  luteum,  though  Born  and  Friinkel  have  sought  to  connect  the  two. 
In  some  women,  particularly  those  of  a  nervous  type,  there  occur,  during  pregnancy,  at  the  time 
of  the  usual  menses,  peculiar  sensations  and  manifestations  which  show  that  some  influences  are 
at  work.  Neuralgic  pains,  especially  in  the  sacrolumbar  region,  insomnia,  skin  eruptions,  increase 
of  the  varicosities,  vomiting,  nausea,  diarrhea,  constipation,  decreased  urine,  sometimes  albumin, 
uterine  pain,  sometimes  small  hemorrhages,  and  the  tendency  to  abort  are  greater  at  these  periods. 
G.  de  Paoli  studied  these  changes  in  30  women,  and  foimd  diminished  lung  capacity-;  lower  blood- 
pressure;  increased  sensibility  of  the  skin  and  of  the  reflexes;  more  rapid  pulse.  Pathologic  con- 
ditions are  more  common  at  these  periods — for  instance,  eclampsia,  fainting,  hysteria,  pains  in  the 
bones. 

8.  Pressure  of  the  presenting  part  on  the  lower  uterine  segment  on  the  cervix  and  the  ner\-es 
of  the  great  cervical  and  retrocervical  ganglia,  and  other  plexuses  around  the  cervix  and  upper 
vagina,  is  an  old  (Galen,  Power)  and  favorite  theory,  but  it  will  not  explain  all  cases,  such  as  breech 
and  transverse  presentation  and  the  uterine  contractions  of  extra-uterine  pregnancy.  In  some  cases 
the  head  maybe  deep  in  the  pelvis,  and  pressing  hard  on  the  cervix,  without  evoking  pains.  Still, 
clinical  experience  shows  that  when  the  child  settles  well  into  the  lower  uterine  segment  the  dila- 
tation of  the  cervix  begins,  and  labor  comes  on.  The  methods  emploj'ed  in  inducing  labor  nearly 
aU  operate  by  irritations  applied  to  the  nerves  of  tlfis  region,  e.  g.,  the  packing  of  the  cer^-ix  \A-ith 


116  PHYSIOLOGY    OF   LABOR 

gauze,  the  application  of  colpeurynters,  bougies,  etc.  One  can  often  bring  on  labor  by  passing  the 
finger  around  the  internal  os  and  stretching  it  a  little. 

These  are  the  principal  theories,  of  which  the  most  plausible  are  pressure  of  the  presenting 
part  on  the  ganglia  and  nerves  of  the  lower  uterus  and  cervix,  the  increased  irritability  of  the  uterus, 
and  changes  in  the  blood  of  the  mother,  fetal  in  origin. 

9.  The  importance  of  accident,  however,  must  not  be  overlooked.  When  everything  is 
ready  for  labor,  the  parts  softened,  the  cervix  begun  to  unfold,  the  uterine  muscle  well  developed 
and  having  attained  a  high  degree  of  irritabihty,  it  is  easy  to  see  how  some  slight  cause,  mechanical 
or  emotional,  may  suddenly  start  the  uterine  contractions.  As  soon  as  one  contraction  has  oc- 
curred it  seems  to  form  the  irritant  for  another,  or  forces  the  ovum  against  the  cervix,  stimulating 
the  nerves,  so  abundant  here,  and  thus  labor  is  put  in  progress.  Such  exciting  causes  are  physical 
shocks, — jolts,  running  up  or  do\\'n  stairs,  coitus,  diarrhea,  straining  at  stool — mental  shocks, — 
sudden  fright  or  joy, — of  which  there  are  numerous  illustrious  examples.  The  Bible  tells  us  that 
the  wife  of  Pliineas,  upon  hearing  that  her  husband  was  killed  in  battle,  went  into  labor.  A 
patient  of  the  author's,  feeling  that  her  labor  was  due,  walked  down  and  up  the  six  flights  of  stairs 
to  her  hotel  apartment.  Pains  came  on  within  a  few  hours.  She  had  a  slight  hemorrhage  behind 
the  placenta.     A  dose  of  castor  oil  or  quinin  will  often  bring  on  labor  at  term. 

Most  recently,  the  onset  of  labor  has  been  ascribed  to  an  anaphylactic  process. 
In  1905  I  began  a  series  of  experiments,  seeking  to  prove  that  ferments  circulating 
in  the  blood  of  parturient  horses  could  invoke  labor  in  pregnant  guinea-pigs,  but 
was  unable  to  prosecute  the  research  to  the  end.  The  action  of  other  hormones  in 
affecting  distant  organs  is  proved,  and  it  is  possible  that  serology  will  finally  clear 
up  the  mystery.  The  action  of  pituitrin  must  be  borne  in  mind.  Experiments  by 
Sauerbruch  and  von.der  Heide  with  rats  show  that  substances  appear  in  the  blood 
in  the  later  weeks  of  pregnancy  which  cause  disease  in  non-pregnant  animals.  Von 
der  Heide  injected  fetal  blood-serum  into  pregnant  women  at  term  and  evoked 
labor  pains.  He  explained  the  reaction  as  anaphylactic.  There  also  seems  to  be 
some  serologic  relation  between  the  mammse  and  the  uterus.     (Healy  and  Kastle.) 


THE  CLINICAL  COURSE  OF  LABOR 

It  will  be  simpler  to  study  the  complicated  problems  of  labor  if,  first,  we  get  a 
clear  picture  of  its  clinical  course;  that  is,  what  may  be  seen  and  felt  while  attending 
a  woman  in  parturition. 

In  most  primiparse  and  many  multiparse  there  is  a  prodromal  stage  of 
labor,  but  in  both  the  symptoms  may  be  so  slight  that  they  may  be  unnoticed, 
and  labor,  therefore,  seems  to  come  suddenly.  The  prodromata  are:  (1)  Light- 
ening, with  its  symptoms,  relief  of  pressure  in  the  upper  belly,  and  increase  of 
pressure  in  the  pelvis,  together  with  a  mucous  discharge  from  the  vagina.  (2) 
False  pains;  in  the  latter  weeks  of  pregnancy  the  patient  is  often  annoyed  by  con- 
tractions of  the  uterus  which  are  painful.  They  occur  especially  at  night,  subsiding 
toward  morning.  The  uterus  contracts  at  intervals  throughout  pregnancy,  and 
shows  greater  irritabilit}^  near  the  end.  This  sign  is  of  value  in  determining  that 
labor  is  at  hand.  Ordinarily,  the  contractions  are  not  painful  until  actual  labor  sets 
in.  False  pains  may  be  simulated  by  gas  in  the  bowels,  constipation,  and  appendi- 
ceal or  gall-stone  colic.  Many  women  complain  of  drawing  sensations  in  the  pelvis 
similar  to  those  experienced  during  menstruation,  sometimes  amounting  to  pain; 
these  are  called  dolores  preesagientcs,  and  often  accomplish  effacement  and  dilata- 
tion of  the  cervix.  (3)  About  twenty-four  or  forty-eight  hours  before  labor  there 
is  a  discharge  of  mucus,  often  mixed  with  blood.  It  is  the  plug  which  formerly 
filled  the  cervix,  closing  off  the  uterine  cavity  from  the  vagina.  The  blood  comes 
from  the  surface  left  bare  by  the  separation  of  the  clecidua.  It  is  more  or  less  pro- 
fuse, is  important,  and  is  called  the  "show."  If  the  placenta  is  situated  low  in  the 
uterus,  the  show  is  likely  to  be  quite  bloody.  Occasionally  the  show  does  not 
appear  until  labor  has  been  in  progress  some  time.  (4)  An  examination  in  the  last 
three  weeks  of  pregnancy  shows  the  cervix  soft,  shortened,  perhaps  completely 
effaced — in  primiparai  the  external  os  opened  for  one  or  perhaps  two  fingers.  In 
multipara  the  cervix  will  admit  two  fingers  to  the  membranes.  Exceptionally,  the 
external  os,  as  well  as  the  internal,  remains  tightly  closed  until  labor  begins,  but 


DEFINITION — CAUSES — CLINICAL    COURSE 


117 


this  is  al)nc)rnial,  and  is  usually  duo  to  cervical  disease.  Occasionally  the  os  is 
dilated  to  admit  two  or  three  fingers — the  "  travail  insensible  "  of  the  French.  How- 
ever, it  is  unsafe  to  predict  with  certainty  the  near  approach  of  labor  from  the  patu- 
lousness  of  the  cervix,  though  it  is  ciuitc;  j)robal)le.  (o)  The  vulva  is  enlarged,  suc- 
culent, and  patulous,  the  pelvic  lloor  pr(jjection  very  decided. 

The  transition  into  labor  is  usually  very  gradual,  but  we  say  that  labor  has  be- 
gun when  the  contractions  of  the  uterus  become  sensible  to  the  patient — that  is, 
painful ;  wlicu  t  hey  recur  at  regular  intervals,  and  when  they  are  effective  in  dilating 
the  cervix  and  os. 

The  ])rocess  of  parturition  naturally  (li\idcs  itself  into  three  stages  or  periods: 
The  first  stage  extends  from  the  beginning  of  regular  uterine  contractions  until 
the  OS  is  completely  dilated  and  flush  with  the  vagina,  thus  completing  the  continu- 
ous channel  called  the  "parturient  canal."     This  is  the  stage  or  period  of  dilatation. 
The  membranes  usually  rupture  at  the  end  of  this  stage — perhaps  during  it.     The 


13G. — Composite  Picture  Showixg  the  Uterus  before  and  during  Contraction. 


first  stage  does  not  include  the  rupture  of  the  ])ag  of  waters,  the  time  of  which  is 
very  variable. 

The  second  stage  extends  from  the  end  of  the  first  stage  until  the  exi^ulsion  of 
the  fetus  is  completed.     It  is  the  stage  of  expulsion. 

The  third  stage  extends  from  the  delivery  of  the  child  until  after  the  exiDulsion 
of  the  placenta  and  membranes  and  contraction  and  retraction  of  the  uterus  are 
completed.     It  is  the  period  of  the  after-birth,  or  the  placental  stage. 

In  the  first  stage,  recurring  regularly  about  fifteen  minutes  apart,  we  notice  the 
uterine  contractions.  These  are  appreciated  by  the  patient  as  pain,  and  have  been, 
therefore,  designated  by  the  various  races  from  time  immemorial  as  "pains," 
"dolores,"  "douleurs,"  "Wehen."  No  normal  lahor  is  painless,  though  quite  a 
few  such  have  been  ol^served.  Writers  of  all  ages  have  described  labor  as  painful. 
The  Bible  mentions  it  in  numerous  places.  Accounts  of  uncivilized  races  disprove 
the  claim  made  by  some  that  with  them  child-bearing  is  painless.  (See  Floss, 
"Das  Weib  in  der  Natur  und  Volkerkunde";  Engelman,  "Labor  Among  Primitive 
Peoples.") 


118 


PHYSIOLOGY    OF   LABOR 


Still,  the  severity  of  the  pain  varies.  Some  races,  especially  the  uncivilized, 
have  generally  easy  labors,  whereas  the  highly  cultured  woman  has  hard,  painful 
labors.  This  is  true  to  a  certain  extent,  in  our  civilized  country,  in  the  difference 
between  the  poor  and  the  rich.  The  pain  varies  in  different  women,  and  the  ability 
to  stand  pain  varies  in  women,  as  it  does  in  men. 

As  the  labor  progresses  the  pains  gradually  grow  stronger.  Whereas  at  first 
the  patient  just  bends  over  a  little,  shows  a  change  of  countenance,  after  a  few  hours 
she  may  utter  a  cry.  The  cry  is  simply  one  of  pain,  similar  to  that  of  a  severe  tooth- 
ache or  intestinal  colic.  One  observes  much  individual  difference  in  women  regard- 
ing the  pain  of  labor.     Those  of  quiet,  even  temperament  and  strong  will-power 


Fig.   137. — B.^ll-valve  Action  of  Head. 
Head  at  A-A  divides  uterus  into  two  cavities.     Pressure  in  G  is  much  less  than  in  B. 


bear  their  sufferings  bravely  and  aid  the  physician  and  nurse,  while  the  nervous, 
hysteric  parturient  cries  out  even  early  in  the  first  stage,  demanding  an  anesthetic 
or  even  delivery,  and  not  seldom  gives  an  otherwise  normal  labor  a  pathologic  trend. 
The  very  first  pains  are  usually  felt  in  the  small  of  the  back,  but  soon  they  draw 
around  to  the  front  and  are  described  as  grinding,  or  like  a  severe  general  intestinal 
colic.  They  often  seem  to  come  in  pairs — a  mild  one  followed  by  a  severe  one. 
They  last  thirty  to  ninety  seconds  or  longer.  The  character  of  the  pain  varies  in 
different  women,  different  labors,  and  different  times  of  one  labor.  They  may  sub- 
side and  recommence  after  hours  or  days  (rare).  The  patient  is  cheerful  between 
pains  or  may  doze.  As  the  pains  grow  stronger  the  intervals  become  shorter — ten, 
eight,  five,  four  minutes.     During  the  pain  one  observes  the  uterus  contract.     This 


DEFINITION — CAUSES — CLINICAL    COURSE 


119 


begins  before  the  i)uiu  is  fell,  and  ends  after  tlie  painfulness  is  over  (Fig.  130).  The" 
uterus  rises  high  in  tlie  abdomen,  increases  in  (Uaineter  anteriorly  and  posteriorly, 
and  decreases  laterall>',  assuming  a  jx'ar  shape.  At  the  same  time  it  becomes 
tendei-,  tense,  and  the  ligaments  stand  out  shari)ly.  There  is  a  stage  of  accrement, 
acme,  and  (k'cremenl  in  each  pain. 


Coiitructioii  ^ 
ring 


Internal  os 


External  03 


Fig.  138. — Cervix  at  Beginning  of  Labor,  Showing  Three  Successive  Stages  of  Effacement  in  a  Primipara. 

Under  the  influence  of  the  uterine  contractions — 

1.  A  larger  amount  of  the  serum  is  forced  into  the  lower  uterine  segment, 
cervix,  and  upper  vagina. 

2.  The  fibers  of  the  lower  uterine  segment  and  cervix  are  drawn  up  into  the 
body  of  the  organ. 


Con- 
trac- 
tion 
ring 


Internal 


y 


Canal  opening 
External  os 


FiQ.  139.— Same  as  Fig.  13S. 
Effacement  half  completed. 


3.  The  liquor  amnii  is  forced  in  the  direction  of  the  internal  os. 

4.  The  membranes  are  bulged  out  through  this. 

5.  The  retraction  of  the  fibers  of  the  lower  uterine  segment  and  cervix,  and  the 
memliranes  ]:)eing  forced  down  into  the  cervix  like  a  Viladder,  cause  a  dilatation  of 
the  cervix  from  above  downward,  and  finally  the  full  opening. of  the  external  os.  This 


120 


PHYSIOLOGY    OF   LABOR 


dilatation  of  the  cervix  by  the  bag  of  waters  is  a  very  gentle  and  efficient  one. 
The  whole  force  of  the  uterus  is  not  used,  since  the  head  resting  against  the  lower 
uterine  segment  divides  the  cavity  into  two  parts  (Fig.  137).  The  resistance  at 
A-A  diminishes  the  power  of  C-C,  therefore  the  tension  in  G  is  not  so  great  as  in  B. 
Should  the  body  not  press  fast  to  A-A,  allowing  the  fluid  in  B  to  communicate  with 
the  fluid  in  G,  the  tension  in  G  would  equal  that  of  the  space  of  B.  This  occurs  often 
clinically.  During  a  pain  the  tension  in  B  rises;  therefore  also  of  G,  but  to  a  less 
degree;  when  the  pain  passes  away  the  tension  in  both  subsides.  Thus  it  is  seen 
how  the  head  acts  as  a  ball-valve,  and  becomes,  with  the  membranes,  the  gentlest 
possible  method  to  efface  and  dilate  the  cervix.  Compare  this  to  the  rough  dilata- 
tion which  would  occur  were  there  no  bag  of  waters,  and  if  the  head  were  driven 
through  the  cervix  by  uterine  and  abdominal  forces.  This  happens  when  the  bag 
of  waters  ruptures  before  labor,  especially  in  primiparse.  These  are  called  "dry 
labors,"  and  are  usually  long,  tedious,  and  painful.  Operative  interference  is 
oftener  necessary  in  dry  labors. 


External  os 


Fig.   140.— Same  as  Fig.  1.38, 
Effacement  complete.     Dilatation  just  beginning. 

We  have  used  two  terms  which  need  explanation — effacement  and  dilatation 
of  the  cervix.     At  the  beginning  of  labor  the  cervix  is  shaped  as  in  Fig.  138. 

By  the  action  of  the  uterus,  which  we  will  later  study  more  minutely,  the  muscle- 
fibers  are  drawn  up  into  the  uterine  body,  the  membranes  are  forced,  pouch  like, 
into  the  cervical  canal,  the  two  processes  resulting  in  a  dilatation  of  the  cervix  from 
above  downward.  The  cervix  is  "taken  up,"  it  is  "obliterated,"  it  is  "shortened," 
it  is  "effaced."  The  latter  term  is  the  one  preferred  by  the  author.  When  the 
cervix  is  so  far  taken  up  that  only  the  external  os  remains,  we  say  that  effacement  is 
complete.  Dilatation  now  begins  (Fig.  143).  When  the  external  os  is  opened  so 
wide  that  it  is  flush,  or  nearly  so,  with  the  vagina,  dilatation  is  complete,  and  the 
child  is  now  able  to  pass  through  it  (Fig.  144).  Coincident  with  the  dilatation  the 
cervix  is  drawn  up  into  the  abdomen,  so  that,  when  the  dilatation  is  complete,  the 
external  os  is  high — almost  out  of  the  reach  of  the  finger.  The  bag  of  waters  usually 
ruptures  at  this  point. 

The  comparison  of  the  parturient  passage  to  the  two  funnels,  one  placed  above 
the  other,  is  quite  apt.  The  child  has  to  pass  first  through  the  upper,  the  cervix, 
and,  second,  through  the  lower,  the  pelvic  floor.  Effacement  of  the  cervix  and  dila- 
tation occasionally  occur  simultaneously,  especially  in  multiparse  (Figs.  141  and  142). 


DEFINITION — CAUSES — CLINICAL    COURSE 


121 


When  tlie  cervix  is  iully  opened,  the  first  stuj^e  ol"  lahor  is  ended,  und  the  second 
stage  l)esins. 

The  Bag  of  Waters. — B;iudeloe(iue  defined  the  bag  of  waters  as  that  portion 
of  the  iiiciiihraiics  wliich  jjouched  into  the  cervix  (hu'ing  the  uterine  contraction. 
Later  writers  gave  the  name  to  that  portion  of  1  he  nninhranes  which  was  uncovered 
by  the  cUlating  (is.     Others  call  the  wIujIc  anmiolic  sac  the  bag  of  waters.     The 


Coiitructiun  rin^; 


Iiitornal  03 


External  03 


Internal  os- 


Fig.  1-il. 


External  os 


Fig.  142. 
Figs.  141  and  142. — Two  Stages  of  the  Combixed  Effacement  and  Dil.\tatiox  of  a  Mcltiparocs  Cervix. 


author  prefers  the  latter  view,  though  when  speaking  of  the  liag  of  waters  the  part 
presenting  over  the  os  is  the  part  usually  referred  to.  At  the  l^eginning  of  labor  the 
membranes  point  into  the  cervix  like  a  flat  cone.  As  the  dilatation  progTesses  the 
bag  of  waters  assumes  the  shape  and  appearance  of  a  large  watch-crystal,  projecting 
through  the  os  (Fig.  146).  If  the  membranes  are  soft  and  exposed  to  the  whole 
pressure  in  the  uterus,  they  bulge  out  into  the  vagina  or  may  rupture  early.     If  the 


122 


PHYSIOLOGY    OF    LABOR 


chorion  ruptures,  the  amnion  may  project  through  the  partly  chlated  os  Hke  a  sac 
(Fig.  148).  If  the  head  fits  closely  onto  the  lower  uterine  segment  and  the  mem- 
branes are  firmly  adherent,  no  bag  of  waters  forms,  and  labor  is  usually  delayed  in 
such  cases  (Fig.  I-IQ). 

The  best  time  for  the  membranes  to  rupture  is  when  the  cervix  is  completely 
effaced  and  dilated,  but  they  may  break  at  any  stage,  even  before  the  pains  begin, 
(dry  labor) .  If  the  chorion  ruptures  alone,  the  amnion  may  be  pushed  out,  cover- 
ing the  head  of  the  advancing  child,  and  may  be  delivered  with  the.  latter.  The 
child  is  said  to  be  born  with  a  "caul"  and  to  be  lucky.  The  caul  must  be  removed 
as  soon  as  the  head  is  born,  to  allow  the  infant  to  breathe. 

The  rupture  of  the  bag  of  waters  usually  takes  place  at  the  height  of  a  strong 
pain,  and  is  oftenest  central,  the  waters  coming  with  a  gush.  Or  the  rupture  may 
take  place  high  up,  and  the  waters  dribble  away  at  each  pain.     Sometimes  an  ac- 


FiG.  143. — Effacement  is  Complete,  Dilatation  is  Going  On. 


cumulation  of  fluid  between  the  two  membranes  occurs,  and  the  chorion  ruptures 
while  the  amnion  remains  intact.     Thus  we  seem  to  have  two  bags  of  water. 

After  the  rupture  of  the  bag  of  waters  there  is  generally  a  short  pause  in  the 
pains.  The  uterus  needs  time  to  accommodate  itself  to  the  diminished  size  of  its 
cavity  and  for  the  retraction  of  its  muscular  lamellse.  A  few  drops  of  blood  may 
now  appear,  coming  from  decidual  separation. 

Coincidentally  with  these  changes  in  the  cervix  the  fetal  body  has  descended 
lower  into  the  pelvis,  the  bag  of  waters  or  the  head  distends  the  vagina  and  may 
reach  the  pelvic  floor.  It  presses  on  the  nerves  of  the  rectum  and  outlet  of  the  pelvis, 
and  the  parturient  feels  like  ])earing  down  as  if  at  stool. 

The  Second  Stage  Has  Begun. — The  pains  grow  stronger,  more  frequent, — 
every  three  or  two  minutes, — and  are  changed  in  character,  being  expulsive.  The 
patient  utters  a  peculiar  cry.  She  feels  there  is  a  body  in  the  pelvis  which  she  must 
force  out;    she  closes  the  glottis,  having  fixed  the  chest  in  inspiration,  braces  the 


DEFINITION — CAUSES — CLINICAL    COURSE 


123 


feet  a^iunst  the  bed,  and,  by  a  j)()\v('rful  action  of  llic  abdoniiiial  inusclfs,  drives  the 
head  downward  against  the  jxTincuni.     During  tlic  eontructicjn  tlie  uterus  becomes 


Fig.   1-14. — Both  Efp.vcement  and  Dilatation  are  Complete. 


Normal  bag  of  waters 
beginning  to  form 


Fig.  145. 


124 


PHYSIOLOGY   OF   LABOR 


board-like  in  hardness.  The  parturient  is  working  hard — indeed,  the  process  is 
rightly  called  labor.  Her  pulse  is  high,  the  veins  of  the  neck  stand  out,  the  thyroid 
is  swollen,  the  face  is  turgid,  the  body  bathed  in  sweat. 


Normal  bag 
near  time  of 
complete 
dilatation 


Fig.  146. 


Bag  protruding  in  vulva 


Fia.   147. 


Owing  to  the  pressure  of  the  hc;ul  on  the  sacral  and  ol)turator  nerves  as  they 
go  out  of  the  pelvis,  tlic  patient  complains  of  i)ains  radiating  into  the  legs  and  to  the 


DEFINITION — CAUSES — CLINICAL    COURSE 


125 


back.  In  gerKM-al  the  ]):i(i('ii(  is  more  hoiicful.  since  she  can  help  and  feels  that  there 
is  prof^ress  in  the  labor,  whereas  in  Ihe  first  stage  all  she  had  to  do  was  to  bear  the 
suffering. 

The  pci'incuni  soon  begins  lo  lialleii  out   and  soften.      Tlie  glaiid.s  pour  out  a 


Polypoid  bag, 
useless   for  dila- 
ting 


Fig.  14S. 
Figs.  1-1.5,  140,  147,  and  148  represent  the  different  shaped  bags  of  waters. 


■~  Membranes 
External  os 


Fig.  149. — Bag  Fits  Fetal  Head  Like  a  Cap.     Does  not  .\id  Dilatation",  and  Often  Obstructs  Labok. 


126 


PHYSIOLOGY    OF   LABOR 


glairy  mucus  which  kibricates  the  passage.  The  woman  complains  of  pressure  on 
the  rectum,  and  may  insist  on  having  the  bed-pan.  Occasionally  there  are  feces  in 
the  bowel  which  is  being  forced  down  by  the  advancing  head,  but  more  often  the 


Fig.  150. — Restraining  Head  after  Episiotomt. 
A  retouched  photograph. 


Fig.  151. — Head  Deuvered. 
A  retouched  photograpli. 


DEFINITION — CAUSES — CLINICAL    CCn'HSE 


127 


sensation  is  clvio  to  the  head  itself  pressing  on  the  rectum.  After  thirty  to  forty 
minutes  the  anus  ije<!;ins  to  ojM'n,  and,  if  the  woman  has  hemorrhoids,  tliese  swell  up 
almost  to  bursting.  Soon  the  lal)ia  part  during  the  height  of  a  pain,  allowing  the 
wrinkled  scalp  to  show.  As  the  pain  subsides  the  elastic  pelvic  floor  forces  the  head 
back.  With  the  next  pain  the  ])criiHUiii  bulges  more,  the  anus  opens  wider,  so  that 
one  may  see  its  anterior  wall,  the  labia  part  further,  and  a  larger  segment  of  the 
seal})  becomes  visible.  As  the  ))ain  disappears  the  head  recedes.  In  the  interval 
between  ]iains  the  woman  lies  back  exhausted,  or  may  have  a  few  moments'  re- 
freshing sleep.  When  the  resistance  of  the  pelvic  floor  has  been  thus  gradually 
overcome,  the  head  comes  to  rest  in  the  rima  vulvse,  the  nape  of  the  neck  stemming 
und(>r  the  pubis.  Now,  by  a  crowning  effort,  under  great  nervous  exaltation  and 
powerful  abdominal  action,  the  head  is  forced  out,  the  occiput  coming  from  behind 
the  pubis,  the  forehead,  face,  and  chin  rolling  over  the  perineum.     The  woman  feels 


Fig.  152. — External  Restitution. 
A  retouched  photograph. 


as  if  she  is  being  torn  asunder.  After  this  there  is  a  pause  of  a  few  minutes,  when 
the  pains  are  renewed,  the  shoulders  are  delivered,  and  then  generally  the  trunk. 
in  one  long,  hard,  expulsive  effort.  The  child  gasps,  lying  between  the  thighs  of 
the  mother,  and  soon  cries  vigorously.  A  little  blood  and  the  rest  of  the  liquor  amnii 
and  the  ends  of  the  membrane  are  now  discharged.  The  uterus  contracts  down  into 
a  ball.  The  patient  feels  much  relieved.  She  may  have  a  chill  now,  but  this  is 
considered  physiologic.  It  may  occur  after  the  placenta  is  expelled  and  is  not  con- 
stant. The  cause  of  this  chill  has  been  much  discussed.  The  author  has  seen  fewer 
and  fewer  chills  with  the  perfection  of  the  aseptic  technic  of  labor,  and  is  inclined  to 
believe  they  are  due  to  absorption  of  toxins  from  the  parturient  canal.  Abdominally, 
one  finds  the  uterus  contracted  to  a  ball  the  size  of  a  cocoanut.  It  still  has  the  work 
of  delivering  the  placenta.  The  second  stage  is  ended.  The  physician  severs  the 
cord,  separating  the  child  from  the  placenta,  and  this  act  establishes  the  legal  status 
of  the  child  as  an  individual. 


128 


PHYSIOLOGY   OF   LABOR 


The  Third  or  Placental  Stage. — After  from  five  to  twenty  minutes,  devoted  to 
rearrangement  of  its  muscular  lamellae,  the  uterus  begins  to  contract  again.  Some 
blood  usually  appears  externally  with  the  first  pain.  The  uterus  at  first  is  somewhat 
relaxed,  slightly  flattened,  but  during  a  pain  it  becomes  smaller,  harder,  and  glob- 
ular. The  after-pains  are  usually  not  very  painful;  often  the  patient  perceives  only 
a  slight  drawing  sensation,  but  the  accoucheur  can  feel  the  regular  (four  to  five 
minutes)  contractions.  After  a  period  varying  from  a  few  minutes  to  an  hour  or 
more  the  fundus  uteri  rises  high  in  the  abdomen,  generally  under  the  liver,  while 


,....;=ssaii*wwx,-^- 


>-V4 


vi-psS^SSfW'-" 


Fig.  153.- 


-Utekcs  liibLxN  IN  Abdomen  Toward  J.iver.     Placenta  Makes    a  Soft  Enlaegement  Above  Pubis. 
Drawu  from  a  photograph. 


below,  over  the  pul)is,  the  abdomen  feels  soft  and  boggy  (Fig.  153).  At  the  same 
time  the  cord  advances  a  few  inches  from  the  vulva.  These  signs  indicate  that  the 
placenta  has  looscmcul  from  the  uterine  wall  and  has  descended  into  the  lower  uterine 
segment  and  upper  ])art  of  the  vagina.  When  the  placenta  is  in  the  uterus,  the 
organ  is  large  anrl  globular.  When  the  placenta  has  been  forced  from  its  bed  into 
the  low(>r  uterine  segment  and  upper  vagina,  the  uterus  assumes  a  flattened  pear 
shape.  The  flattening  is  from  before  backward  and  the  fundus  is  sharp.  On  the 
anterior  or  posterior  surface  often  a  broad,  shallow  dimple  is  to  be  felt — the  site  of 
the  placenta.     After  a  few  contractions  or,  if  blood  accumulates  in  the  uterus,  its 


DEFINITION — CAUSES — CLINICAL  COURSE 


129 


shape  aftain  bocomcs  more  j^h^hular.     The  sliarp  fundus  and  the  flat  dimple  are 
other  (evidences  that  the  placenta  has  left  the  uterine  cavity. 

After  a  period,  if  the  patient  is  let  alone,  varyinfz;  from  fifteen  minutes  to  three 
hours  or  lon{2;er,  the  placenta  is  sjiontaneousl}'  exijelled  by  the  combined  efforts  of 
the  abdominal  muscles  and  the  uterus.  Generally,  the  attendant  does  not  wait  for 
this  termination,  but  completes  the  process  himself.  The  placenta  is  usually  in- 
verted like  an  umbrella,  and  draws  tiie  membranes  after  it,  peeling  them  off  the 
uteriiu^  wall  (Schultze's  method).  Sometimes  the  placenta  slides  out  without  doub- 
ling up,  the  lower  portion  appearing  first  (Duncan's  metliodj.     With  the  after- 


FiG.  154. — Expressing  Placenta. 
A  retouched  photograph. 

birth  a  less  or  greater  quantity  of  blood  is  discharged.  Now  the  uterus  contracts 
down  into  a  hard  lump  in  the  inlet  of  the  pelvis,  extending  to  the  navel.  It  is  of  the 
size  of  a  fetal  head. 

The  third  stage  is  ended.     The  piierperium  has  begun.     The  parturient  has 
become  a  puerpera. 


THE  PAINS 

The  uterine  contractions,  the  most  prominent  s}^llptom  of  labor,  deserve  more 
consideration. 

1.  They  are  involuntary.  The  woman  has  no  control  over  them,  liut  they  are 
under  the  domain  of  the  cerebrospinal  svstem.  A  mental  shock  may  augment  or 
9 


130 


PHYSIOLOGY    OF   LABOR 


paralyze  the  uterine  action.  For  instance,  the  abrupt  entrance  of  a  stranger  may 
"  drive  the  pains  away."  In  one  case  of  exceedingly  slow  labor  the  author  expressed 
his  intention  to  insert  a  colpeurynter.  Strong  pains  came  on  at  once  and  delivery 
was  effected  within  an  hour. 

2.  The  action  of  the  uterus  is  not  peristaltic  to  the  degree  that  exists  in  animals. 
The  uterus  may  contract  in  one  portion,  the  hardening  extending  quickly  all  over. 
This  the  author  has  repeatedly  observed  after  delivery  of  the  child  in  cesarean  sec- 
tions. Portions  of  the  uterus  may  contract  while  the  rest  remains  in  a  state  of  re- 
traction— for  instance,  "hour-glass"  contraction;    cornual  contraction. 


2  3  4 

Fig.  155. — Schatz's  Pain  Tracing  in  the  First  Stage. 


5 

MINUTES 


3.  The  action  of  the  uterus  is  intermittent — that  is,  the  pains  recur  at  intervals. 
This  intermittence  aids  the  circulation  in  the  parts.  During  uterine  systole  the 
blood  in  the  veins  is  forced  toward  the  broad  ligaments;  during  diastole  the  uterus 
becomes  turgid — to  be  observed  at  cesarean  sections.  Pelvic  congestion  is  thus 
produced,  and  the  resulting  succulence  of  the  cervix  and  vagina  is  a  strong  factor  in 
their  dilatation.  By  coordinated  action  the  arteries  dilate  and  more  blood  is  brought 
to  the  uterus  (Werth).  The  blood  in  the  uterine  sinuses  would  be  stagnant  were 
it  not  for  these  intermittent  uterine  contractions,  which  much  resemble  the  action 
of  a  local  heart.     The  fetus  is  thus  provided  with  sufficient  oxygen.     In  cases  of 


248 


2  345    rilNUTE,5 

Fig.  156. — Schatz's  Pain  Tracing  in  the  Second  Stage. 


tetanus  uteri  the  child  may  die  of  asphyxia  because  the  hard,  contracted  uterus  will 
not  allow  enough  blood  to  flow  through  it. 

The  intermittence  provides  for  the  necessary  rest  of  the  muscle,  the  removal  of 
waste,  and  the  proper  application  of  uterine  force  to  the  mechanical  object  of  labor. 
The  uterine  action  is  a  Vjeautiful  cxamplo  of  applied  power. 

4.  The  contractions  are  rhythmic,  having  three  phases — increment,  acme,  and 
decrement.  The  increment  is  longer  than  the  acme  and  decrement  (Figs.  155  and 
156).  Schatz  placed  rubber  bags  in  the  functionating  uterus  and  registered  the 
pressure  variations  with  a  manometer,  calling  the  apparatus  a  "  tokodynamometer," 
His  work  is  classic.    The  pain  lasts  from  sixty  to  ninety  seconds,  the  intervals  from  a 


DEFINITION — CAUSES — CLINICAL    COURSE  131 

few  soconds  to  an  hour,  (l('])('ii(linft"  on  tlio  stage  of  labor  and  individual  cliaractoris- 
tics.  Sonic  ])ain.s  arc  double.  Sonietinies  a  weak  pain  i)reccdes  a  stronj^  one.  The 
first-stage  ])ain  differs  from  that  of  the  second  stage.  The  addition  of  the  abdomi- 
nal pressure  alters  the  character  of  the  curve.     (Compare  Figs.  155  and  150.) 

The  contraction  is  well  under  way  before  the  patient  feels  the  pain,  and  con- 
tinues a  siiort  time  after  the  pain  is  gone.  The  pains  grow  stronger  with  the  in- 
creased fre(iuency.  The  educated  hand  laid  on  tlu;  abdomen  can  discoveriiearly 
all  these  points. 

5.  The  uterine  contractions  are  painful.  No  other  bodily  function  involving 
contraction  of  unstriped  muscle  is  painful,  and  why  these  should  be  is  incompre- 
hensible if  labor  is  to  ])e  considered  a  normal  function. 

Before  labor  has  actively  begun  the  pains  are  called  dolores  prsesagientes. 
When  the  os  is  beginning  to  dilate,  they  become  quite  painful,  and  are  called  dolores 
prseparantes.  They  seem  to  have  their  seat  in  different  places — sometimes  in  the 
back,  in  the  pelvis,  again  in  the  abdomen. 

The  first  pains  of  labor  are  felt  in  the  back,  near  the  kidneys,  and  are  called  by 
the  French  women  ''pains  of  the  kidneys."  They  may  be  felt  only  as  a  sensation  of 
weakness,  and  the  patient  supports  her  back.  Later  the  pains  are  felt  more  in  the 
pelvis.  In  the  first  stage  the  pain  is  due  to  the  pressure  of  the  presenting  part  on 
the  nerves  of  the  cervix,  to  the  stretching  of  the  same  during  the  dilatation  of  the  os 
by  the  })rescnting  part  (Madame  Boivin,  who  had  personal  experience),  or  to'  the 
compression  of  the  nerves  in  the  wall  of  the  uterus.  Perhaps  all  three  causes  are 
combined.  The  pains  are  described  by  the  women  as  grinding,  twisting,  or  re- 
sembling severe  abdominal  colic. 

The  pain  in  the  small  of  the  back  is  due  to  radiation,  such  as  is  common  in 
pelvic  neuralgias.  The  nerves  involved  are  the  sacral  and  lumbar  plexuses.  The 
pain  caused  by  the  dilatation  of  the  last  fibers  of  the  cervix  is  particularly  acute, 
and  sometimes  a  slight  amount  of  blood  may  show  itself,  indicating  a  tear  in  the 
external  os. 

When  the  head  passes  down  into  the  vagina  and  begins  to  press  on  the  perineum, 
the  pains  are  due  to  the  stretching  of  these  parts  and  are  spoken  of  as  tearing. 

The  patient  now  bears  down  and  the  pain  cry  is  altered.  She  does  not  com- 
plain so  much,  but  helps  the  labor  along  by  pressing  do^\^l  with  the  abdominal 
muscles.  When  the  head  goes  through  the  vulva,  the  greatest  anguish  is  felt,  the 
patient  feeling  as  if  she  were  torn  open  (dolores  conquassantes).  The  pain  may  be 
so  great  that  the  patient  faints  or  is  temporarily  insane,  but  both  are  rare. 

These  pains  are  called  dolores  ad  partum.  After  the  birth  of  the  child  the 
uterine  contractioixs  are  called  after-pains,  or  dolores  ad  secundum  partum.  They 
usually  are  not  so  severe  as  the  others,  but  in  some  patients  they  are  very  painful. 

After  delivery  the  pains  are  called  dolores  postpartum,  or  "after-pains,"  and, 
especially  in  multiparse,  disturb  the  first  days  of  the  puerperium,  often  requiring 
treatment. 

Painless  labors  do  occur,  but  are  verj'  rare.  If  not  due  to  disease  of  the  spinal 
cord,  it  is  hard  to  explain  them.  The  women  feel  simply  the  desire  to  strain,  as  at 
stool,  and  delivery  is  usually  quick.  "Christian  Scientists"  claim  to  have  no  pain, 
but  I  have  often  observed  they  present  positive  evidences  of  suffering,  reminding 
one  of  the  stoical  martvrs  in  Rome. 


CHAPTER  VII 
THE  EFFECTS  OF  LABOR  ON  THE  MATERNAL  ORGANISM 

It  is  not  to  be  expected  that  a  process  requiring  so  much  muscular  exercise, 
such  anxiety,  and  accompanied  by  such  pain,  can  be  without  a  strong  influence  on 
the  maternal  organism.  The  patient  eats  little,  sometimes  vomits,  is  usually  rest- 
less, and  does  not  sleep  much  during  labor.  She  may  even  have  had  pain  at  nights 
and  very  little  sleep  for  a  week,  both  of  which  exhaust  her.  A  labor  lasting  a  few 
da^^s  leaves  the  patient  Aveak  and  completely  tired  out,  but  this  depends  on  the 
leng-th  of  the  labor  and  the  strength  of  the  woman  in  the  first  place. 

The  Duration  of  Labor. — The  length  of  parturition  is  variable,  which  is  true 
also  of  the  same  woman  in  different  labors.  In  the  uncivilized  races  labor  is  some- 
what shorter.  It  is  said  that  some  Indian  women,  while  the  tribe  is  on  the  march, 
feeling  the  pains  of  labor  coming  on,  go  off  to  the  side  in  the  underbrush,  bear  the 
child,  and,  after  expressing  the  after-birth,  hurry  to  catch  up  with  the  rest  of  the 
train,  but  this  is  exceptional,  and  later  writers  tell  us  that  obstetric  disease  and 
mortality  are  large  among  the  uncivilized  races. 

In  primiparge  labors  are  longer  than  in  multiparse;  labor  is  shorter  in  warm 
climates,  also  during  summer;  in  poor,  hard-working  women  than  in  the  rich  and 
pampered;  therefore  shorter  in  the  country  than  in  the  city. 

The  size  of  the  fetus  has  a  great  deal  to  do  with  it-^a  large  fetus,  long  labor. 
The  same  holds  true  if  the  fetal  head  is  large  and  hard.  In  young,  strong  primiparse 
labor  is  easier  than  in  old  primiparse,  the  average  in  the  latter  being  twenty-seven 
hours,  but  one  is  often  surprised  to  see  an  easy  labor  in  a  primiparous  patient  over 
forty  years  old.  Labor  is  longer  in  fat  women,  longer  with  boys  than  with  girls, 
because  they  are  larger.  The  lengths  of  the  various  stages  of  labor  are  about  as 
follows:  Primiparse,  first  stage,  sixteen  hours;  second  stage,  one  and  three-quarter 
to  three  hours;  third  stage,  from  a  few  minutes  to  several  hours.  Multiparse,  first 
stage,  twelve  hours;  second  stage,  one-quarter  to  one-half  hour;  third  stage,  from 
a  few  minutes  to  several  hours. 

Extremes  are  not  rare.  We  have  had  cases  where  labor  was  completed  in  even 
less  than  one  hour.  Again,  there  are  labors  which  are  slow  from  the  start,  requiring 
days  for  completion.  Labor  may  intermit,  an  interval  of  hours  or  days  occurring 
after  the  pains  have  begun  and  dilatation  of  the  os  has  been  effected.  The  differ- 
ence in  the  length  of  labor  in  primiparse  and  multiparse  is  due  to  the  slowness  of 
dilatation  of  the  cervix,  perineum,  and  vulvar  orifice  in  the  former.  In  multiparse, 
owing  to  stretching  by  previous  deliveries,  the  resistances  offered  by  the  soft  parts 
are  less  and  much  more  readily  overcome.  If  many  years  elapse  between  deliveries, 
some  of  the  original  resistance  may  have  been  regained. 

In  1000  labors  at  the  Chicago  Lying-in  Hospital  the  pains  began  as  follows: 

HOURS  OF  BEGINNING  LABOR 

Between  6  p.  m.  and  midnight 274 

'*         midnight  and  6  a.  m 306 

"        6  A.  M.  and  noon 238 

"        noon  and  6  p.  m 182 

1000 
132 


THE    EFFECTS    OF    LAI50H    ON    THE    MATERNAL    ORGANISM  133 

HOURS  OF  DELIVERY 

Between  6  p.  m.  and  midnight 229 

"         midnight  and  (i  a.  m 27S 

"         0  A.  M.  anil  iiodii 267 

"         noon  and  0  i'.  m 226 

1(K)0 

The  Temperature.-  The  muscular  exertion  durinji;  lulnjr  would  raise  the  tem- 
perature if  the  loss  of  heat  were  not  so  great.  Perspiration  is  increased,  exposure  (jf 
the  body  fi;reater,  respiration  faster — all  tend  to  keep  the  woman's  temperature  near 
normal.  Accurate  takings  have  shown,  however,  that  there  is  a  sliji;ht  rise  during 
labor,  which  is  greatest  right  after  delivery  of  the  child,  and  varies  with  the  usual 
daily  variations,  but  does  not  normally  exceed  1°F.  During  the  pain  the  tempera- 
ture rises  a  little.  The  temperature  is  likely  to  rise  during  a  prolonged  second  stage. 
Overstrain  and  sleeplessness  conduce  to  it  (Adami).  The  author  is  convinced  that 
fever  of  more  than  one  degree  during  labor  is  toxinemic  or  septic  in  origin,  and  comes 
from  the  absorption  of  toxins  or  bacteria  from  the  puerperal  wounds.  H.  Miiller 
came  to  the  same  conclusion.  With  the  perfection  of  an  aseptic  technic  slight  fevers 
in  labor  are  very  rare,  and  the  postpartum,  so-called  "physiologic,"  chill  has  become 
almost  unknown.  The  chill  formerly  was  ascribed  to  exhaustion  of  the  mother,  pro- 
longed exposure  of  her  person,  loss  of  a  source  of  heat,  the  child,  readjustment  of 
the  abdominal  circulatory  conditions,  nervousness,  etc.,  but  the  author  believes 
that  the  chill,  too,  is  due  to  infection  during  labor.  Proof  of  this  is  hard  to  bring, 
but  if  the  other  causes  mentioned  were  real,  the  chill  ought  to  follow  nearly  every 
labor,  whereas  statistics  show  that  it  occurs  in  only  20  to  30  per  cent.  In  the 
author's  practice  it  has  almost  disappeared  with  the  perfection  of  asepsis,  the  use 
of  rubber  gloves,  and  the  restriction  of  the  internal  examinations.  If  not  due  to 
infection,  the  possibility  that  it  might  be  of  an  anaphylactic  nature  is  to  be 
considered. 

The  Circulation. — The  rate  of  the  heart-beat  increases  somewhat  during  labor, 
reaching  100  or  110,  but  between  the  pains  may  be  normal.  The  advent  of  a  pain 
is  heralded  by  a  faster  heart-beat.  In  the  second  stage,  during  the  severe  muscular 
exertion,  the  pulse-rate  increases  a  good  deal,  but  in  the  third  stage,  if  no  hemor- 
rhage be  present,  it  is  usually  normal.  Any  marked  rapidity  must  put  you  on  your 
gTiard  against  hemorrhage,  external  or  internal.  Arterial  tension  is  increased  until 
after  the  third  stage  unless  there  is  hemorrhage  or  chloroform  narcosis.  During 
the  pain  the  arterial  tension  is  greater  than  in  the  intervals,  and  a  moderately 
heightened  blood-pressure  continues  a  few  days  into  the  puerperium.  The  edu- 
cated finger  can  determine  these  points,  but  the  newer  instrument,  the  sphygmo- 
manometer, proves  them  scientifically  (Slemons).  In  order  to  make  a  firm  support 
for  the  action  of  the  abdominal  muscles  in  the  second  stage,  the  parturient  fixes  the 
chest  in  inspiration  and  holds  her  breath.  If  the  bearing-do'u-n  efforts  are  very 
hard  and  prolonged,  the  pulmonary  circulation  is  interfered  with,  the  right  heart  is 
congested,  the  blood  cannot  get  into  the  chest,  there  is  marked  turgidity  of  the  veins 
of  the  neck  and  head,  and  from  this  there  sometimes  result  enlargement  of  the  thj'- 
roid,  which  disappears  postpartum,  edema  of  the  face,  even  tiny  hemorrhages  in 
the  conjunctivae.  These  evidences  of  venous  congestion  are,  in  bad  cases,  found 
also  in  the  brain  (Hodge). 

The  respirations  are  increased  during  the  pains,  but  between  pains  are  normal. 
Some  nervous  w^omen  hold  the  breath  during  the  pains,  even  in  the  first  stage.  In 
the  second  stage  breathing  is  more  rapid,  irregular,  and  altered  by  the  bearing-do'^Ti 
efforts  and  cries  of  pain.  In  the  thirtl  stage  they  are  again  normal,  unless  there  be 
hemorrhage,  when  an  increase  in  number,  or  gasping,  shortness  of  breath,  persistent 
yawning,  shows  that  there  is  something  wrong. 

More  CO2  is  excreted  during  labor,  and  the  rapid  breathing  helps  to  keep  down 


134  PHYSIOLOGY    OF   LABOR 

the  temperature.  Too  rapid  breathing  may  produce  acapnia,  a  condition  which 
bears  some  relation  to  shock.  Emphysema  of  the  chest  and  head  may  result  from 
too  powerful  bearing-down  efforts. 

Turgidity  and  swelling  of  the  turbinate  bones  are  usually  observed  during 
labor.  If  the  patient  has  a  nasal  catarrh,  obstruction  of  the  nares  may  result. 
Fliess  associates  this  condition  with  the  uterine  action,  and  claims  that  the  latter 
may  be  influenced  by  treatment  directed  to  the  nose. 

The  Intestinal  Tract. — Anorexia  is  the  rule.  Thirst  is  common.  Many  women 
vomit  during  labor.  The  old  midwdves  say  that  sick  labors  are  easy,  but  the  author 
cannot  confirm  this.  It  was  once  the  custom  to  give  emetics  on  this  theory  to 
relax  the  cervix,  but  the  practice  is  bad.  When  the  head  is  passing  through  the  os, 
the  great  distention  may  cause  reflex  vomiting,  and  some  women  vomit  frequently 
during  the  second  stage.  Persistent  vomiting  at  any  stage  of  labor  should  always 
be  suspected,  and  its  cause  sought  for  carefully.  It  may  indicate  threatened  or 
actual  rupture  of  the  uterus,  eclampsia,  uremia,  internal  hemorrhage,  peritonitis. 
In  the  third  stage  vomiting  almost  never  occurs  normally.  Anesthesia,  especially 
after  operations,  may  cause  it,  but  even  then  it  is  rarely  so  severe  as  in  surgical  cases. 
Persistent  nausea  and  vomiting  after  a  delivery  are  a  significant  symptom,  and  their 
cause  must  be  discovered. 

The  bowels  are  often  loose  at  the  very  beginning  of  labor,  and  borborygmus  is 
often  heard  during  its  progress,  but  the  head  in  the  pelvis  prevents  defecation.  In 
the  second  stage  the  advancing  head  forces  feces  from  the  rectum,  an  occurrence 
annoying  to  the  mother,  and  dangerous,  too,  because,  in  the  manipulations  the 
doctor  makes  he  may  carry  infectious  matter  into  the  parturient  tract.  A  cathartic 
given  in  labor  may  stimulate  the  pains — an  old  remedy  for  inertia  uteri. 

The  mental  condition  of  the  patient  during  the  first  stage  of  labor  usually  does 
not  differ  from  that  of  a  woman  suffering  pain.  In  predisposed  women  it  may  be 
marked  by  hysteric  manifestations.  In  the  second  stage,  especially  at  the  end,  the 
parturient  may  become  delirious  or  even  maniacal  from  the  suffering,  but  this  is 
rare.  Real  fainting  is  also  rare  in  normal  labors.  Whenever  I  have  seen  it,  the 
cause  has  been  hemorrhage  or  shock.  That  a  woman  may  give  birth  during  a  faint 
is  theoretically  certain  and  medicolegally  proved.  This  is  important  from  a  legal 
standpoint,  as  in  cases  of  infanticide.  (For  full  consideration  of  this  subject  see 
Moritz  Freyer.) 

The  woman's  demeanor  is  usually  cheerful,  but  may  be  the  opposite,  she  as- 
serting her  inability  to  bear  the  pain  or  that  she  will  surely  die.  In  the  second 
stage,  when  the  parturient  feels  the  progress  of  the  head,  she  complains  less.  Be- 
tween pains  the  woman  may  doze  or  sleep  soundly. 

When  the  head  enters  the  lower  pelvis,  it  may  compress  the  obturator  or  sacral 
nerves.  Cramps  in  the  leg  are  thus  produced — in  the  anterior  upper  thigh  in  the 
former,  on  the  posterior  surface  of  the  leg  in  the  latter,  instance. 

After  the  child  is  delivered  the  parturient  may  fall  asleep,  which  is  especially 
common  at  the  end  of  prolonged,  exhausting  labors. 

The  Urinary  System. — The  disposition  of  the  bladder  during  labor  varies  in 
different  women.  Usually  the  lower  uterine  segment  in  its  development  pulls 
away  from  the  viscus,  leaving  it  behind  the  pubis,  but  in  some  cases,  where  the  two 
organs  are  more  intimately  adherent,  the  bladder  rises  into  the  abdomen  with  the 
lower  portion  of  the  uterus.  In  either  case  the  full  bladder  distends  the  lower  hypo- 
gastrium,  but  there  is  a  difference  in  the  depth  of  the  anterior  culdesac. 

The  ureters  are  also  drawn  upward  with  the  receding  uterus.  Early  in  labor 
they  may  be  felt  coursing  around  the  cervix  toward  the  brim  of  the  pelvis.  Later 
one  cannot  feel  them.  Frozen  sections  (Tandler)  show  that  they  cross  the  brim 
higher  and  more  anteriorly  than  in  the  non-pregnant  state.  The  urethra  is  length- 
ened, compressed  by  the  head,  and  much  bruised  during  labor.     If  the  head  is  too 


THE    EFFECTS    OF    LABOR    OX    TlfE    MATERN'AL    ORGANISM 


135 


loiip;  iinpaftcd  in  the  jiclvis  the  iifctlii-;i  ami  i)act  of  the  hlaildcr  may  slough  out, 
lt'aviii{4'  urimiry  fistulas. 

In  general  the  kidneys  are  more  active  during  labor.  Tlic  ijolyiiiia  is  due  to 
the  hoiglitonod  arterial  tension  and  stimulation  of  the  kidneys  throuf^h  tlie  sympa- 
thetic from  the  uterus.  In  nervous  or  hysteric  women  the  general  nervous  system 
plays  a  i)aft.  Polyuria  is  usual,  hut  not  con.stant,  some  women  having  less  than 
normal.  The  full  hladiler  disturlis  the  course  of  labor,  may  prevent  the  engage- 
ment of  the  head,  and  in  the  third  stage  may  delay  the  exit  of  the  placenta  and 
cause  posti)artuni  hemorrhage. 

The  specihc  gravity  of  the  urine  is  reduced,  urea,  phosphate,  and  sulphate 


Vena  iliaca 

Lateral  umbilical  ligament 
Artoria  utorina 


Ureter 


Posterior  culdeaac 


Vagina 


Fornix 


Posterior  lip  Cervix 

Fig.   157. — The  Ureter  .^t  Term    (from  Tandler  and  Halban). 


content  also,  while  the  sodium  chlorid  is  increased  (v.  Winckel).  AllHunin  is  found 
in  one-fifth  of  the  cases,  being  three  times  commoner  in  primipara^,  more  freciuent 
in  very  young  and  very  old  parturients,  in  hard  and  prolonged  labors,  after  the 
administration  of  anesthetics,  with  fever  in  labor,  and  in  w^omen  who  have  had  al- 
buminuria during  pregnancy.  The  amount  in  normal  cases  does  not  exceed  1/1000 
Esbach.  Larger  ciuantities  indicate  pathogenic  conditions.  The  cause  of  the 
albmiiinuria  may  be  sought  in  the  increased  muscular  exertion  of  labor,  the  high 
blood-pressure,  and  perhaps  in  the  deportation  of  placental  villi  (Veit)  under  the 
force  of  the  uterine  contractions.     (See  Eclampsia.) 

Formed  elements,  especially  hyaline  casts,  are  often  found,  even  white  and  red 
blood-corpuscles,  all  three  in  proportion  to  the  albuminuria.     In  general,  it  may  be 


136 


PHYSIOLOGY    OF   LABOR 


said  that  the  urinary  findings  during  labor  bear  only  slightly  less  significance  than 
at  any  other  time  during  pregnancy. 

General  Metabolism.— The  mother  loses  about  one-tenth  of  her  body  weight 
(Baumm  and  Gassner).  This  is  made  up  of  the  child,  the  placenta  and  membranes, 
the  liquor  amnii,  blood,  excretions  from  the  skin,  lungs,  kidneys,  etc.     The  average 


Urethra 


Fig.  158.— i' 


Bladder 


riiE  ruKTER   (Tandler  and  Halban). 


Arteria 

hypo; 

gastrica 


Lateral 

umbilical 

ligament 


Vesical  artery 


loss  is  6564  gm.,  of  which  oOOO  fall  to  the  ovum,  1000  to  the  liquor  amnii,  and  there 
is  a  loss  of  about  400  gm.  of  blood. 

A  marked  leukocytosis  is  found  during  labor,  which,  according  to  Hofbauer,  is 
due  to  muscular  work,  but  is  more  probably  an  antitoxic  reaction.  The  whites 
vary  from  9  to  34,000.  The  polynuclear  neutrophiles  are  increased,  the  eosinophiles 
much  decreased  (Cova). 

Parturition  is  the  only  function  normally  attended  by  hemorrhage.  Bloodless 
labors  are  rare,  and  are  so  usually  because  the  fetus  has  been  dead  some  weeks. 


THE    EFFECTS   OF   LABOR    ON    THE    MATERNAL    OKGANLSM  137 

Tho  amount  of  blood  lost  varies  in  wide  limits  from  a  few  ounces  to  several  quarts. 
Where  tlu^  normal  limit  lies  (lej)en(ls  on  the  individual  patient.  Autliorities  differ  as 
to  what  should  be  considered  normal.  Ahlfeld  says  even  1000  gm.  may  be  a 
normal  loss,  but  that  the  average  is  400  gm.  The  amount  of  blood  lost  is  influenced 
by  the  size  of  the  child,  tho  area  of  the  placenta,  its  location  in  the  uterus,  the  rapid- 
ity of  the  separation  <jf  the  i)laeenta,  the  strength  of  the  uterine  contraction  and  re- 
traction, the  age  of  the  parturient,  and  the  number  of  children  she  has  borne,  being 
greater  in  multiparie.  The  method  of  conduct  of  the  labor  by  the  medical  attendant 
also  influences  the  blood  loss  and  pathologic  conditions  to  be  later  considered.  No 
exact  figure  may  be  given  as  to  what  is  a  normal  loss  of  blood  in  labor.  The  author 
believes  that  500  gm.  should  ])e  the  limit  in  ordinary  cases,  and  that  in  small,  anemic, 
or  otherwise  tlebilitated  women  the  loss  should  not  exceed  150  gm.  Nearly  all  the 
blood  comes  during  and  after  the  third  stage,  either  free  or  contained  in  the  folded 
placenta  as  the  retroplacental  hematoma.  A  little  blood  appears  in  the  "show" 
at  the  })eginning  of  the  first  stage;  a  little  more  comes  when  the  last  fibers  of  the 
cervix  are  giving  way;  more  may  appear  when  the  head  bursts  through  the  vulva, 
from  tears  of  the  clitoris  and  outlet.  The  bleeding  now  comes  from  the  placental 
site  and  cervical  and  perineal  lacerations,  and  when  the  placenta  comes,  the  greatest 
discharge  occurs.  The  oozing  after  the  delivery  of  the  placenta  comes  from  the 
placental  site  and  the  puerperal  wounds,  and  in  the  first  two  hours  should  not  exceed 
two  ounces. 

Literature 

Adami:  Gen.  Pathologj',  1909,  p.  360. — Ahlfeld:  Lehrbuch  der  Geb.,  1903,  p.  14.5. — Cova:  Trans.  Internat.  Cong., 
Rome,  1902. — de  Paoli:  Arch,  di  Ost.  e  Gin.,  January,  1903. — Freyer:  Die  Ohnmacht  bei  der  Geburt,  Springer, 
Berlin,  18S7. — Healy  and  Kastle:  Jour.  Infect.  Dis.,  1912,  vol.  x,  p.  244. — Schatz:  Arch.  f.  Gyn.,  vol.  iii. — 
Slemons  and  Goldsborouyh:  Centralbl.  f.  Gyn.,  1908,  p.  700. — TaftrfZer  and  i/a/bare;  Die  Topographie  des  weib- 
lichen  Ureters,  Vienna. — von  der  Heide:  Jour.  Amer.  Med.  Assoc.,  September  29,  1911,  p.  1090. 


CHAPTER  VIII 
THE  EFFECT  OF  LABOR  ON  THE  CHILD'S  ORGANISM 

During  the  last  weeks  of  pregnancy  the  child  is  quieter,  due  to  the  restriction 
of  its  movements  from  lack  of  room.  The  question,  Does  the  child  suffer  pain 
during  delivery?  has  been  answered  both  ways.  It  probably  does.  The  author 
has  felt  the  infant  withdraw  its  hand  after  being  pinched,  and  the  infant,  a  few 
seconds  after  birth,  cries  lustily  when  spanked. 

A  not  small  percentage  of  children  die,  even  in  so-called  normal  labor — esti- 
mated by  various  authors  from  3  to  5  per  cent.  In  Paris  it  is  9  per  cent.  (Cham- 
brelent).     The  shock  of  labor  to  the  infant  must  be  reckoned  with. 

Careful  examination  of  the  fetal  heart  during  labor  shows  that  its  rapidity  is 
much  affected  by  the  pains.  When  the  uterus  begins  to  contract,  the  fetal  pulse 
beats  faster;  during  the  height  of  the  pain  it  is  slow;  as  the  pain  wanes  it  beats  fast 
again,  graduallj^  slowing  down  to  normal.  These  findings  are  more  pronounced 
after  the  membranes  are  ruptured  and  with  strong  pains.  Sometimes  the  heart  is 
accelerated  by  the  pains.     As  labor  progresses  the  fetal  heart  usually  becomes 

SECONDS  5      10      15    20    25    30    35    40    45    50    55    60 


HEART 
TONES 


^ 

y 

y 

^ 

\ 

10 

11 

12 

12 

11 

10 

9 

10 

11 

11 

10 

11 

Fig.  159. — Tracing  op  Fetal  Heart-beat  During  a  Pain. 
Lower  figures  are  the  numbers  of  beats  per  five  seconds. 


slower,  and  as  the  head  passes  through  the  pelvic  floor,  the  slowing  may  be  so  marked 
that  the  attendant  becomes  alarmed.  The  author  has  counted,  during  the  pains, 
a  beat  as  low  as  60  while  the  head  was  being  delivered.  A  consideration  of  the  fetal 
heart -Vjeat  as  an  indication  of  danger  to  the  child  will  be  reserved  for  the  chapter  on 
Asphyxia  Neonatorum.  The  cause  of  these  variations  is  unknown.  Schultze 
ascribes  them  to  stimulation  of  the  vagus  by  the  insufficiently  oxidized  fetal  blood, 
the  uterine  contraction  forcing  the  maternal  blood  out  of  the  placenta.  Kehrer 
believed  that  the  compression  of  the  skull  slowed  the  heart  by  direct  vagus  irritation. 
Probably  both  explanations  apply.  The  slowing  of  the  heart  is  not  constant;  the 
author  has  noticed  that  the  pulse  does  not  vary  much,  in  some  few  labors,  from  the 
beginning  to  the  end.  When  the  child  is  in  danger,  its  heart  beats  very  fast,  very 
slowly,  or  irregularly,  yet  occasionally  we  note  these  signs  and  the  child  does 
not  suffer.  The  child  may,  in  pathologic  cases,  make  respiratory  movements 
before  its  delivery.  Even  in  normal  deliveries  close  observation  of  the  head  as  it 
lies  in  the  vulva  will  discover  little  twitchings  that  indicate  attempts  to  inspire,  and 
the  accoucheur  will  find  that  the  infant  has  filled  its  mouth  with  blood  or  mucus 
from  the  vagina.     Von  Winckel  discovered  these  movements  by  examinations  by 

138 


THE    EFFECT    OF    LABOR    OX   THE    CHILd's    ORGANISM 


139 


the  ref'tum.  It  is  wise  to  hasten  the  dcMvcry  wlu'ii  stu-li  action  is  (Hsoovorcd,  be- 
cause the  infant  may  get  foreign  matter  into  tiie  hnigs  or  stomach  and  later  develop 
pulmonary  atelectasis  or  intestinal  infection.  Occasionally  the  infant  will  gasp  and 
cry  as  soon  as  the  head  is  out,  but  usually  the  first  cry  escapes  after  the  body  is  de- 
livered. At  first  the  chest  moves  with  tiny  excursions;  in  a  few  moments  a  deep 
gasp  fills  the  luuKs,  then  comes  a  sneeze  or  a  cough,  which  expels  the  mucus  from  the 
throat,  following  wiiich  is  the  lusty  cry  of  the  new-born. 

The  Cause  of  the  First  Respiration. — The  theory  of  Preyer,  that  the  irritation 
of  the  skin  from  tiie  trauma  of  labor-  causes  the  respiration  l)y  stimulating  the  respira- 


FiG.    100. — Attitude   of   Child   ix   Utero   at   Beginning   of   Labor. 


tory  center  reflexly,  is  not  probable.  The  child  in  utero  exists  in  a  state  of  apnea. 
Stimuli  applied  in  this  condition  have  no  effect  on  the  center,  as  is  shown  by  clinical 
experience.  Rough  palpation,  attempts  at  version,  forceps,  do  not  affect  the  child 
in  utero.  Should  the  child,  however,  be  partlj'  asphyxiated,  the  respiratory  center 
will  react  to  these  stimuli.  The  theory  that  the  exposure  to  cold  when  the  child 
is  born  causes  the  respiration  has  been  refuted.  Ahlfeld  delivered  several  children 
into  warm  saline  solution  and  the  respiration  began  as  usual.  Again,  sometimes  a 
half-minute  will  elapse  before  the  first  gasp  occurs,  and  a  reflex  should  be  quicker 
than  this.  The  most  accepted  theory  is  that  the  gradual  deoxidation  and  hj-per- 
carbonization  of  the  blood  make  the  respiratory  center  more  irritable  (Schwartz). 


140 


PHYSIOLOGY    OF    LABOR 


This  condition  occurs  in  the  latter  months  of  pregnancy,  clue  to  the  gradual  narrow- 
ing of  the  ducti  arteriosus  and  venosus.  During  labor  this  partial  asphyxia  is  in- 
creased. When  the  child's  head  is  born,  the  placenta  is  beginning  to  separate,  and 
when  the  baby  is  delivered,  the  placenta  is  almost  completely  detached.  As  a 
result,  the  fetus  passes  from  a  condition  of  apnea  to  one  of  dyspnea,  the  respiratory 
center  is  irritated,  and  respiration  begins.  The  same  condition  occurs  in  utero 
when  the  placental  circulation  is  cut  off.     A  slightly  asphyxiated  child  responds 


Fig.    lOL — Attitude   of  Child  at  End   of  Expulsion. 


promptly  to  external  stimuli,  such  as  cold,  slapping,  friction.  If  the  child  is  rapidly 
delivered,  as  in  cesarean  section,  or  in  multipara}  with  a  short  second  stage,  it  may 
come  into  the  world  with  sufficient  oxygen  for  a  short  time;  it  is  in  its  intra-uterine 
condition  of  apnea,  and  a  few  minutes  may  elapse  before  the  respiratory  center  be- 
comes sufficiently  irritated  by  the  increasingly  venous  blood  to  evoke  respiratory 
action. 

The  Changes  in  the  Fetal  Circulation. — With  the  first  inspiration  the  lungs  ex- 
pand.    The  pulmonary  vessels  are  dilated,  and  Ijlood  rushes  into  them  from  the 


THE    EFFECT    OF    LAHOR    OX    THK    CfllLD's    ORGANISM 


141 


right  ventriclo.  Tiicrc  is  no  blood  to  i)ass  through  the  ductus  BotalU.  It,  therefore, 
collapses.  This  may  be  due  to  a  valve-like  formation  at  its  junction  with  the  aorta 
(Strassman)  or  to  a  twisting  of  the  duct,  due  to  the  change  of  j)osition  of  the  heart, 
caused  by  the  filling  of  the  auricles  and  distention  of  the  lungs.  There  is  less  blood 
coming  from  the  ascending  vena  cava,  the  um])ilical  vein  contracting;  the  pressure 
in  the  right  auricle  sinks.  The  result  is  an  aspirat  ion  toward  tlie  heart  of  the  Ijlood 
in  the  vena  cava  and  umbilical  vein. 

The  distal  ends  of  I  lie  hypogastric  arteries  contract  and  thrombose.     This  is 
due  to  the  fact  that  the  left  ventricle  cannot  send  the  Ijlood  the  long  distance  through 


/ 


Fig.    1Ci2. — Extreme  Head   Molding  in-  a  PRiMiPAnors  Labor. 


them,  since  it  is  no  longer  assisted  by  the  right  ventricle  through  the  ductus  BotaUi. 
Also,  cold  contracts  the  arteries,  which  have  a  powerful  muscular  coat.  The  pulsa- 
tion in  the  cord  ceases.  Since  the  pressure  in  the  right  auricle  is  low  and  that  in  the 
left  higher,  the  valve  of  the  foramen  ovale  applies  itself  to  the  sei:)tum  auriculorum, 
and  thus  the  two  sides  of  the  heart  become  distinct. 

The  circulation  is  now  just  the  same  as  in  the  adult.  The  ductus  Arantii  and 
ductus  Botalli  grow  smaller  by  contraction  of  their  muscular  fibers  and  the  applica- 
tion of  their  walls  to  each  other.  No  thrombosis  occurs  in  them,  nor  in  the  vein  of  the 
umbilical  cord — only  in  the  arteries.     They  become  obliterated  in  one  or  two  weeks. 


142 


PHYSIOLOGY   OF   LABOR 


The  Plastic  Changes  Wrought  on  the  Fetus. — The  conditions  during  labor  are 
unlike  those  enjoyed  l_)y  the  child  during  pregnancy.  The  contracting  uterus  com- 
presses the  fetus  into  a  definite  shape,  and  gives  it  a  certain  attitude,  both  of  which 


Fig.   163. — Rear  View  of  Skull  AIolded  in   O.L.A. 


are  to  facilitate  its  passage  through  the  parturient  canal.  The  legs  are  flexed  on  the 
thighs  and  crossed  over  each  other,  the  thighs  on  the  abdomen;  the  arms  are  folded 
across  the  chest,  the  head  flexed  so  that  the  chin  rests  on  the  sternum  (Fig.  160). 


Fig.   164. — Side  View  of  Skull  Molded  ix  O.L.A. 


The  pressure  of  the  uterus  on  the  crossed  legs  may  bend  the  tibia  and  fibula,  but  the 
deformity  lasts  only  a  week  or  more. 

The  head  undergoes  marked  changes,  which  vary  Avith  the  presentation  of  the 
child  for  delivery,  and  are  caused  by  pressure  exerted  by  the  maternal  structures. 


THE    EFFECT    OF    LAHOR    OX    TIIK    <'1IILI)  S    OROAXISM 


143 


In  ordinary  head  presentations,  witii  a  moderately  tifi;lit  parturient  passage,  the  face 
and  tile  loi'eliead  are  ilattened,  tlie  oceiput  long  drawn  out  (Fig.  l(J2j,  the  l;ones 
overlapped.  Usually  the  occipital  bone  is  pressed  under  the  two  parietals — the 
frontal  also  somewhat  below  them.  One  parietal  overlaps  the  other,  the  one  that 
Hes  against  the  i)romontory  being  the  one  that  is  depressed  (Figs.  103  and  104j.  The 
head  offers  thus  a  long  narrow  cylinder  to  the  birth-canal,  instead  of  a  round  ))all. 
These  changes  in  shape,  or  "molding,"  are  possible  because  of  the  softness  of  the 
bones  and  the  loose  connection  they  have  with  each  other  at  the  sutures.  When 
this  molding  is  absent,  labor  is  more  difficult.  Some  slight  diminution  in  the  size  of 
the  head  occurs  in  labor,  especially  if  the  pelvis  is  contracted,  and  it  is  due  to  the 
escape,  under  pressure,  of  the  cerebrospinal  fluid  into  the  spinal  canal.  Necessarily, 
it  is  small  and  cuts  little  figure  in  the  mechanism  of  delivery. 

Along  the  sutures  it  is  not  uncommon  to  find  numerous  small  hemorrhages  in 
and  under  the  dura  mater  and  under  the  external  periosteum.     They  are  due  to  the 


Fig.  165. — Epidural  Hemorrhages  Along  Longitudinal  Sinus. 


overlapping  of  the  bones,  and  are  most  marked  in  cases  where  the  head  has  been 
forced  through  a  narrow  pelvis  or  compressed  by  the  forceps  (Fig.  165).  On  that 
part  of  the  head  least  sul^jected  to  pressure  there  appears  in  long  labors  a  soft,  boggy, 
circumscribed  tumor.  In  vertex  presentations  it  is  formed  on  one  parietal  bone.  It 
is  caused  by  the  pressure  of  the  uterus  on  the  body  of  the  child  being  greater  than 
that  on  the  portion  which  lies  below  the  girdle  of  resistance — that  is,  through  the 
opening  in  the  cervix  or  the  vagina,  or  even  in  the  vulva  (Fig.  166).  The  action  is 
similar  to  that  occurring  in  a  limb  tightly  gartered — the  blood  cannot  return;  venous 
congestion  with  edema  and  extravasation  of  blood  results.  These  small  hemor- 
rhages persist  long  after  the  edema  is  absorbed,  and  mark  the  site  of  the  tmnor  on 
the  head.  The  swelling  is  called  caput  succedaneum,  and  it  occurs  in  and  under 
the  scalp,  not  under  the  periosteum,  in  ordinary  cases.  It  is,  therefore,  movable  on 
the  skull.  It  may  sag  toward  the  side  on  which  the  child  lies  after  delivery,  but  the 
blood  extravasations  will  not  change.  If  the  pressure  has  been  prolonged,  the 
hemorrhagic  infiltration  affects  the  periosteum,  the  bone,  and  corresponding  regions 


144 


PHYSIOLOGY   OF   LABOR 


of  the  meninges.  A  caput  succedaneum  can  form  before  the  bag  of  waters  breaks 
because  the  pressure  in  the  bag  is  less  than  that  in  the  general  uterine  cavity,  but  it 
is  rare.  Most  commonly  we  find  the  largest  caput  in  a  contracted  pelvis  with  pro- 
longed and  powerful  pains,  and,  second,  when  the  head  is  arrested  at  the  bony  outlet. 
In  either  of  these  cases,  but  especially  in  the  latter  instance,  the  caput  may  be  visible 
at  the  vulva.  It  may  make  the  attendant  believe  that  the  labor  is  advancing,  when 
in  reality  the  growing  caput  indicates  that  the  head  has  met  an  obstruction  (Fig. 
167).  Thus  it  may  give  warning  of  the  necessity  to  interfere  in  labor.  One  must 
distinguish  between  caput  succedaneum  and  cephalhematcrma,  which  is  an  accumu- 
lation of  l^lood  under  the  periosteum.     (See  Chapter  LXII.) 

The  caput  exaggerates  the  obliquity  of  the  head  produced  by  the  depression  of 
the  parietal  bone  by  the  promontory  of  the  sacrum  or  the  pelvic  floor.     (See  Figs. 


Fig.  ICG. — Showing  How  a  C.vruT  is  Formed. 


163  and  164.)  The  caput  is  absorbed  in  twenty-four  to  thirty-six  hours;  the  asym- 
metry of  the  head  produced  })y  the  mechanical  factors  in  labor  disappears  by  the 
end  of  a  week,  but  there  often  remains  a  permanent  asymmetry  of  the  skull,  called 
that  of  Stadtfeld,  who  first  described  it.  All  forms  of  growth  have  a  slightly  spiral 
direction.  This  is  true  also  of  the  fetus.  There  is  a  congenital  scoliosis  of  the 
spinal  column.  The  right  parietal  bone  is  pushed  anteriorly  in  a  horizontal  plane, 
appearing  flat,  while  the  left  is  more  convex.  This  asymmetry  is  permanent  and 
has  been  demonstrated  in  the  adult.  The  head  tracings  to  be  seen  in  any  hat-shop 
show  it.  While  the  right  side  is  usually  affected,  the  twisting  may  be  reversed. 
The  asymmetry  of  Stadtfeld  may  be  counteracted  by  the  molding  produced  during 
labor.  After  the  latter  disappears,  the  true  shape  of  the  skull  returns.  In  primi- 
parse  long  compression  of  the  head  by  the  lower  uterine  segment  and  pelvis  results 
in  dolichocephalus,  which  may  be  permanent. 


THE    EFFECT    OF    LAHOlt    ()\    THE    CHILD  S    ORGANISM 


145 


In  brooch  prosontations  the  head  may  \)o  flattonod  by  the  pressure  of  tho  fundus 
against  it  for  a  lonj;-  time.  In  a  ti}j;htly  built  i)riinipara  tho  fiattoninj^  may  begin  in 
tho  latter  months  (A  pregnancy  and  may  be  permaMcut.  Sometimes  corresponding 
shortening  of  tho  sternocleidomastoid  muscle  results  from  the  strained  attitude  of 
the  child,  and  wry-neck  is  produced. 

Without  doubt  lalxjr  affects  tho  fetus  in  more  ways  than  our  i)ros('nt  nujaiis  of 


Fia.  I(i7. — IjARge  Caput  Succedaxeum  Showing  Hemorrhages  Into  Skix. 

investigation  disclose.  Perhaps  tiny  hemorrhages  in  tho  brain  may  explain  some 
of  the  so-called  congenital  deformities  and  diseases,  for  instance,  strabismus,  ptosis 
palpebrarum,  epilepsy,  persistent  headache,  idiocy. 


THE  PROGNOSIS  OF  LABOR 

In  ideal  labor  there  should  be  no  mortality  of  either  mother  or  child,  but,  un- 
fortunately, we  are  far  from  this  ideal. 

In  the  United  States  of  America,  from  a  registered  area  of  a  little  more  than  one- 
half  of  the  total  area  of  the  country,  over  8000  women  die  annually  in  childbirth. 
(See  table  below.)      The  number  seems  to  be  gromng  all  the  time. 

The  increase  year  by  year  is  explained  by  tho  increasing  area  of  registration 
and  the  improvement  in  the  statistical  reports.  Without  doubt  several  thousand 
women  die  in  childbirth  every  year  and  are  buried  under  another  diagnosis.  Hun- 
dreds die  months  and  even  years  after,  but,  nevertheless,  from  the  cUrect  results  of 
labor,  from  their  injuries,  from  infection,  and  from  operations  undertaken  to  cure 
them.  Then,  too,  the  given  statistics  cover  only  half  of  the  area  of  the  country, 
though  the  most  densely  jiopulated  portion. 
10 


U6 


PHYSIOLOGY    OF    LABOR 

DEATHS  IN  CHILDBIRTH  IN  THE  UNITED  STATES 


Year 

Sepsis 

Eclampsia 

Other  Causes 

Total 

1902 

1813 

768 

1583 

4164 

1903 

1992 

925 

1648 

4569 

1904 

2291 

1075 

1743 

5109 

1905 

2309 

981 

1787 

5077 

1906 

2622 

1348 

2371 

6341 

1907 

2916 

1470 

2433 

6719 

1908 

3284 

1619 

2441 

7344 

1909 

3450 

1706 

2635 

7791 

1910 

4122* 

1824 

2509 

8455 

W.  Williams  reviews  the  mortality  in  England  and  Wales  from  1847  to  1901. 
Part  of  his  table  is  here  reproduced : 


DEATHS  IN  CHILDBIRTH  IN  ENGLAND  AND  WALES 

Year            Total  Births 

Sepsis 

Accidents  op 
Births 

Total 

Rates  per  1000  Births 
of  Live  Children 

1897 
1898 
1899 
1900 
1901 

921,693 
923,265 
928,646 
927,062 
927,807 

1836 
1707 
1908 
1941 
2079 

2414 
2367 
2418 
2514 
2315 

4250 
4074 
4326 
4454 
4394 

2.62 
2.56 
2.63 
2.71 
2.49 

These  figures  are  incomplete  because  the  birth  of  still-born  infants  is  not  recorded,  and  the 
mortality  of  the  mothers  following  such  births  is  not  included. 

In  Norway  (Dreyer)  the  mortality  in  1904  was  2.8  per  thousand,  an  improve- 
ment over  1870,  when  it  was  7  per  thousand. 

If  all  deaths  were  reported,  the  mortality  tables  would  be  still  more  alarming. 
At  present  it  is  safe  to  say  that  of  every  200  women  who  become  pregnant,  one  dies 
before  the  reproductive  function  is  completed. 

In  S23eaking  of  these  deaths  we  must  distinguish  between  the  preventable  and 
the  unavoidable.  Without  question  the  mortality  of  childbirth  could  be  reduced 
to  one  per  thousand  if  the  public  were  properly  instructed  regarding  the  needful  pre- 
cautions, and  if  the  physicians  were  all  capable  of  meeting  obstetric  emergencies, 
and,  most  important,  practised  an  aseptic  technic.  It  will  be  noticed  in  all  the 
statistics  that  nearly  half  the  deaths  were  from  infection. 

There  is  an  unavoidable  mortality  in  childbirth,  and  it  comes  from  disease  of 
the  uterus,  adnexa,  and  pelvis,  and  from  general  affections  aggravated  by  parturi- 
tion, but  it  is  small  compared  with  the  preventable  mortality. 

Labor  shows  a  high  morbidity,  that  is,  the  women  are  sickened  or  injured  in 
the  process  of  reproduction.  The  author  has  never  seen  a  woman  as  anatomically 
perfect  after  delivery  as  she  was  before  pregnancy  occurred.  Many  women  date 
life-long  invalidism  from  a  confinement.  Overdistention  of  the  abdomen  often 
leaves  weakness  of  the  abdominal  wall  and  visceroptosis;  the  urogenital  septum  is 
always  torn,  and  prolapse  of  the  urethra  and  anterior  vaginal  wall  occurs,  the  patu- 
lous vulva  opening  the  way  for  infectious  catarrhs  of  the  bladder  and  of  the  cervix 
and  chronic  metritis;  laceration  or  overstretching  of  the  pelvic  floor  is  an  almost 
invariable  occurrence  in  greater  or  less  degree,  inviting  prolapse  of  the  uterus — 
these  are  some  of  the  inevitable  consequences  of  labor.  If  to  these  be  added  the 
frequent  infections  of  the  uterus  and  adnexa,  the  damage  to  the  soft  parts  from 
operative  deliveries,  disease  of  the  kidneys,  of  the  liver,  etc.,  one  quickly  appreciates 

*  Owing  to  changes  in  classification  for  the  year  1910,  these  figures  may  not  be  compared 
with  those  of  previous  years. 


THK    EFFECT    OF    LAIJOIi    OS    THE    C1I1LI>'.S    OIUJANIS.VI  147 

the  hifth  morbidity  of  tlic  rcprfxluctivc  function  in  the  human  female  in  our  day. 
Naturally,  it  is  imi)os.sil)l('  to  compile  .statistics  as  to  the  frec^uency  of  these  affections, 
but  the  records  of  the  hospitals  show  a  continual  stream  of  women  seeking  relief 
from  the  bad  effects  of  childbirth.  Most  of  these  diseases  and  accidents  can,  even 
with  our  present  knowletlge,  be  prevented,  and  no  field  in  all  preventive  medicine 
promises  f;-reatcr  results. 

Prognosis  for  the  Infant. — The  hi<j;hest  mortality  that  befalls  the  human  race 
in  one  day  occurs  on  the  day  of  birth.  Schultze  estimates  that  5  per  cent,  of  chil- 
dren are  still-born,  dying  during  labor,  and  1.5  per  cent,  die  shortly  after  birth,  the 
result  of  the  trauma  of  labor.  Broth(M-s  found  that  in  New  York  city,  in  the  four 
years  from  188!)  to  18i)2,  over  16, ()()()  chihlreu  were  born  dead  or  died  immediately 
after  labor.  In  Chicago  about  2000  children  die  annually  from  birth  accidents 
(Evans).  In  Paris  9  per  cent.  cUe.  It  is  safe  to  say  that  in  the  United  States 
75,000  children  die  annually  during  delivery.  Asphyxia  and  injury  during  labor 
are  frequent  causes  of  fetal  death,  but  a  large  part  of  the  mortality  is  due  to  con- 
genital defects,  syphilis,  alcoholism  of  the  parents,  and  general  cUseases. 

Besides  this  mortality,  the  children  are  frequently  injured  during  deliver}-, 
either  by  the  natural  powers  or,  and  more  often,  by  operative  procedure.  Hemor- 
rhages into  the  brain,  tentorium  tears,  fracture  of  the  skull,  dislocation  and  fracture 
of  the  vertebrae,  joints,  and  extremities,  often  result  from  the  brutal  deliveries  ren- 
dered necessary  in  cases  of  mechanical  disproportion.  ]\Iilder  injuries  of  brain, 
nerves,  and  bones  are  very  frequent,  but  are  often  overlooked  until  their  later 
effects  become  prominent;  for  example,  Little's  disease  from  injury  to  the  brain  and 
spinal  cord,  chronic  hydrocephalus,  athetosis,  idiocy,  etc. 

One  such  brief  glance  into  the  subject  will  show  the  immensity  of  this  field  of 
preventive  medicine,  and  prove  to  the  reader  that  obstetrics  is  not  one  of  the  minor 
branches  of  medicine,  but  a  specialty  deserving  the  attention  of  the  best  minds  in 
the  profession. 

Literature 

Brothers:  Amer.  Jour.  Obstet.,  May,  1896,  p.  756. — Chamhrelenl:  L'Obstetrique,  November,  1911,  p.  1067. — Dreyer: 
Ref.  Centralbl.  f.  Gyn.,  1908,  p.  1460.— Schultze:  Handbuch  d.  Ivinderkrankh.,  vol.  ii,  p.  15. — Williams,  W.: 
London  Lancet,  June  lS-25th;  July  2d  and  9th,  1904. 


CHAPTER  IX 

THE  MECHANISM  OF  LABOR 

The  details  of  the  "svonderful  process  of  parturition,  whose  cHnical  manifesta- 
tions we  have  just  considered,  deserve  separate  study.  The  mode  and  manner  by 
which  the  ovum  is  separated  and  extruded  from  the  uterus  comprise  the  mechanism 
of  labor,  and  deserve  the  closest  attention  of  the  practising  obstetrician.     Indeed, 


Fig.  168. — Internal  Utkrixe  Pbessukk  (I.U.P.).     Effect  of  Uterine  Contraction. 

without  accurate  knowledge  of  this  mechanism  he  ceases  to  be  a  scientific  practi- 
tioner and  becomes  a  midwife.  The  accoucheur  who  knows  the  science  of  the 
mechanism  of  labor  will  early  recognize  deviations  from  the  normal,  and,  by  some 
simple,  harmless  manipulation,  may  direct  the  course  of  la])or  into  the  normal  again. 
He  also  will  bo  able  to  deal  with  the  pathologic  mechanisms  with  the  least  possible 
danger  of  injury  to  the  mother  and  child.     The  ignorant  accoucheur,  on  the  other 

148 


Till-:    iMlOCHAXI.SM    OK    LAIlOIt 


149 


hand,  will  allow  the  labor  to  <i;o  on  iiiilil  positive  obstruction  exists  and  the  lives  of 
parent  and  child  are  placed  in  jeopardy.  Then  he  nnist  use  brute  force  to  overcome 
mechanical  difficulty,  with  the  almost  invariable  result  of  severe  maternal  injury 
and  frequent  ch^struction  of  the  child.  Although  a  daily  occurrence,  and  the  ol)ject 
of  a  century  of  study  by  the  most  eminent  accoucheurs,  the  intricate  processes  of 
l)arturiti()n  are  not  all  understood,  and  many  of  them  are  not  yet  satisfactorily 
explained. 

The  subject  falls  naturally  into  the  consideration  of  three  factors:    first,  the 
powers;    second,  the  passadcs;    Ihird,  the  passengers.     After  this  the  action  of  the 


Fig.  169. — Action  of  the  Uterine  Ligaments. 


powers  on  the  passengers  in  forcing  them  through  the  prepared  passages  must  be 
studied. 

The  Powers,— The  uterus  is  the  main  driving  engine,  with  the  al^dominal 
muscles  as  a  powerful  auxiliary.  Gravity,  that  is,  the  weight  of  the  child,  is  of 
small  influence,  while  the  elastic  contraction  of  the  vagina  and  perineal  floor  has 
hardly  any  effect  on  the  propulsion  of  the  ovum. 

A\  hen  the  uterus  contracts,  it  exerts  ecfual  pressure  on  its  contents  in  all  direc- 
tions, obeying  the  law  of  pressure  on  fluids.  If  the  pressure  were  met  all  over  by 
equal  resistances,  it  would  return  to  the  uterine  wall  nullified,  but  since  there  is  a 
weak  spot  in  the  uterine  wall,  the  lower  uterine  segment  and  internal  os,  the  contents 
of  the  uterus  will  all  be  forced  in  this  direction.     The  resultants  of  all  the  forces 


150 


PHYSIOLOGY    OF   LABOR 


applied  to  the  bodies  in  the  uterus  will  point  toward  the  internal  os  (Fig.  168). 
This  hydraulic  pressure  is  the  most  important  factor  in  the  work  of  the  uterus,  but 
other  factors  have  been  invoked.  Lahs  and  Schatz  believed  that  the  uterus,  com- 
pressing the  fetus  from  side  to  side,  lengthened  its  spinal  column,  forcing  the  breech 
against  the  fundus  and  the  head  doA^aiward  into  the  pelvis.  This  pressure  is  called 
the  fetal  axis  pressure,  and  is  absent  in  polyhydramnion,  and  with  a  small  or  macer- 
ated fetus.  The  change  of  the  C-formed  spinal  column  to  the  straighter  form  results 
in  a  leng-thening  of  the  fetal  cyhnder  of  10  cm.     Whether  the  uterus  presses  on  the 


Fig.  170. — Action  of  the  IxTnA-.\BDOMiXAL  PRES.strnE  ix  Aitomentixg  Ixtr.a-uterixe  Pressure. 
Girdles  of  resistance  indicated  by  white  lines. 

pelvic  extremity  of  the  fetal  axis  and  thus  causes  an  advance  of  the  child  or  not  is 
still  a  disputed  question,  with  the  decision  probably  in  the  negative. 

Intra-uterine  pressure  accomplishes — (1)  The  protrusion  of  the  bag  of  waters; 
(2)  the  dilatation  of  the  lower  uterine  segment  and  cervix;  (3)  it  causes  edema  and 
succulence  of  the  soft  parts— the  so-caUed  "vital  dilatation";  (4)  the  expulsion  of 
the  fetus  and  placenta. 

The  round,  the  uterosacral,  and  the  broad  ligaments  have  important  func- 
tions. They  are  part  of  the  uterus, — mere  extensions  of  its  muscle-fibers, — 
and  contract  when  it  contracts.     These  bands  serve  to  moor  the  uterus  to  the 


TlIK    MKCIIAMS.M    OK    l.AUOH  151 

pelvis  jind  i)r('V('nt  too  f^rviit  rctruction  above  tlic  child.  T\\('  round  ligaments 
])ull  the  tundus  forward  and  bring  its  axis  jjarallcl  with  the  axis  of  the  inlet  (Fig. 
109).  The  uterosacral  ligaments  i:)ull  the  cervix  backward  and  downward  and  also 
help  oi)en  up  llic  lower  uterine  segment  and  upper  cervix.  All  the  ligaments,  by 
the  force  exei'ted,  increase  I  he  iiit  la-iileriin'  pi'cssure  and  help  expel  the  fetus. 

The  al)d()minal  pressure  is  a  powerful  auxiliary  in  labor,  and  may  substitute 
the  uterine  contraction  more  or  less  comi)letely.  During  the  first  stage  the  ab- 
dominal muscles  do  not,  and  should  not,  take  any  part  in  the  process  of  labor,  but 
in  the  second  stage  they  are  called  upon  to  assist  and  complete  the  work  of  the 
uteiine  contractions.  During  an  expulsive  pain  the  woman  closes  the  glottis  and 
makes  a  pow(n*ful  bearing-down  effort.  She  forces  down  the  diaphragm  and  con- 
tracts the  recti,  the  ol)li([ui,  and  the  muscles  of  the  flanks.  There  is  now  a  great 
increase  of  the  intra-abdominal  pressure,  which,  obeying  the  law,  is  transmitted 
equally  in  all  directions,  the  uterus  receiving  its  share.  It  is  easy  to  see  how  the 
abdominal  pressure  is  simply  added  to  the  intra-uterine  pressure,  resulting  in  in- 
creased general  intra-uterine  pressure  (Fig.  170). 

After  the  dilatation  of  the  cervix  the  abdominal  muscles  alone  are  able  to  expel 
the  child,  and  usually  do  it,  since  the  uterus  by  this  time  has  retracted  so  high  over 
the  fetal  cylinder  and  its  muscle-fibers  are  so  shortened  that  it  has  very  little  ex- 
pulsive power. 

In  i)athologic  labor  the  abdominal  muscles  are  particularly  useful  in  overcom- 
ing the  abnormal  resistances,  in  preventing  uterine  rupture  by  restraining  the  up- 
ward displacement  of  the  uterus,  and  in  other  ways.  In  the  third  stage  of  labor  the 
placenta  is  expelled  by  the  exertions  of  the  abdominal  wall,  but  only  after  the  pla- 
centa is  separated  and  lies  in  the  lower  uterine  segment  and  vagina. 

The  power  of  the  uterine  contraction  cannot  be  accurately  measured.  Duncan 
tried  to  do  it  b}"  testing  the  resistance  of  the  fetal  membranes.  The  force  necessary 
to  rupture  them  varies  greatly.  Schatz,  with  his  tokodynamometer,  a  rubber  bag 
half  filled  with  water,  lying  in  the  uterus,  connected  with  a  manometer,  found  that 
the  uterine  contraction  during  the  first  stage  showed  a  pressure  of  from  17  to  55 
pounds,  and  during  the  second  stage,  when  the  force  of  the  abdominal  muscles  was 
added,  it  was  about  doubled.  Clinically,  the  power  of  the  uterine  contraction  may 
often  be  appreciated.  It  may  crush  the  baby's  head  or  fracture  its  bones.  The 
accoucheur's  hand  in  the  uterus  may  be  squeezed  so  hard  that  it  becomes  insensible 
and  paralyzed.  In  rare  cases  tumultuous  action  of  the  uterus  and  abdominal 
muscles  may  eject  the  infant  from  the  vulva  with  much  force.  Probably  the  or- 
dinary amount  of  force  exerted  by  the  uterus  and  abdomen  rarely  exceeds  30  pounds. 

Gravity  plays  but  a  small  role  in  labor.  The  difference  in  specific  gravity  of 
the  fetus  and  its  liquor  amnii  is  not  great.  The  constant  slight  pressure  exerted  by 
the  head  on  the  lower  uterine  segment  may  soften  this  portion  of  the  uterus,  or  it 
may  elicit  stronger  pains.  One  often  observes  that  a  change  of  the  parturient's 
position,  which  brings  the  weight  of  the  fetus  onto  the  cervix,  such  as  walking  or 
sitting  up,  will  strengthen  the  uterine  contractions. 


CHAPTER  X 

THE  PASSAGES 

The  fetus  has  to  traverse  a  bent  passage,  which  is  partly  bony  and  partly 
fibrous  and  muscular.  The  bony  portion  is  the  pelvis,  which  is  divided  into  two 
parts  by  a  ridge  called  the  linea  terminalis.  The  upper,  large,  or  false  pelvis  is  of 
little  obstetric  interest.  It  is  made  up  of  the  flaring  iliac  plates  at  the  sides,  the 
spine  behind,  and  the  gap  in  front  over  the  pubis  is  filled  in  by  strong  abdominal 


Fig.    171. — Normal  Female  Pelvis. 

muscles.  The  false  or  upper  pelvis  is  shaped  like  a  flat  funnel,  and  forms  a  support 
for  the  uterus  and  child  during  pregnancy,  directing  the  latter  into  the  true  pelvis 
at  the  proper  time.  The  shape  and  size  of  the  false  pelvis,  too,  give  the  obstetrician 
some  conception  of  the  shape  and  size  of  the  true  pelvis.  (See  p.  234.)  The 
true,  lower,  or  small  pelvis  (pelvis  minor)  is  of  immense  ol^stetric  importance,  since 
it  supports  the  muscles  of  the  pelvic  floor  and  gives  shape  and  direction  to  the  par- 

152 


THK    PASSAGES 


153 


turiciit  ctUKil,  itself  f'ciriuiiifi;  part  of  .same.  A  plaster  cast  of  a  true  pelvis,  as  first 
made  by  Ilodj;*',  shows  its  cavity  {o  have  the  shape  of  a  cylinder  with  a  bluntly 
pointed  exaxial  lower  end.  It  is  very  sli<>;li1l>-  curved  anteriorly.  The  entrance 
and  outlet  of  the  true  pelvis  are  smaller  than  t  he  middle  portion,  and  have,  therefore, 
been  called  straits — the  superior  and  inferior.  The  region  between,  being  large  and 
roomy,  is  called  the  excavation.  Anteriorly,  the  canal  is  short — 4}/2  fm.;  posteriorh', 
long,  th(.'  length  of  the  sacrum — 12}/^  cm.  Laterally,  the  pelvic  canal  is  longer,  and 
the  sides  nariow  slightly  from  above  downward,  especially  liehind,  near  the  spines 
of  the  ischia,  but  broadening  out  below  at  the  tuberosities.  The  contour  of  the 
canal,  therefore,  varies  much  at  different  levels,  and  it  is  cu.stomary  to  describe  these 
variations  by  means  of  ])lanes  drawn  more  or  less  arbitrarily  through  the  pelvis. 
It  must  be  clearly  understood  that  the  so-called  planes  about  to  be  described  are 


Fig.   172. — The  Pelvic  Inlet  tnith  Diameters. 


really  not  such  in  a  mathematic  sense,  but  represent  regions  or  portions  of  the  pelvis, 
and  have  three  dimensions. 

The  plane  of  the  inlet,  l^rim,  superior  strait,  isthmus,  margin,  or  apertura  pelvis 
superior,  is  Ixnnided  l)y  the  u})per  border  of  the  pul^is  in  front,  the  linea  innominata 
or  linea  terminalis  at  the  sides,  and  the  sacral  promontory  behind  (Fig.  172).  This 
plane  is  heart-shaped — that  is,  a  transverse  ellipse  on  which  the  sacrum  intrudes 
behind.  The  depth  of  the  region  of  the  inlet  is  about  2  cm.,  and  represents  the 
distance  from  a  line  drawn  in  the  pubosacral  diameter  to  a  transverse  line  in  the 
low^est  level  of  the  linea  terminalis.  (See  Fig.  173.)  It  is  deeper  behind  than  near 
the  pubis,  and  varies  very  much  in  all  three  dimensions — that  is,  in  shape  and  depth. 
(For  detailed  description  see  chapter  on  Contracted  Pehns.)  The  inlet  is  a 
very  important  region  of  the  pelvis,  because  contraction  and  distortion  of  the  bones, 
due  to  disease,  are  likely  to  be  marked  here,  and,  further,  it  is  an  important  factor  in 
normal  labor.  Its  diameters  are,  first,  the  anteroposterior,  pubosacral,  or  conjugata 
vera  (C.  \.),  named  by  von  Roederer,  extencUng  from  the  top  of  the  pubis  to  the 


154 


PHYSIOLOGY    OF   LABOR 


tip  of  the  sacral  promontorj^,  measuring  113/2  era.  Tliis  is  the  true  or  anatomic 
conjugate.  The  shortest  anteroposterior  diameter  is  from  a  point  1  cm.  lower  on 
the  surface  of  the  pubis  to  the  promontory,  and  is  called  the  obstetric  conjugate 
(Michaelis),  because  intimately  concerned  in  the  mechanism  of  labor,  especially  in 
contracted  pelves.  It  measures  11  cm.  in  the  normal  pelvis,  but  may  be  reduced  to 
a  few  centimeters  in  abnormal  pelves.  When  we  speak  of  a  pelvis  of  8  cm.  we 
mean  one  with  a  C.  V.  of  8  cm.  It  is  impossible  satisfactorily  to  measure  the  C.  V. 
on  the  living,  though  numerous  instruments  are  vaunted  for  the  purpose.  We  can 
gather  an  approximately  correct  idea  of  its  length  from  the  measurement  of  the 
distance  from  the  under  margin  of  the  pubis  to  the  promontory.     This  diameter  is 


Fig.   173. — The  Regions  of  the  Pelvis. 


called  the  conjugata  diagonalis  (C.  D.),  and  is,  in  normal  pelves,  about  1^  cm. 
longer  than  the  C.  V.,  that  is,  about  123^^  cm.  (See  Pelvimetry,  p.  238.)  Trans- 
versely, the  inlet  measures  13  cm.,  while  the  two  obliques  measure  12  and  123/^  re- 
spectively. The  oljliquo  diameters  are  named  first  and  second,  or,  better,  right  and 
left,  using  the  sacro-iliac  joints  as  the  denominator,  according  to  the  recommenda- 
tion voted  at  the  Congress  at  Washington  in  1887  (Bar).  The  right  oblique  extends 
from  the  right  sacro-iliac  joint  to  the  left  iliopubic  tubercle;  the  left,  between  cor- 
responding points.  They  are  important  diameters,  because  the  head  usually  enters 
the  pelvis  in  one  or  the  other.  Since  most  individuals  step  harder  on  the  right  foot, 
and  since  they  also  have  a  slight  right  scoliosis,  the  right  half  of  the  pelvis  is  a  bit 
flattened,  and  the  left  oblique,  therefore  a  trifle  shorter  than  the  right.     The  inlet 


THE    PASSAGES 


155 


is  encroached  upon  ])y  tlie  iliopsoas  nmsclcs  (Fig.  175),  Init  pro]ja])ly  not  enough 
usually  to  disturl)  the  niechanisin  of  labor.  It"  the  child  should  he  large  and  the 
muscle  well  developed,  the  nniscle  might  delay  the  engagement  of  tlu;  head.  Pos- 
ture to  relax  the  muscle  would  relieve  the  obstruction. 

The  wide  pelvic  plane  is  one  passing  from  the  middle  of  the  pubis  to  the  junc- 
tion of  tlu!  second  and  third  sacral  vertebra;  (Fig.  17G).  It  is  about  the  center  of 
the  region  called  the  "excavation"  of  the  jielvis,  and  is,  therefore,  sometimes  called 
the  midplaiic,  this  lattci-  Icnu  being  iiiiich  used  in  operative  obstetrics.     This  plane 


Fig.  174. — Sagittal  Section  of  Pelvis  Showing  Diameters  (Hodge). 
C.  v.,  Anatomic  conjugate;  C.  V.  O.,  obstetric  conjugate;    CD.,  diagonal  conjugate. 


is  irregularly  ovoid,  occupying  the  roomiest  portion  of  the  pelvis,  and  A^dth  an 
anteroposterior  diameter  of  133^  cm.  and  a  transverse  of  123^  cm. 

The  narrow  pelvic  plane  passes  tlirough  the  apex  of  the  pubic  arch,  the  spines 
of  the  ischia,  and  the  end  of  the  sacrum  (Fig.  177).  This  is  the  smallest  strait  of 
the  pelvis,  and  is  frequently  the  site  of  contracture,  a  fact  which  is  only  lately  being 
adequately  appreciated.  This  plane  is  ovoid,  with  the  large  end  anteriorly  and  the 
smaller  end  behind,  formed  by  the  sacrosciatic  ligaments.  OA\'ing  to  the  incurvation 
of  the  spines  of  the  ischia  and  the  attachments  of  the  levator  ani  muscle  and  fascia 
the  child,  in  its  passage,  is  crowded  into  the  anterior  portion  of  this  plane.  Its  most 
important  chameter  is  that  between  the  spines — 10}  2  ciiT^-  An  imaginary  line  drawn 
between  the  spines  of  the  ischia  is  used  to  determine  the  descent  of  the  head  into 
the  pelvis.  The  narrow  pelvic  plane  is  important  also  because  it  is  the  beginning 
of  the  bend  of  the  cylindric  birth-canal.     In  labor,  the  head  descends  straight  into 


156 


PHYSIOLOGY    OF   LABOR 


the  pelvis  until  it  reaches  this  plane,  then  begins  to  rotate  and  slide  forward  under 
the  pubis. 

The  plane  of  the  outlet  passes  through  the  arch  of  the  pubis,  the  rami  of  the 
pubes,  the  tuberosities,  and  the  tip  of  the  coccyx.  This  plane  is  the  lower  boundary 
of  the  region  of  the  bony  outlet,  and  is  not  seldom  the  seat  of  contracture.  There 
are  really  two  planes,  roughly  resembling  triangles  bent  at  their  applied  bases  on  the 
tuberosities.  During  labor  the  head  pushes  the  coccyx  back  (Fig.  174),  bringing 
the  two  parts  more  into  one  plane,  and  at  the  same  time  increasing  the  antero- 
posterior diameter  from  93^  to  12  cm.  The  transverse  diameter  of  this  plane  is 
important — 11  cm. 

The  above  is  a  description  of  the  classic  pelvic  planes  dating  from  the  time  of 


Psoas  major 
Psoas  minor 


Psoas  major 
Psoas  minor 


Fig.  175. — Showing  Inlet  Encroached  on  by  Iliopsoas  Mttscles. 


Levret  (1770).  Hodge,  of  Philadelphia,  constructed  a  series  of  more  arbitrary 
planes,  all  running  parallel  to  the  inlet  (Fig.  179).  The  first  parallel  is  in  the  inlet; 
the  second  parallel,  called  by  Veit  the  "chief  plane,"  touches  the  arch  of  the  pubis 
and  strikes  the  lower  part  of  the  second  sacral  vertebra;  the  third  cuts  the  spines  of 
the  ischia,  and  the  fourth  goes  through  the  tip  of  the  coccyx  and  represents  the 
pelvic  floor.  The  Hodge  system  never  obtained  general  recognition,  and  one  mod- 
ern author  calls  it  obsolete,  but  Sellheim,  to  whom  we  owe  much  in  the  study  of  the 
mechanism  of  labor,  recently  (1909)  declared  it  the  only  scientific  method  for  the 
study  of  the  pelvis  and  the  mechanism  of  labor,  and  recommended  its  general  adop- 
tion by  teachers  and  writers.     It  is  a  fact  that  the  head  enters  the  pelvis  in  the  axis 


THE    PASSAGES 


157 


of  the  inlet,  passing  succc'ssivcly  throuKli  these  planes,  and,  too,  since  we  can  easily 
determine  the  location  and  direction  of  the  inlet,  it  is  a  simple  matter  to  orient 
one's  self  as  to  the  location  of  the  planes  parallel  to  it.  The  author  has  used  the 
Hodge  system  of  ])lan(>s  in  his  studies  of  the  mechanism  of  labor,  and  agrees  with 
Sellheini  us  (o  t  heir  scientific  worth,  lii  the  comparative  study  of  contracted  pelves 
(Hegar)  and  in  gynecologic  diagnosis  they  are  equally  valuable. 


Fig.  176. — Wide  Pelvic  Plane. 


When  the  woman  is  in  the  erect  position,  the  inlet  makes  an  angle  of  about  55 
degrees  with  the  horizon,  but  this  varies  from  40  degrees  to  100  degrees,  depending 
on  the  rotation  of  the  thighs  and  the  carriage  of  the  shoulders.  This  is  called  the 
inclinatio  pelvis.  A  cjuick  method  to  determine  if  this  inclination  of  the  pelvis  is 
normal  is  to  see  if  the  anterosuperior  spine  of  the  ilium  and  the  pubis  are  in  a 
vertical  plane.     In  the  lying  position  the  inlet  is  25  degrees  below  the  horizontal. 


Fig.   177. — Narrow  Pelvic  Pl.\^ne. 


The  crests  of  the  ilium  run  about  parallel  to  the  plane  of  the  inlet.  Formerly,  great 
importance  was  attached  to  the  pelvic  inclination  as  affecting  the  mechanism  of 
labor,  lately  not  much. 

Contrary  to  what  would  be  expected,  the  pelvis  is  not  a  solid  and  fixed  bony 
structure.  The  coccjtc  is  easily  pressed  back  by  the  advancing  head,  enlarging  the 
outlet  2  to  2.5  cm.     The  pelvic  joints  are  fixed  by  strong  ligaments,  but  during 


158 


PHYSIOLOGY    OF   LABOR 


pregnancy  these  soften  and  allow  a  certain  degree  of  mobility  to  the  bones.     While 
they  do  not  permit  much  actual  enlargement  of  the  pelvic  cavity,  as  believed  the 


Fig.  178.— The  Pelvic  Outlet. 


First  parallel 


Second  parallel 


Fourth 
parallel 


Fia.  179. — Hodge's  System  of  Parallel  Pelvic  Planes. 


ancients,  and  as  occurs  in  many  animals,  the  loosening  of  the  joints  allows  the  hip 
bones  to  rotate  on  the  sacrum  when  the  body  is  bent  into  forced  extension  and  flexion. 
Thus,  the  sacrum  being  fixed,  the  pubis  moves  downward  in  forced  extension  of 


THE    PASSAGES 


159 


the  thighs, — Wah-hcr's  position, — (•iihirj;iii<i;  llie  inlet  by  0.5  to  1  cm.  CFig.  180).  In 
forced  flexion,  the  knees  being  pressed  against  the  abdc^nen,  tlie  pubis  is  forced 
up,  the  ossa  innominata  rotate  upward  and  dip  outward,  enlarging  the  outlet  of 
thi'  pelvis.  These  changes  in  the  shape  of  the  pelvis  are  made  use  of  in  the  con- 
duct of  labor.     (See  Chapter  LVIII.) 


Fig.  ISO. — Showing  the  Mobility  op  the  Pelvic  Joints  in  Flexing  and  Extending  the  Thighs. 
A  represents  the  pelvis  when  the  patient  lies  prone;   B,  when  the  thighs  are  strongly  flexed  on  the  belly;   C,  when 
the  legs  are  allowed  to  depend  fully.    A-E  shows  the  available  conjugate  in  the  Walcher  position,  and  the  shaded  area  the 
gain  in  space  in  the  region  of  the  inlet. 

Literature 

Bar,  P.:  Report  sur  I'unification  de  la  nomenclature  obstetricale  au  Congress  k  Rome,  190.3. — Burns:  Report  of 
Committee  on  Obstetric  Nomenclature  to  the  American  Medical  Association,  June,  1912. — Edgar:  The  Prac- 
tice of  Obstetrics. — Hodge:  A  System  of  Obstetrics,  1S6.5. — L'Obstetrique,  1903,  part  2. — Report  of  the  Ninth 
International  Medical  Congress,  Washington,  1SS7. — Walcher:    Cent.  f.  Gyn.,  1SS9,  p.  892. 


THE  SOFT  PARTS 

Fig.  175  shows  the  relation  of  the  psoas  and  iliacus  muscles  to  the  inlet.  It  'will 
be  seen  that  they  give  it  a  more  quadrangular  shape;  that  they  encroach  but  little 
on  its  lumen;  and  that  only  in  cases  of  transversely  contracted  pelves  ^nll  they  in- 
terfere in  the  mechanism  of  labor.  The  rectum  lies  on  the  left  side  behind,  and  pro- 
jects into  the  cavity  only  when  filled.  It  may  thus  cause  dystocia.  The  midplane 
is  encroached  on  by  the  obturator  internus  and  behind  by  the  pjTiformis — very 
sHghtly,  however.  The  nerves  in  the  pelvis  make  no  obstruction,  and,  owing  to  the 
projecting  spines  of  the  ischia  and  the  forward  dip  of  the  pelvic  floor,  rarely  are 
subject  to  pressure.  When  they  do  suffer  pressure,  the  parturient  has  pains  ruiuiing 
down  the  legs  and  up  the  back.  The  peritoneum  and  fat  count  very  little  in  the 
general  configuration  of  the  parturient  canal,  as  was  proved  by  Hodge  with  plaster 
casts. 


160 


PHYSIOLOGY    OF   LABOR 


The  cervix  and  the  lower  uterine  segment  have  already  been  considered.  Of 
most  obstetric  interest  is  the  pelvic  floor.  This  consists  of  those  soft  tissues  which 
fill  out  the  irregular!}'  shaped  outlet  of  the  pelvis.  A  great  many  structures  enter 
into  its  formation — the  pelvic  fascia,  the  levator  ani  and  coccygeus,  the  deep  and 
superficial  transverse  perineal  muscles,  the  constrictor  cunni,  the  urogenital  septum, 
fat  and  sldn,  and  the  organs — rectum,  vagina,  and  urethra.  Careful  dissection  and 
embrj'ologic  study  enable  us  to  distinguish  two  diaphragms  in  the  pelvic  floor  (Holl) 
— an  upper  stronger,  a  muscular  system,  modified  from  that  formerly  used  for  the 
tail,  and  a  lower,  weaker,  developed  from  the  sphincter  cloacae,  which  closes  the 
orifices  in  the  pelvic  floor. 

The  cUaphragma  pelvis  rectale,  or  proprium,  shortly  referred  to  as  the  pelvic 


Luschka  s  fibres 


M.obturator 

Intern.  aj7d 

gemelLL 


Fig.  181. — Levator  Ani  from  Below. 


floor  or  diaphragm,  is  made  up  of  the  levator  ani  and  the  coccygeus,  together  with 
the  pelvic  fascia  above  and  below.  Anteriorly,  the  muscle  is  attached  to  the  back 
of  the  rami  of  the  pubis,  leaving  an  incomplete  space,  23^  cm.  wide,  behind  the 
symphysis.  It  extends  on  either  side  across  the  opening  of  the  obturator  foramen, 
being  attached  to  the  fascia  covering  the  o])turator  internus  muscle  by  the  "white 
line,"  or  arcus  tendinfeus  musculi  levatoris  ani.  On  vaginal  examination  this  atcus 
tendineus,  or  junction  of  the  fascia  obturatoria,  with  the  fascia  diaphragma  pelvis 
superiora,  can  often  be  felt  by  the  finger.  The  insertion  of  the  muscle  extends  to 
the  spines  of  the  ischia.  From  this  extensive  area  of  insertion  the  muscle-fibers  pass 
downward  and  inward  toward  the  median  line.  Posteriorly,  they  come  together 
on  the  lower  end  of  the  sacrum  and  the  coccyx;  anterior  to  this  they  interlace  in  the 
median  line  behind  the  anus;   next  they  fuse  into  a  sling-like  hammock  under  the 


THE    PASSAGES 


161 


perineal  curve  of  the  rectum;  finally  a  very  few  fibers  meet  between  the  anus  and 
vagina  in  the  perineal  body  (Luschka's  fibers).  HoU  gave  different  portions  of  the 
broad  muscle  si)ecial  names.  That  portion  going  from  the  spine  of  the  ischium  to 
the  coccyx  he  called  the  i.schiococcygcus;  that  from  the  arcus  tendineus  to  the 
raphe,  the  iliococcygous;  that  from  the  posterior  surface  of  the  pubis,  pa.ssing  along- 
side the  urethra,  vagina,  and  rectum,  to  meet  its  fellow  in  a  tendinous  raphe  ex- 
tending from  the  tip  of  the  coccyx  toward  the  rectum,  the  pubococcygeus;  and, 
fourth,  a  strong  band  running  from  the  pubis  around  the  lower  part  of  the  rectum, 
shng-like,  tiie  puborectalis.  A  very  few  of  tliese  fibers  pass  in  front  of  the  rectum 
into  the  perineal  body;  a  few  attach  to  the  rectum  and  skin  (Fig.  181).  The 
diaphragm  thus  resembles  a  concave  broad  horseshoe,  incomplete  in  front,  leaving 
an  elliptic  opening.  Through  this  elliptic  space  pass  the  urethra,  vagina,  and  rec- 
tum. The  sides  of  the  muscle  slope  together  in  the  middle,  forming  a  V-shaped 
gutter,  leading  down  under  the  arch  of  the  pubis.  Fig.  182  shows  the  distribution 
and  action  of  the  various  portions  of  the  levator  ani  and  the  opposing  action  of  the 


Fig.  182. — Shows  Lhtvatob  Aia  from  Side — Sijxg-like  Action. 

a,  \'agina;  5,  rectum;  c,  posterior  fibers  of  sphincter:  d,  anterior  fibers  of  sphincter  ani;  e,  levator  ani;  /,  musciilus 

coccygeus  (somewhat  modified  from  Luschka). 


sphincter  ani.  \Yhen  the  levator  contracts  it  pulls  the  rectum  and  vagina  up  against 
the  pubis;  when  the  sphincter  contracts  it  draws  the  anus  and  the  lowest  portion 
of  the  rectum  backward,  the  result  of  the  two  forces  being  to  bend  the  rectum, 
closing  it  most  effectually.  On  vaginal  examination  the  pubococcygeal  portions 
of  the  levator  can  easily  be  felt  as  two  roundish  pillars  at  the  sides  of  the  vagina 
and  when  they  contract  the  finger  is  raised  up  to  the  pubis.  Beneath  the  pelvic 
diaphragm  lie  the  ischiorectal  fossie,  the  perineal  body,  the  diaphragma  urogenitale, 
the  vulva,  and  its  glands.  Of  these  we  need  consider  only  the  diaphragma  urogeni- 
tale (Fig.  184),  which  closes  the  hiatus  genitalis.  This  is  a  three-cornered,  musculo- 
fibrous  septum,  fitted  into  the  pubic  arch  and  extending  backward  to  the  anterior 
wall  of  the  rectmn.  It  is  made  up  of  the  deep  la\'er  of  the  perineal  fascia,  inclosing 
the  fibers  of  the  musculus  transversus  perinei  profundus  and  the  compressor 
urethrae.  A  few  of  these  fillers  reach  around  the  vagma  and  are  called  the  sphincter 
urogenitalis  (Kalischer).  On  this  septum  lie  the  musculi  bulbocavemosi  (sphincter 
cunni),  the  ischiocavemosi,  and  the  transversi  perinei  superficiales.  These  muscles, 
mostl}-  rudimentary,  center  at  a  point  between  the  rectum  and  the  vagina  called 
11 


162 


PHYSIOLOGY   OF   LABOR 


by  Waldeyer  the  centrum  perineale,  or  centrum  tendineum  perinei  (Holl),  or  perineal 
body.  The  perineal  body  is  a  pyramidal  structure,  lying  between  the  rectum  and 
vagina,  with  its  apex  in  the  pelvic  diaphragm.  Its  base  is  the  skin  between  the  anus 
and  the  vulva.  Its  anterior  wall  is  the  vagina  and  fossa  navicularis,  the  posterior 
wall,  the  anus  and  rectum;  at  the  sides  it  broadens  out  into  the  ischiorectal  fossae. 
It  is  composed  of  fat,  fasciae,  the  rear  part  of  the  urogenital  septum,  the  fused  ends 
of  the  transverse  perineal  muscles,  the  bulbocavernosi,  the  anterior  fibers  of  the 
sphincter  ani,  and  the  skin.  It  has  great  obstetric  importance,  but  not  so  much  as 
that  of  the  pelvic  floor,  a  point  frequently  overlooked.     During  labor  the  perineal 


''^"•^.. 


y 


Fig.  183. — Diapheagma  Pelvis. 
Levator  ani  viewed  from  above. 


body  is  flattened  out,  its  apex  is  pressed  down  and  back,  so  that  its  structures  come 
to  lie  on  the  distended  pelvic  diaphragm. 

The  sphincter  ani  cxternus  lies  between  the  skin  and  the  pelvic  diaphragm, 
surrounding  the  lower  end  of  the  rectum.  It  is  attached  posteriorly  to  the  coccyx 
by  the  ligamentum  anococcygeus,  and  anteriorly  to  the  centrum  tendineum.  Some 
of  its  fibers  go  circularly  around  the  anus,  some  continue  into  the  bullDocavernosus, 
some  circle  in  the  skin  near  the  anal  margin.  The  sphincter  ani  varies  much  in  size 
in  different  women:  it  may  be  as  thick  as  the  little  finger  and  as  broad  as  the  thumb- 
nail, or  only  half  the  size.     This  is  true  of  all  the  perineal  muscles. 


THE    PASSAGES 


163 


Fig.  184. — Diaphr.\gma  Uuogenitale. 
CI.,  Clitoris;  C.c,  cms  clitoridis;    Tr.u.,  trigonum  urogenitale  (triangular  ligament);    B.v.,  bulbus  vestibuli;  G., 
glandula  vestibularis  major  (Bartholini) ;  Tr.  p.s.,  musculus  transversus  perinei  superficialis;   S.a.e.,  musculus  sphincter 
ani  oxtornus;   I.e.,  musculus  isehiocavernosus. 

Literature 

Dickinson,  R.  L.:  "The  Pelvic  Floor,"  Amer.  Jour.  Obstet.,  May,  1902. — Holl:  Handbuch  der  Anatomic  des  Men- 
.schcn,  V.  Bardcleben,  1897,  vol.  vii,  2,  Jena. — Kalischer,  O.:  Die  urogenital  Muskulatur  des  Dammes,  Karger, 
Berlin,  1900. — Thomas:  "The  Female  Perineum,"  Amer.  Jour.  Obst.,  vol.  xiii. 


THE  FORMATION  OF  THE  PARTURIENT  CANAL 
Before  it  can  reach  the  external  world,  the  child  has  to  pass  through  three 
rings  the  cervix,  the  opening  in  the  levator  ani  and  the  hiatus  genitalis,  the  vulva 
and  perineum.  It  is  forced  like  a  wedge  against  the  resistances  offered  by  these 
structures,  and  the  overcoming  of  these  structures  is  the  main  function  of  the  powers 
of  labor.  Normally,  the  head  is  forced  through  the  cervix  before  it  comes  do'^Ti 
onto  the  pelvic  floor.  The  dilatation  of  the  diaphragma  urogenitale  occurs  together 
with  the  diaphragma  proprium,  and  together  they  are  made  to  form  a  fi])romuscular 
canal  attached  to  the  bony  pelvic  outlet.  How  the  cervix  is  dilated  until  it  is  flush 
with  the  vagina  has  been  described  on  p.  121,  Fig.  185  shows  the  condition  of  the 
parturient  canal  at  the  time  when,  dilatation  being  complete,  the  fetal  head  has 
passed  through  the  cervix  and  come  to  rest  on  the  pelvic  floor.  Now  the  levator 
ani  begins  to  stretch.  It  is  displaced  downward  and  backward  with  all  the  soft 
parts  of  the  pelvic  outlet;  thus  these  structures  suffer  a  displacement  in  an  axial 
direction,  in  addition  to  being  dilated  radially.  This  lengthening  of  the  soft  parts 
is  greater  on  the  posterior  wall  than  on  the  anterior,  l^eing  only  2  or  3  cm.  here, 
while  the  posterior  wall  is  stretched  10  cm.  The  bundles  of  the  levator  ani  are 
separated  and  long  drawnii  out  (Figs.  186  and  187),  so  that  the^'  form,  -with  the  pubic 
arch,  a  canal  whose  circumference  is  equal  to  the  head  of  the  child — 33  to  35  cm. 
The  urogenital  septum  lies  flat  on  the  outside  of  the  canal  and  dilates  with  it. 
Since  the  latter  septum  has  little  muscle,  and  connective  tissue  dilates  poorly,  it  is 
the  rule  for  tears  to  occur  in  this  structure  in  all  full-term  labors.  These  tears 
allow  a  sagging  of  the  anterior  vaginal  wall  and  urethra,  producing  the  so-called 


164 


PHYSIOLOGY    OF   LABOR 


"physiologic"  prolapse  of  these  structures.  The  sphincter  ani  is  stretched  from 
side  to  side  as  well  as  from  before  and  backward.  The  anus,  therefore,  gapes 
widely  as  the  head  descends  low,  exposing  the  anterior  wall  of  the  rectum.  The 
rectum  is  flattened  out  against  the  sacrum  and  levator  ani.  Owing  to  the  attach- 
ment of  the  bladder  to  the  lower  part  of  the  uterus  it  is  drawn  up  into  the  abdominal 
cavity  together  with  this  portion  of  the  retracting  organ.  Indeed,  all  the  soft  parts 
behind  the  pubis,  the  "pubic  segment"  (Barbour),  have  a  tendency  to  retract  up- 
ward, while  those  below,  in  front  of  the  sacrum,  the  "sacral  segment,"  are  pushed 
downward.  Hart  and  Barbour  have  likened  this  action  to  that  of  folding  doors, 
one  being  pulled,  the  other  being  pushed,  to  allow  an  object  to  pass  through  them. 
The  vagina  is  dilated  radially  and  axially,  to  form  a  lining  membrane  for  the  canal. 


External  os 


Contraction  ring 


Fig.  185. — Bbaune's  Frozen  Section. 
The  head  has  passed  through  the  cervix  and  come  to  rest  on  the  pelvic  floor. 


When  the  pelvic  floor  tears,  the  vagina  usually  does  also,  l^ut  it  may  not.  These 
submucous  lacerations  of  the  levator  ani  are  difficult  to  recognize  and  hard  to  repair. 

We  may  show  the  shape  of  the  parturient  canal,  as  in  Fig.  188,  but  the  reader 
will  understand  that  it  exists  as  such,  in  its  entirety,  at  no  time  during  labor.  The 
advancing  head  produces  such  a  disposition  of  the  surrounding  structures  only  at 
the  moment  it  is  passing  through  them.  For  the  purpose  of  instruction,  however, 
we  may  illustrate  the  completely  dilated  passages. 

Schroder  divided  the  canal  into  a  contractile  and  a  dilating  portion.  AH 
under  the  contraction  ring  or  internal  os  dilates;  the  uterine  muscle  above  it  con- 
tracts. Since  the  vagina  is  fastened  to  the  pelvic  floor,  contraction  of  the  uterus 
stretches  the  canal  from  this  point  upward,  and  the  advancing  head  pushes  the 
tissues  from  this  point  downward.     This  axial  stretching  of  the  canal,  if  carried 


TflK    PASSAGES 


lOo 


beyond  the  normal,  may  result  in  rupture  of  the  uterus  or  vagina,  and  expericnec 
shows  that  this  oeeurs  most  often  in  tlic  zone  exteiuUnK  from  the  internal  os  to  the 
vaj>;ina.  The  radial  stretehiufi;  of  the  canal  is  ji,reatest  when  the  larj^cst  fetal  plane 
is  passing  a  given  point.  After  this  the  elasticity  of  the  walls  of  the  canal  adapts 
them  to  the  reduced  size  of  the  fetal  cylinder. 


Skin 


Pubopoc- 
cygeus 

Anus 

Iliococcygeus 

I.schiococcygeus 
Fig.   ISO. — Pelvic  Diaphragm  Reconstructed  After  Delivery   (drawn  from  Sellheim's  model.     Outside  view). 


Constrictor 
cunni 


Fig.  1S7.— Pelvic  Diaphragm  Recon'STrccted  After  Delivery   (drawn  from  Sellheim's  model.     Inside  ^^ew). 


166 


PHYSIOLOGY    OF   LABOR 


A  study  of  the  parturient  canal  will  show  that  it  runs  straight  down  until  it 
reaches  the  narrow  pelvic  plane  or  the  third  parallel  of  Hodge,  then  bends  forward  in 
a  sharp  curve  whose  center  is  the  symphysis  pubis.  If  the  passage  uses  the  space 
under  the  arch  of  the  pubis,  the  bend  in  it  is  quite  sharp.     If  the  arch  of  the  pubis  is 


Cavum  uteri 


Contraction  ring 


Cervix 

Vagina 


Contraction  ring 


Fig.  188. — The  Completed  Partuhient  Canal. 
Black  line  indicates  the  axis  of  canal.     Note  sharp  bend  at  narrow  pelvic  plane. 


narrow,  or  if  the  fetal  head  is  very  large,  the  occiput  stems  on  the  rami  pubis, 
forcing  the  pelvic  floor  further  back  toward  the  sacrum,  making  a  more  obtuse  angle 
in  the  parturient  canal.  The  axis  of  the  parturient  canal  is,  therefore,  not  a  curve 
(the  curve  of  Carus),  but  a  straight  line  with  a  bend  at  the  pelvic  floor  and  a  curve 
(Fig.  189). 

Literature 

IJnrl  and  Barbour:  Structural  Anatomy  of  the  Pelvic  Floor,  Edinburgh,  1S80. — -Schroder:  Lehrbuch  der  Geburts- 
hilfe,  1899. 


Fni.  ISO. — Frozen  Section  (Bumm  and  Blumrcich) . 
Cervix  is  complotely  dilated.      Xotc  placenta  on  anterior  wall  and  the  formation  of  contraction  rings  to  fit 

depressions  in  fetal  cylinder. 


CHAPTER  XI 

THE  PASSENGERS 

For  the  study  of  tlie  incclumisiu  of  labor  a  consideration  of  the  fetus 
as  a  mechanical  object  is  essential, — more  so  than  has  generally  been  allowed, 
— and  we  must  consider  its  size,  shape,  compressibility,  and  plial)ility.  The  head 
is  larger  and  more  important,  but  the  trunk  takes  no  inconsiderable  part  in  the 
normal  mechanism  of  labor,  and,  when  pathologically  enlarged,  may  give  rise  to 
dystocia  and  even  cause  the  death  of  mother  or  child  or  both.  In  the  fetus  at  term 
the  face  is  small,  the  vault  of  the  cranium  forming  the  major  portion  of  the  head. 
Four  large  squamous  bones  make  up  the  cranial  vault — the  two  parietal,  the  frontal, 
and  the  occipital.  At  the  sides  the  temporal  l)ones  unite  with  the  parietals.  To 
lirovide  for  the  molding  necessary  in  the  child's  passage  through  the  maternal  parts, 


Bi  P. 


Bi  T. 


Fig.  ino. — Fetal  Head  with  Diameters. 

and  for  the  rapid  growth  of  the  brain  in  the  first  year  of  life,  these  bones  are  not 
united,  but  the  ossification  halts  at  the  lines  of  impingement,  which  later  become 
the  sutures  of  the  skull.  The  bones  are  held  together  by  the  membrane  in  which 
ossification  takes  place — the  chondrocranium.  The  lines  of  impingement  are 
called  sutures,  and  at  the  junctions  of  the  sutures,  owing  to  rounding  of  the  bony 
corners  of  the  separate  bones,  spaces  filled  by  membrane  are  left,  and  these  spaces 
are  termed  fontanels  (fonticuli).  Outside  of  the  configiirabilit}^  conferred  on  the 
head  by  the  sutures  and  fontanels,  these  spaces  are  of  vital  importance  to  the  prac- 
tising accoucheur,  for  by  means  of  them  he  determines  the  relation  of  the  head  to 
the  maternal  pehds,  studies  the  mechanism  of  labor,  and  guides  his  application  of  the 
obstetric  forceps. 

Between  the  two  parietal  bones  hes  the  sagittal  suture  (Fig.  190) ;  between  the 
parietals  and  occipital,  the  bent  lamlxloid  suture;  between  the  frontal  bone  and 
the  parietals,  the  coronary  suture,  while  between  the  two  plates  of  the  frontal  bone 

167 


168 


PHYSIOLOGY    OF   LABOR 


lies  the  frontal  suture,  whose  length  varies.  At  the  sides,  where  the  parietal  bones 
touch  the  temporals,  lie  the  lateral  or  temporal  sutures,  of  little  obstetric  importance. 

At  the  junction  of  the  sagittal,  frontal,  and  coronal  sutures  lies  a  lozenge- 
shaped  space,  the  anterior  or  large  fontanel.  Its  size  depends  on  the  degree  of 
ossification  of  the  abutting  bones,  and  its  shape  also,  since  with  advanced  ossifica- 
tion it  becomes  more  square.  Four  sutures  run  into  the  large  fontanel,  which  fact 
distinguishes  it  from  the  others,  and,  of  its  angles,  three  are  obtuse  and  one  acute, 
which  points  enable  us  to  diagnose  the  position  of  the  fetal  head  in  the  pelvis.  The 
shortest,  obtuse  angle  (Fig.  191)  points  toward  the  occiput,  or  posterior  pole  of  the 
head,  the  long  acute  angle,  toward  the  face. 

Behind,  at  the  junction  of  the  sagittal  suture  with  the  lambdoid,  a  small  tri- 
angular space  exists,  called  the  posterior  or  small  fontanel.  It  is  best  to  use  the 
terms  small  and  large  fontanel  to  avoid  confusion  in  the  study  of  the  mechanism  of 
labor.     Three  sutures  enter  the  small  fontanel,  which  during  labor  is  obliterated  as 


Frontal  suture 


Lateral 


Coronary 
suture 


Lambdoid  suture 
Fio.  191. — Diagram  op  the  Sutures  and  Fontanels. 


a  space,  the  three  lines  coming  together  at  a  point  like  the  letter  Y.  The  stem  of 
the  Y  is  the  sagittal  suture  and  runs  toward  the  face. 

Where  the  lateral  sutures  meet  the  ends  of  the  coronary  and  lambdoid,  spaces 
exist  which  are  called  the  lateral  fontanels.  They  are  important  because  they  may 
impose  as  the  other  fontanels  and  lead  to  costly  diagnostic  errors.  The  ear  is  clos& 
to  the  posterior  lateral  fontanel,  the  bony  orbit  next  to  the  anterior,  and  hereby 
mistakes  are  readily  avoided.  Wormian  bones  are  accessory  centers  of  ossification 
which  sometimes  occupy  the  spaces  of  the  fontanels,  but  they  have  no  obstetric 
importance.  In  the  sagittal  suture  occasionally  a  (juadrangular  space  is  found 
(Fig.  190),  which  is  most  easily  mistaken  for  the  large  fontanel,  and  may  cause  seri- 
ous errors  in  diagnosis.  It  is  a  false  fontanel.  Confusion  may  be  avoided  by  follow- 
ing the  sagittal  suture  to  its  terminal  fontanels. 

We  distinguish  the  regions  of  the  skull  by  particular  names.  The  occiput  is 
that  portion  (Fig.  193)  lying  behind  the  small  fontanel;  the  sinciput  is  that  portion 
lying  anterior  to  the  large  fontanel;   the  bregma,  the  region  of  the  large  fontanel; 


THE    PASSENGERS  169 

the  vertex,  the  rofrion  ])et\veen  tlie  two  fontanels  antl  extending  to  the  parietal  pro- 
tul)erances.  In  shajx'  tlie  fetal  head  is  irrcj^uhirly  ovoid — narrow  in  front,  broad 
l)('hind.  The  frontal  hone  is  (luite  s(iuare,  the  result  of  the  anj^ularity  of  the  fnjntal 
protuberances,  and  the  jjarietal  bones  iiave  on  <'aeh  side  a  prominence  which  is 
more  or  less  sharp — the  parietal  bosses  (tubera  parietalia).  Tiiey  mark  the  points 
where  the  head  meets  the  greatest  resistance  in  passing  through  the  pelvis.  No 
inference  may  be  made  icgarding  the  shape  of  the  child's  head  by  considering  those 
of  its  parents  because  it  may  resemble  either  one;  usually,  however,  the  mother 
makes  th(>  greater  impress.  Certain  vagaries  have  been  noted  in  the  ossification  of 
the  sutures,  which  give  the  skull  peculiar  shapes.  If  the  sagittal  suture  unites  too 
early,  a  scaphocephahis  results:  the  head  is  ])oat -shaped,  being  as  broad  in  front  as 
behind.  If  the  frontal  suture  ossifies  early,  a  three-cornered  head  results — tri- 
gonoec^phalus.  In  similar  ways  brachycejihalus — short  head — and  dolichocepha- 
lus — long  head — are  produced.  These  various  shapes  modify  the  mechanism  of 
labor  and  may  produce  dystocia. 

The  fetal  head  diameters  vary  quite  a  little  within  normal  limits.     For  com- 

s-o    B. 


S-O  B. 
9^  C.M. 

Fig.  192. — Side  View  of  Fetal  Sktjll. 

parison  with  those  of  labor  they  should  be  taken  the  fourth  day  after  birth.     The 
measurements  here  given  are  the  averages  of  a  large  number  of  chilch'en  (Jaggard) : 

Diameter  biparictalis — B.P.,  93^9  cm. 

Diameter  bitcmporalis — Bi.T.,  8  cm. 

Diameter  suboccipitobregmaticus — S.O.B.,  9J/2  cm. 

Diameter  occipitofrontalis — O.F.,  11  cm. 

Diameter  occipitomentalis — O.M.,  13  cm. 

There  are  many  other  diameters,  but  these  are  the  only  ones  practically  neces- 
sary. Two  circumferences  of  the  head  should  be  taken,  the  large  and  the  small,  the 
first  taken  around  the  occipitofrontal  diameter,  the  other  around  the  suboccipito- 
bregmatic.     They  measure  34  and  31  cm.  respectively. 

The  trunk,  while  apparently  larger,  presents  smaller  diameters  to  the  birth- 
canal,  l)ecause  it  may  be  compressed  to  assume  cylindric  proportions.  In  some 
children  the  shoulders  are  very  broad,  in  others  relativelj^  much  smaller  than  the 
head.  Boys  usually  have  larger  heads  at  birth,  and  this  is  also  true  of  the  first 
child,  regardless  of  sex.  The  bisacromial  diameter  of  the  fetus  is  11  cm. ;  the  bisiliac, 
9  cm.     The  circumference  of  the  shoulders  is  34  cm. ;   of  the  chest,  32  cm. 

By  "attitude"  is  meant  the  relation  of  the  various  parts  of  the  fetal  body  to 
each  other.     The  normal  attitude  of  the  child,  when  there  is  no  scarcity  of  liquor 


170 


PHYSIOLOGY   OF   LABOR 


amnii,  is  one  of  flexion  of  all  the  joints,  head  slightly  bent  on  the  chest,  arms  on  the 
chest,  legs  on  the  thighs,  thighs  on  the  abdomen,  and  the  back  of  the  child  is  curved. 


Fig.  193. — Back  View  of  Fetal  Skull. 


In  addition,  there  is  usually  some  lateral  flexure  of  the  head  on  one  shoulder.     (See 
Fig.  194.)     When  the  amount  of  liquor  amnii  is  small,  so  that  the  child  has  insufli- 


Fio.  194. — Posture  of  Child  in  Utero. 
Shows  lateriflexiori  of  trunk. 


THE    PASSENGERS 


171 


cient  space  to  stretch  out,  its  attitude  is  one  of  cramped  flexion.  The  extremities 
are  pressed  into  the  body,  crossing  each  other,  sometimes  even  with  bending  the 
long  l)ones,  and  slujrtening  of  th(!  nuisdes.  Occasionally  one  flnds  decubitus  over 
the  bony  prominences.  Lal)or  in  such  cases  is  harder  and  is  often  attended  by 
irregular,  anomalous  uterine  action.     (See  Labor  in  Oligohjalramnion.) 

Changes  in  the  Fetus  the  Result  of  Labor. — Sellheim's  x-ray  plates  and  Bar- 
bour's frozen  section,  toj^ctlier  with  clinical  studies,  give  us  a  clear  idea  of  the  mold- 
ing of  the  child  during  lal)or.  The  child  as  a  mechanical  object  for  labor  presents 
two  ovoids  joined  by  a  flexible  shaft,  the  neck.  The  trunk  is  flexible  to  a  certain 
degree,  and  more  flexible  in  certain  directions  than  in  others.  Since  this  jointed 
object  has  to  pass  through  a  bent  canal,  one  can  readily  perceive  that  this  adapta- 
bility will  come  into  jilay.  Tlu;  neck  is  most  readily  extended,  and  extension  is  its 
greatest  movement,  because  the  strong  posterior  neck  muscles  prevent  any  great 


Fia.  195. — Fetus  from  a  Frozen  Section  (Barbour). 


degree  of  flexion  of  the  chin  onto  the  sternum.  The  child  can  bend  its  dorsal  spine 
best  in  a  lateral  direction,  because  the  arms  and  thighs,  by  pressure  against  the 
trunk  from  the  front,  act  like  splints. 

When  lal)or  is  well  under  way,  the  frankly  ovoid  shape  of  the  fetus  is  changed 
into  a  long  cjdinder  or  ellipsoid.  The  uterus,  by  its  contractions,  forces  open  the 
lower  uterine  segment  and  cervix.  Its  cavity,  therefore,  lengthens,  its  walls  apply 
themselves  closer  on  the  fetus,  the  extremities  of  the  latter  are  pressed  against  the 
trunk,  the  latter  is  straightened  out,  the  fetus  is  lengthened.  This  lengthening  of 
the  child  is  easily  determined  during  every  normal  labor — one  finds  the  fundus  uteri 
rising  higher  toward  the  ensiform,  w^hile  the  head  advances  through  the  birth-canal. 

By  the  same  forces  the  head  is  flexed  on  the  sternum,  the  shoulders  thrown  up 
under  the  ears,  the  clavicles  standing  almost  vertically,  a  fact  easily  proved  by  ex- 
amination after  the  head  is  delivered.  This  action  fixes  the  head  on  the  trunk,  so 
that  there  is  only  one  direction  in  which  the  head  can  bend  readily,  and  that  is  ex- 


172  PHYSIOLOGY    OF   LABOR 

tension.     The  effect  of  such  a  condition  on  the  mechanism  of  labor  will  be  studied 
shortl}'. 

Fehling  proved  that  the  size  of  the  head  can  be  slightly  reduced  under  the 
pressure  of  labor  by  the  escape  of  cerebral  fluid  into  the  spinal  canal.  Perhaps,  too, 
some  of  the  blood  in  the  brain  may  escape  into  the  cervical  veins.  It  is  questionable, 
however,  if  such  a  small  reduction  as  is  thus  possible  is  of  any  real  influence  in  the 
mechanism  of  labor.  The  configurability  of  the  skull,  on  the  other  hand,  is  of  ut- 
most importance.  Figs.  162,  163,  and  164  show  how  the  head  is  molded  in  the 
most  common  delivery.  When  the  child  comes  in  face  presentation,  other  cranial 
shapes  are  produced.  The  circular  pressure  of  the  uterus  forces  all  the  fetal  tissues 
into  conformation  with  the  cylindric  bore  of  the  birth-canal,  and  one  thus  finds  cross- 
sections  of  the  fetal  ellipsoid  to  show  almost  circular  outlines.  The  reduction  of  the 
])isacromial  diameter  may  be  as  much  as  2  cm.,  depending  on  the  hardness  of  the 
fetal  tissues.  If  the  child  is  overgrown,  it  is  poor  in  water,  and  the  flesh  is  tougher 
and  less  compressible.     Dystocia  is  common  in  these  cases. 

Literature 

Barbour:  Atlas  of    the  Anatomy  of  Labor,  Plate  22. — Sellheim:  Geburtskanal    und  Geburtsobjekt,  Thieme,  Leipzig, 
1906. 

PRESENTATIONS  AND  POSITIONS 

Authors  are  not  in  accord  in  classifying  the  various  ways  in  which  the  fetus 
may  present  itself  for  delivery.  Baudelocque  (1775)  described  94  presentations. 
Almost  any  portion  of  the  child's  person  can  present  itself  first  for  delivery, 
and  since  the  attitude  and  position  of  the  child  change  during  labor,  the  difficulties  in 
the  way  of  a  universally  acceptable  classification  are  apparent.  That  accepted  at 
the  Ninth  International  Medical  Congress  at  Washington,  1887,  is  generally  recog- 


FiG.   196. — The  FotiR  Quadrants  of  the  Pelvis. 

nized  as  the  best,  but  it  is  not  complete  enough.  In  the  terminology,  that  adopted 
by  the  Basic  Congress  has  been  employed. 

Definitions. — By  "presentation"  is  meant  that  portion  of  the  fetus  which  is 
touf;hed  by  the  examining  finger  through  the  cervix,  or,  during  labor,  is  bounded 
by  the  girdle  of  resistance.  According  to  Hodge,  it  is  that  part  felt  by  the  examin- 
ing finger  "toward  the  center  of  the  pelvis."  Much  confusion  will  be  avoided  if 
the  word  presentation  is  adopted  as  here  defined,  and  made  synonymous  with  the 
much-used  expression  "presenting  part." 

"Position"  is  the  situation  of  the  child  in  the  pelvis,  and  is  determined  by  the 
relation  of  a  given,  arbitrary  point  in  the  presenting  part  to  the  periphery  of  the 
pelvic  planes. 

"  The  point  of  direction"  is  this  ar])itrary  point  in  the  presenting  part,  by  which 
we  determine  the  topographic  rehition  of  the  presenting  part  to  the  periphery  of 
the  pelvic  planes.     In  occipital  presentation  the  occiput  is  the  point  of  direction; 


THE    PASSENGERS 


173 


in  hrceeh  i)rosentation,  the  sacruin;    in  shoulder  prcscMitation,  tho  scapula;    in  face, 
the  chin,  etc.     The  (Jerinans  use  the  back  as  the  point  of  direction. 

'^Attitude"  is  the  relation  of  the  fetal  lucmhers  to  each  other;  it  is  hal)itus  or 
posture.  The  attitude  of  the  fetus  has  much  to  do  with  its  presentation,  l)ut  they 
are  not  identical.     Attitude  may  be  (Usturbed  by  the  arms  leaving  the  chest,  the 


Fig.  197.— O.L.A. 


legs  leaving  the  al)domen  and  prolapsing,  or  the  cord  prolapsing,  the  chin  extending, 
making  the  various  deflexion  presentations,  etc. 

All  terms  as  to  direction  are  referred  to  the  mother  in  the  erect  position.  The 
term  upper  means  the  part  in  the  direction  of  the  fundus  uteri;  lower,  the  part 
nearer  the  \'Tilva;   anterior,  means  the  direction  to  the  front  of  the  mother;    right, 


174 


PHYSIOLOGY    OF   LABOR 


the  right  side  of  the  mother,  etc. — these  terms  having  no  apphcation  to  the  child. 
By  keeping  this  rule  in  mind,  confusion  will  be  avoided. 

For  convenience  of  description  the  pelvis  is  divided  into  four  quadrants — 
an  anterior  left,  an  anterior  right,  a  posterior  right  and  left  (Fig.  196).  The  posi- 
tion of  the  presenting  part  is  defined  according  to  that  quadrant  in  which  the  point 
of  direction  lies.     Three  grand  divisions  of  the  presentation  are  recognized: 


Fig.   198.— O.D.A. 


I.  Cephalic  presentation  and  its  varieties — vertex,  brcgmatic,  brow, 
and  face.  The  vertex  is  the  normal,  the  others  are  transitional,  or 
pathologic,  being  due  to  deflexion  of  the  head.  They  are  sometimes 
called  "deflexion  attitudes." 
II.  Pelvic  or  breech  presentation  and  its  varieties — complete  breech, 
footling,  double  footling,  knee,  double  knee,  and  single  breech. 
III.  Transvers(!  presentation,  including  shoulder,  arm,  and  any  part  of 
the  trunk. 


THE    PASSENGERS 


i: 


In  the  first  two  fijroups  tlic  iixis  of  the  lotus  lies  purullcl  witli  tliat  of  the  uterus: 
in  the  last  group  it  lies  obliquely,  more  or  less. 

Presentutiou  has  to  do  with  the  part  of  the  fetus  which  presents  itself  to  the 
parturient  ])assage  first  for  (l(;liver3^  It  is  deterniined  by  the  attitude  of  the  child 
and  the  relation  of  its  axis  to  that  of  the  birth-canal.  Position,  in  its  technical 
sense,  means  the  relation  of  the  presenting  part  to  the  plane  of  the  pelvis  in  which  it 
lies;    that  is,  to  the  four  (juatlrants  of  the  pelvis.     Each  presenting  part  may  so 


Fig.  199.— O.D.P. 


occupy  the  pelvis  that  its  point  of  direction  may  lie  in  any  pelvic  diameter;  for 
example,  the  occiput  may  be  to  the  right,  to  the  left,  behind,  in  front,  or  at  anj' 
intermediate  point,  when  labor  l^egins.  The  most  common  locations  are  used  for 
teaching.  The  Committee  at  Washington  adopted  four  main  positions.  Six  are 
here  given,  and  other  writers  (Williams,  Farabeuf  and  Varnier)  also  distinguish 
them.  The  Latin  terms  and  abbreviations  are  to  be  preferred.  In  the  follo\\-ing 
table  the  positions  are  named  about  in  the  order  of  frequency: 


176 


PHYSIOLOGY   OF   LABOR 


CEPHALIC  PRESENTATIONS 

1.  Vertex — occiput,  the  point  of  direction. 

Occipito-lseva  anterior O.L.Ao 

"        Iseva  transversa O.L.T. 

"        dextra  posterior O.D.P. 

"        dextra  transversa  .  .  , O.D.T. 

"        dextra  anterior O.D.A. 

"        Iseva  posterior O.D.P. 

2.  Face — chin,  the  point  of  direction. 

Mento-dextra  posterior M.D.P. 

"       Iseva  anterior M.L.A. 

"       dextra  transversa M.D.T. 

"       dextra  anterior M.D.A. 

"       Iseva  transversa M.L.T. 

"       Iseva  posterior M.L.P, 

3.  Brow — the  brow  the  point  of  direction. 

Fronto-dextra  posterior F.D.P. 

"       Iseva  anterior F.L.A. 

"       dextra  transversa F.D.T. 

"       dextra  anterior F.D.A. 

"       laeva  transversa F.L.T. 

"       Iseva  posterior F.L.P. 

PELVIC  OR  BREECH  PRESENTATIONS 

1.  Complete  Breech — the  sacrum  the  point  of  direction  (feet  crossed  and 
thighs  flexed  on  belly). 

Sacro-lseva  anterior S.L.A. 

Iseva  transversa S.L.T. 

dextra  posterior S.D.P. 

dextra  anterior S.D.A. 

dextra  transversa S.D.T. 

Iseva  posterior S.L.P. 


When  the  breech  is  incomplete,^that  is,  when  one  or  both  feet  have  been  pro- 
lapsed, or  one  or  both  knees  are  down,  or  when  the  feet  are  turned  upward  along 
the  chest,  so-called  single  breech, — the  sacrum  is  still  the  point  of  direction,  the 
designations  remaining  as  above,  and  one  simply  adds  the  qualification  footling, 
knee,  etc. 

TRANSVERSE  PRESENTATIONS 
1.  Shoulder — the  scapula  being  the  point  of  direction. 
Scapulo-lseva  anterior Sc.L.A. 


dextra  anterior  , 
dextra  posterior 
Iseva  posterior.  . 


Sc.D.A. 


..Sc.D.P. 


Sc.L.P. 


Back, 
ante- 
rior 

positions 
Back, 
poste- 
rior 
positions 


The  back,  side,  or  belly  may  present,  but  these  are  rare,  and  come  readily 
under  the  above  classification. 

One  important  dimension  is  lacking  in  this  presentment.  How  are  we  to  de- 
termine the  distance  the  fetus  has  advanced  down  the  birth-canal  toward  the  vulvar 
outlet?     How  shall  we  convey  the  idea  of  the  location  or  degree  of  advancement  of 


TlllO    PASSENGERS 


177 


tho  prosonting  part  in  the  hirth-caiial?  Miiller  suft-pjostfd  tho  word  "station"  or 
"statio,"  and  used  it  tlius,  for  example,  "statio  in  aditu,"  presenting  part  in  the  in- 
let, "statio  ill  exitii,"  at  the  oiiilci.  Bacon  is  the  only  American  teacher  who  has 
adopted  this  form.  Location  would  be  a  l)etter  word.  The  term  "degree  of  en- 
gagement" was  used  by  Jaggard  and  is  often  employed,  and  the  entry  of  the  head 
into  the  pelvis  he  called  engagement. 

A  head  is  "not  engaged"  when  its  greatest  diameter  is  still  above  the  plimc  of 


Fig.  200.— O.L.P. 


the  inlet.  If  freely  movable,  we  call  it  "floating,"  or  "caput  ballitabile."  A  head  is 
fixed  on  the  inlet  or  "engaging"  when  the  largest  diameter  is  just  about  to  pass  the 
inlet — "  caput  mobile."  A  head  is  "engaged "  when  the  largest  diameter  has  passed 
the  plane  of  the  inlet — "caput  ponderosum."  A  head  is  "deeply  engaged"  when 
the  largest  diameter  lies  in  the  narrow  pelvic  plane.  A  head  is  "at  the  outlet" 
when  the  largest  diameter  is  passing  the  bony  outlet.  The  perineum  is  beginning 
to  bulge  at  this  time.  A  head  is  "on  the  perineum"  when  the  largest  diameter  has 
passed  the  bony  outlet  and  the  head  begins  to  show  in  the  vulva.  This  might  be 
called  the  period  of  disengagement. 
12 


1/0  PHYSIOLOGY    OF   LABOR 

A  diagnosis  of  the  mechanical  conditions  of  a  given  labor,  therefore,  requires  a 
statement  of  the  presentation,  the  position  of  the  presentation,  and  the  location  or 
degree  of  engagement  of  the  presenting  part.  The  last  is  of  great  importance,  but 
much  neglected,  and  often  with  fatal  results  to  mother  and  child. 

Literature 

MilUer:  Monatsschr.  f.  Geb.  u.  Gyn.,  vol.  xvi,  p.  848. — Williams,  Faraheuf  and  Varnier:  Text-books. 

FREQUENCY  OF  THE  PRESENTATIONS  AND  POSITIONS 

Karl  Braun,  in  48,449  cases,  found  vertex  presentations  in  95.9  per  cent.; 
pelvic  presentations,  2.7  per  cent. ;  face,  0.6  per  cent. ;  transverse,  0.7  per  cent.  Of  the 
vertex  presentations,  70  per  cent,  were  O.L.A.,  29  per  cent.  O.D.P.,  and  1  per  cent, 
the  other  two  positions.  Schroder,  from  a  clinical  study  of  over  250,000  cases, 
finds  the  vertex  in  95  per  cent.;  breech  in  3.11  per  cent.;  the  face,  0.6  per  cent.; 
and  transverse  presentations  in  0.56  per  cent.  Much  labor  has  been  spent  in  com- 
piling these  statistics,  but  their  value  is  not  great,  because  everything  depends  on 
the  time  when  the  diagnosis  is  made.  During  the  last  few  weeks  of  pregnancy  both 
the  presentation  and  the  position  of  the  fetus  may  change,  Schroder  claiming  this 
to  occur  in  32  per  cent,  of  the  cases.  The  most  frequent  changes  are  breech  and 
shoulder,  to  head.  Ordinarily  the  presentation  is  permanent  after  the  presenting 
part  has  engaged  in  the  pelvis,  but  this  is  not  invariable.  The  author  has  observed 
a  head  which  had  sunk  deep  into  the  excavation  rise  up  into  the  abdomen  again 
before  labor  set  in.  Hippocrates  believed  that  at  the  seventh  month  the  child, 
which  up  to  then  presented  by  the  breech,  turned  a  somersault  (variously  named, 
Culbute,  Inversio  Fetus — Peristrophe)  and  the  head  came  over  the  inlet. 

While  changes  of  the  long  axis  of  the  child  are  not  infrequent,  changes  in  posi- 
tion are  of  almost  daily  occurrence.  Examination  of  the  woman  on  successive  days, 
in  the  morning  and  evening,  will  show  the  back  now  on  one  side,  now  on  the  other. 
Multiparse,  because  of  the  lax  uterine  and  abdominal  walls,  show  the  most  marked 
mobility  of  the  fetus.  During  labor  the  fetus  may  also  alter  its  presentation  and 
position,  particularly  the  latter.  If  the  observer  happens  to  examine  the  patient 
early  in  labor,  he  may  find  an  O.L.P. ;  if  a  few  hours  later,  an  O.L.T.,  and  again  later 
an  O.L.A.,  or  even  an  O.D.A.  Hospital  statistics  differ  from  those  in  private 
practice  because  pathologic  labors  are  sent  to  hospitals.  Figures  from  the  one 
source  show  a  large  percentage  of  abnormal  presentations;  from  the  other,  a  neces- 
sarily smaller  percentage.  The  effect  of  all  these  factors  on  the  value  of  our  statistical 
information  is  evident. 

During  pregnancy  the  child  is  more  movable  and  accommodates  itself  to  the 
varying  position  of  the  mother.  When  she  is  erect,  its  back  falls  forward;  when  on 
the  side,  it  drops  to  the  side  on  which  she  lies.  This  explains  the  frequency  of  O.L.T., 
O.D.T.,  O.D.P.,  and  O.L.P.  in  our  routine  pregnancy  examinations.  One  examiner 
may  diagnose  O.D.A. ,  and  his  follower  O.D.P.,  the  change  having  resulted  from  the 
prolonged  dorsal  position  of  the  mother  and  displacement  by  the  palpating  hand. 

Causes  of  the  Frequency  of  the  Cephalic  Presentations. — Hippocrates  believed 
gravitation  explained  the  predominance  of  head  presentation.  The  heavier  head 
sinks  to  the  lowest  part  of  the  uterus.  This  idea  was  held  until  very  recently,  when 
it  was  shown  that  the  head  is  very  little,  if  any,  heavier  than  the  breech,  and  that 
the  conditions  of  the  uterine  cavity  are  such  that  any  movement,  the  result  of  dif- 
ference in  weight,  would  be  more  than  nullified  by  the  friction  of  the  fetus  on  the 
uterine  wall.  Dubois  believed  the  fetus  instinctively  sought  that  position  which 
was  most  comfortable;  Simpson  referred  the  head  presentation  to  the  reflex  move- 
ments of  the  child  when  it  was  forced  out  of  the  position  in  which  it  could  be  most 
easily  accommodated.     Cohnstein  gives  the  older  theories  in  full. 

The  law  of  accommodation  of  Pajot  explains  it  best.  Where  an  ovoid  body 
lies  free  in  an  ovoid  container,  the  two  long  axes  tend  to  become  parallel,  which  is 


THE    PASSENGERS 


179 


especially  true;  if  the  container  lias  (;ontra(;til(!  power,  as  has  the  uterus.  The  child, 
as  it  lies  folded  together,  is  ovoid;  the  uterus,  at  the  end  of  pregnancy,  likewise. 
The  ut(!rus  is  not  a  flaccid  sac,  but  has  stjnie  tonus  and  keeps  its  form,  and  further 
it  contracts  frequently  (the  contra(;tions  of  pregnancy).  During  these  contractions 
it  assumes  an  exquisitely  oval  shape,  and  one  can  readily  perceive  how  it  would 
gradually  force  the  contained  fetal  ovoid  to  conform  to  the  shape  of  its  cavity  (Figs. 
201,  202,  and  203).  lOven  in  early  i)regnancy  the  head  lies  in  the  lower  segment  of 
the  uterus,  and  this  tendency  is  enhanced  by  the  shape  of  the  uterus  growing  more 
ovoid  all  the  time.  After  the  head  is  once  in  the  smaller  end  of  the  ovoid  it  is,  to 
an  extent,  anchored.  The  explanation  of  the  occurrence  of  the  various  positions  of 
the  child  is  (^asy.  With  the  woman  in  the  erect  posture  the  back  of  the  child 
will  naturally  occupy  the  roomy  anterior  half  of  the  uterus.  Behind,  the  lumbar 
spine  projects  sharplj^  into  the  uterine  ovoid  (Fig.  204),  and,  when  the  woman  lies 
down,  the  round  heavy  fetal  back  falls  to  one  or  the  other  side  of  it  (P'ig.  205). 
Since  the  uterus  has  some  dextrolateral  torsion,  and  since  the  sigmoid  and  rectum 
push  forward  the  left  side  of  the  uterus,  a  cross-section  of  its  cavity  will  appear 
elliptic.     A  glance  at  the  figures  will  show  why  the  back  is  more  likely  to  be  found 


Fig.  201. 


Fig.  202. 


Fig.  203. 


Figs.  201,  202,  axd  20.3. — Diagrams   to   Illustrate  Action  of  Uterus  in  Altering  Present.\tion  of  Fetus 

(modified  from  Kristelier). 


in  the  left  anterior  portion  of  the  uterus  or  in  the  right  posterior.  The  back  com- 
municates its  forward  or  backward  tendency  to  the  head,  rotating  it  on  an  axial 
diameter  so  as  to  bring  the  occiput  to  the  front  or  rear.  The  left  occipito-anterior 
position  is  over  t"\\ace  as  frequent  as  the  right  posterior,  and  this  disproportion  be- 
comes greater  until  the  end  of  pregnancy.  During  the  twenty-four  hours  a  woman 
remains  twice  as  long  in  the  erect  posture  as  lying  down,  and,  therefore,  the  back  is 
more  likely  to  fall  to  the  front.  This  accounts  for  the  predominance  of  O.L.A. 
We  use  this  laiowledge  to  influence  the  mechanism  of  labor.  Other  reasons  for  the 
frequency  of  O.L.A.  have  been  advanced,  as  the  flattening  of  the  right  half  of 
the  pelvis  and  enlargement  of  the  left  half,  the  right  obliciue  diameter  of  the  inlet 
being  greater  than  the  left;  the  inclination  of  the  pelvis  to  the  left  side;  the  pres- 
ence of  the  liver  on  the  right  side,  Ijut  they  have  little  influence.  The  location  of  the 
placenta  affects  the  location  of  the  back,  the  latter  usually  hang  opposite  the  former 
(Figs.  204  and  205). 

Abnormal  and  unusual  presentations  are  caused  by  absence  or  inefficiency  of 
the  above-mentioned  factors.  If  the  uterus  is  overdistended,  as  by  polyhydramnion 
or  t^\^ns,  its  walls  cannot  grasp  the  fetal  ovoid,  which,  therefore,  is  often  found  pre- 
senting \ATongly.  INIultiparse  with  flaccid  uterus  and  lax  abdominal  walls  (pendulous 
belly)  suffer  often  with  malpresentations. 

A  small  or  premature  fetus  is  more  likely  to  present  by  the  breech  than  an  over- 


180 


PHYSIOLOGY    OF   LABOR 


growni  child.  Hydrocephalic  children  and  anencephali  predispose  to  breech  pres- 
entation. Accident  is  a  factor,  as  when  labor  begins  suddenly  or  the  bag  of  waters 
ruptures  when  the  fetus  is  in  an  unfavorable  position. 

Abnormalities  in  the  shape  of  the  uterus  cause  malpresentations.     Uterus 
arcuatus  and  bicornate  uterus  are  often  attended  with  breech  or  shoulder  presenta- 


FiG.  204. — Showixg  Effect  of  Projection  of  Lumbak  Spine,  and  also  of  the  Location  or  Placenta  on  Anterior 

Uterine  Wall.   O.L.A. 


Fig.  205.— O.D.P. 


tion.      In  one  such  case  the  author  delivered  two  breech  presentations,  and  in 
another  the  sixth  successive  footling. 

Contracted  pelvis,  tumors  of  the  lower  uterus  or  pelvis,  placenta  prsevia, — in 
short,  all  conditions  which  prevent  the  engagement  of  the  head, — predispose  to 
shoulder  and  breech  presentations. 

Literature 

Cohnstein:    "Die  Atiologie  der  normalon  Kindeslagen,"  Monatsschr.  f.  Geburtsk.,  1868,  vol.  xxxi,  p  141. — Schroder: 
Lehrbuch  d.  Geburtshilfe,  p.  1.39. — SeiU:   Handbuch  d.  Geb.,  vol.  i,  2,  p.  1024. 


CHAPTER  XII 

THE  MECHANISM  OF  LABOR  IN  OCCIPITAL  PRESENTATION 

Although  tho  inovcnionts  imparted  to  the  child  by  the  powers  of  labor  were 
known  to  the  older  writers,  Baudelocque,  Sniellio,  and  others,  and  Nacgele,  in  1819, 
described  them  minutely,  opinion  is  still  divided  as  to  their  causes.  If  the  student 
wishes  to  study  these  movements,  a  multipara  will  offer  better  advantages  than  a 
primipara,  because,  in  the  latter,  the  head  is  already  engaged  when  labor  begins. 
The  demands  of  asepsis  restrict  the  frequent  examination  of  the  parturient  which  is 
necessary  for  a  minute  study  of  the  mechanism.     The  use  of  sterile  rubber  gloves 


Plane  of  inlet 
Fig.  206. — Synclitism. 


Occipitofrontal  plane 


and  extreme  antiseptic  precautions  will  reduce  the  danger  of  infection,  and  a  few 
thorough  examinations  will  give  the  student  a  great  deal  of  information. 

Broadly,  the  mechanism  of  delivery  is  as  follows:  An  object  consisting  of  two 
ovoids  united  by  a  hinge  (/.  e.,  the  head  and  trunk  united  by  the  neck)  is  to  be 
forced  through  a  passage,  straight  at  the  beginning  and  sharply  curved  at  its  lower 
end.  We  must  consider  the  manner  of  passage  of  the  head  and  of  the  trunk. 
Each  makes  three  movements — engagement,  or  entry  into  the  pelvis;  rotation,  or 
adaptation  to  the  shape  of  the  pelvis,  and  disengagement,  or  exit  from  the  peh-is. 

Engagement  of  the  Head. — Multipara,  O.L.A. — At  the  beginning  of  labor 
the  head  lies  over  the  inlet,  inclined  but  little  on  either  shoulder.     The  sagittal 

181 


182 


PHYSIOLOGY   OF   LABOR 


suture  lies  about  midway  between  the  promontory  and  the  pubis — perhaps  a  httle 
nearer  the  pubis  if  the  promontory  juts  sharply  forward.  The  head  is  then  said  to 
be  sjaiclitic  or  in  synclitism  (Fig.  206).  The  occipitofrontal  plane  lies  parallel  to 
the  region  of  the  inlet.  If  the  woman  has  a  pendulous  belly,  being  a  multipara,  or 
if  the  pelvis  is  contracted,  preventing  a  normal  mechanism,  the  body  of  the  fetus 
falls  forward,  the  sagittal  suture  nears  the  promontory,  the  head  presents  its  an- 
terior parietal  bone  to  the  parturient  canal,  the  parallelism  between  the  occipito- 
frontal plane  of  the  head  and  the  plane  of  the  inlet  is  destroyed,  the  head  is  asyn- 
clitic — it  is  in  anterior  asynclitism.  This  is  often  called  Naegele's  obliquity  (Fig. 
207).  If  the  woman  is  a  primipara,  the  abdominal  walls  holding  the  child  firmly 
against  the  spine,  the  head  may  be  inclined  on  the  inlet  with  the  posterior  parietal 
bone  more  to  the  front,  again  disturbing  the  parallelism.     This  is  posterior  asyn- 


Plane  of  inlet 
Fig.  207. — Anterior  Asynclitism. 


elitism  (Fig.  208).  Naegele  believed  the  head  usually  entered  the  pelvis  in  anterior 
asynclitism,  but  extended  investigation  has  disproved  this  view.  The  author  has 
usually  found  the  sagittal  suture  about  midway  between  the  promontory  and  the 
pubis.  Marked  asynclitism  is  pathologic.  (See  p.  696.)  The  sagittal  suture  also 
usually  runs  transversely  across  the  pelvis,  and,  in  a  multipara,  one  finds  the  small 
and  the  large  fontanels  in  the  same  plane  of  the  pelvis.  The  head,  therefore,  usually 
enters  the  inlet  with  its  long  diameter  in  the  transverse  of  the  pelvis;  and  since  the 
two  fontanels  are  about  as  easily  reached  by  the  examining  finger,  we  conclude  that 
the  head  is  not  strongly  flexed  on  the  chest.  Many  authors  dispute  the  former  of 
these  statements,  claiming  that  the  head  enters  the  pelvis  in  one  of  its  oblique  di- 
ameters, especially  the  right,  but  the  author,  after  careful  study  of  hundreds  of 
labors,  believes  the  head  enters  transversely  in  the  majority  of  cases.  Naegele 
showed  it  entered  either  in  the  oblique  or  in  the  transverse.     Sir  Fielding  Ould,  of 


THE    MECHANISM    OK    LA150H    IN    OCCII'ITAL    PRESENTATION 


183 


Dublin,  corrected  the  iiiicieiil  notion  tiiut  the  lieud  enlercd  tlie  inlet  with  the 
occiput  to  the  pubis.     Pathologically  it  may  do  so. 

Descent. — As  soon  as  the  uterine  eontracticjns  begin,  general  intra-iiteiine  pres- 
sure tends  t(^  force  the  fetus  downward,  and  when  the  os  is  (completely  dilated,  rapid 
descent  begins.  Descent  of  the  head  is  also  favored  by  the  extension  of  the  fetal 
body.     (See  p.  171.) 

One  result  of  descent  is  an  increase  of  \\\('  Jlcrion  of  the  head.  Mechanically 
the  head  acts  like  a  two-armed  lever,  with  the  fulcrum  at  the  junction  of  the  spine 
with  the  occi])ital  condyles.  The  sinciput  and  occiput  meet  equal  resistances  in 
the  birth-canal,  l)ut  the  sincipital  end  of  the  head  lever  is  longer  than  the  occipital 
end,  wherefore  the  sinciput  is  held  back  and  the  occiput  descends.  Any  ellipsoid 
body  ])assing  through  a  canal,  in  order  to  cause  the  least  resistance,  will  adapt  its 
long  axis  to  the  long  a.xis  of  the  canal.     The  mechanical  gain  in  flexion  is  that  in- 


^:}^y 


Occipitofrontal  plane 


-Plane  of  inlet 
Fig.  20S. — Posterior  Asynclitism. 


stead  of  an  occipitofrontal  diameter  of  12  cm.  and  a  circumference  of  35  cm.,  there 
is  presented  to  the  birth-canal  the  suboccipitobregmatic  plane  with  a  diameter  of 
9  cm.  and  a  circumference  of  31  cm.  Flexion  may  be  marked,  as  occurs  in  generallj' 
contractetl  pelves.  It  may  not  occur  until  the  head  is  well  down  on  the  pelvic  floor, 
and  thus  labor  may  be  delayed.  Another  result  of  descent  and  flexion  is  the  dis- 
appearance of  asynclitism,  that  is,  the  parallelism  is  restored,  ''leveling"  occurs, 
the  sagittal  suture  approaches  the  middle  of  the  pelvis  (Fig.  209). 

In  pathologic  cases  the  asynclitism  persists  after  engagement  and  may  interfere 
with  the  next  movement,  rotation.  Descent  of  the  head  into  the  pelvis,  or  engage- 
ment, is  one  of  the  most  important  phenomena  of  labor  presented  to  the  accoucheur 
for  stud}',  and  clinically  its  importance  is  vital.  A  head  is  engaged  in  the  pelvis 
when  the  l^ijiarietal  diameter  has  passed  the  region  of  the  inlet. 

Internal  Rotation. — The  lowest  part  of  the  head  now  nears  the  pelvic  floor  and 


184 


PHYSIOLOGY    OF    LABOR 


a  new  movement  is  imparted  to  it.  The  occiput  rotates  from  the  transverse  diam- 
eter into  the  obhque,  and,  finally,  anteroposteriorly.  This  movement  is  called 
internal  anterior  rotation,  and  many  theories  are  advanced  to  explain  it.  One  of 
the  oldest  notions  was  that  the  pelvis  presented  a  long  transverse  diameter  in  the 
inlet  and  a  long  sagittal  diameter  at  the  outlet,  and  that  the  head  had  to  seek  these 
diameters  in  its  passage.  This  is  only  partly  true.  If  one  looks  into  a  pelvis  from 
above,  one  will  see  the  spines  of  the  ischia  projecting  sharply  into  its  lumen.  The 
sides  of  the  pelvis  anterior  to  the  spines  curve  gracefully  downward,  forward, 
and  inward.  A  finger  following  the  curve  glides  gently  forward  under  the  pubis. 
AVithout  doubt  this  portion  of  the  bone  forming  a  part  of  the  lateral  inclined  planes, 
so  important  to  Hodge,  has  some  slight  function  in  anterior  rotation.     Its  action 


Plane  of  inlet 
Sagittal  suture,  median 

Fig.  209. — The  Synclitic  Movement,  or  Leveling. 


may  be  likened  to  the  ways  of  a  ferry-boat.  The  levator  ani  hangs  like  a  sling,  or 
trough  or  gutter,  from  the  sides  of  the  pubis,  with  the  direction  of  its  canal  from 
behind  forward.  The  occiput,  sliding  down  the  side  of  the  pelvis,  is  directed  under 
the  pubis,  the  long  diameter  of  the'  head  accommodating  itself  to  the  leng-th  of  the 
trough,  according  to  the  law  of  inclined  planes.  Since  the  occiput  is  almost  always 
lower  than  the  sinciput,  it  strikes  the  pelvic  floor  first,  and,  therefore,  has  the  greater 
tendency  to  rotate  anteriorly  under  the  pubis  (Fig.  210).  Examination  at  this 
period  of  labor  will  demonstrate  the  action  of  the  pelvic  floor  in  rotating  the  head 
forward.  Experiment — forcing  the  head  through  the  pelvis  of  a  female  cadaver — 
shows  that,  as  long  as  the  integrity  of  the  pelvic  floor  is  preserved,  its  action  is  to 
force  the  occiput  forward  (Fig.  211).  In  women  with  old  lacerations  of  the  pelvic 
floor  anterior  rotation  is  often  delayed  or  absent. 


THE    MECHANISM    OK    LAHCJU    l.\    OCCIPITAL    l'lil> 


K.NTATION 


185 


Schroder  and  Olsliausen  believe  that  the  rotation  of  the  back  is  communicated 
to  the  head.  When  the  uterus  contracts  in  the  second  stage  it  flattens  from  side 
to  side,  and  the  trunk  of  the  child  finds  better  lodgment  in  the  anterior  bellying 


tor  am 
Rcctiun 


Fig.  210. — Head  Coming  Down  Onto  Levator  Ani. 
Note  lateriflexion  of  head  and  twisting  of  body. 


Fig.  211. — Anterior  Rot.\tion  Completed. 
Head  on  the  levator  ani.     Note  lateriflexion  is  corrected.     Body  still  twisted. 


186 


PHYSIOLOGY   OF   LABOR 


of  the  uterus.  That  the  back  rotates  to  the  front  is  easily  demonstrable  in  most 
labors.  The  flexion  of  the  chin  on  the  sternum  and  the  raising  of  the  shoulders 
against  the  head  tend  to  fix  the  head  and  trunk  so  that  when  the  back  turns,  the 
head  goes  vnih  it.  One  may  easily  convince  himself  of  this  by  making  the  move- 
ment with  a  new-born  infant.  After  the  head  has  rotated  and  is  deep  in  the  pelvis, 
the  back  does  not  follow  it  fully,  remaining  behind  about  30  degrees  (Schatz). 
In  cases  where  the  back  remains  persistently  behind,  anterior  rotation  does  not 
occur,  and  such  conditions  are  pathologic.  In  manual  correction  of  occipitopos- 
terior  positions  the  operator  knows  that  unless  he  can  get  the  back  to  the  front, 
rotation  of  the  head  is  incomplete  or  impossible  or  unstable. 

Sellheim,  in  most  elaborate  fashion,  proves  that  the  body  of  the  child  possesses 
qualities  which  determine  its  movements  in  the  birth-canal.  As  was  described 
before,  the  child  during  labor,  in  order  to  present  the  least  resistance  to  the  birth- 
canal,  is  compressed  into  the  shape  of  a  cylinder.  This  fetal  cylinder  bends  with 
facility  only  in  certain  directions.     The  head  bends  backward,  i.  e.,  deflexes  easily, 


Fig.  212. — Action  of  an  Evenly  Flexible  Cylinder  when  Forced  through  a  Curved  Passage. 
The  cylinder  A,  uniformly  flexible,  in  going  through  the  canal  C,  will  simply  bend,  the  line  x-y  not  changing  its  relation 

toC. 


and  this  deflexion  is  aided  by  the  natural  movements  of  the  child.  The  head 
cannot  be  bent  much  onto  the  chest.  Owing  to  the  pressure  of  the  arms  and  legs 
onto  the  body  and  the  construction  of  the  spinal  column,  the  trunk  cannot  bend 
sagittally,  but  may  bend  easily  toward  one  or  the  other  side. 

One  may  readily  see  that  the  fetal  cylinder  will  be  bent  in  its  passage  through 
the  curved  Vjirth-canal,  to  correspond  with  the  curve  of  the  canal.  If  the  child 
were  flexible  evenly  in  all  directions,  a  bending  of  the  cylinder  in  an  anteroposterior 
diameter  would  be  all  that  would  be  necessary.  But  the  bending  of  the  cylinder 
can  occur  only  in  certain  ways — at  the  neck  from  before  behind,  in  the  trunk  from 
one  side  to  the  other,  and  these  two  directions  cross  each  other  at  a  right  angle. 
Therefore,  in  order  for  the  fetal  cylinder  to  pass  through  the  curved  canal,  it  must 
rotate  on  its  long  axis  so  as  to  bring  the  plane  in  which  the  bending  can  most  easily 
occur  to  correspond  with  the  axis  of  the  birth-canal  (Fig.  212).  In  other  words, 
the  child  is  forced  to  rotate  until  that  part  of  its  body  which  can  be  most  easily 
bent,  that  is,  the  nape  of  the  neck,  comes  to  be  adapted  to  the  knee  of  the  canal. 
The  movement  is  similar  to  that  of  pushing  the  foot  into  a  boot  when  the  action  is 


THE    MKCHANISM    OF    LABOU    I.\    OCCIPITAL    PUESENTATIOX 


187 


started  wrongly — as  the  foot  advances  it  rotates  until  the  eurve  at  the  ankle  corre- 
sponds to  the  curve  of  tiie  hoot  (Fig-  2i;ij. 

Anterior  rotation  of  the  child  from  all  positicjns  of  the  pelvis  may  he  explained 
by  this  law  of  the  accommodation  of  elastic  resistance  to  the  shape  of  the  container 
(Sellheim). 

While  admitting  the  full  power  of  Sellheim's  arguments  and  proof,  and  agree- 
ing with  him  that  tiiis  law  exi)lains  the  rotation  of  the  head  and  trunk,  the  other 
factors,  especially  the  construction  of  the  [K'lvic  gutter  and  the  action  of  the  trunk 
on  tile  heatl,  nmst  bo  also  atle({uately  evaluated. 


Y 


]"i(;.   213. — Action  of  an  Unevenly  Flexible  Cylinder  when  Forced  through  a 
Curved  Passage. 
The  cylinder  A  has  a  flat  steel  rod  at  X  Y.     This  rod  cannot  bend  on  the  edge,  only 
on  the  flat.     Therefore,  in  order  to  accommodate  itself  to  the  curve  of  C,  it  must  rotate 
the  cylinder  A.     Note  the  direction  of  the  arrows. 


Literature 

Otild:  "Positio  Occipito-pubica."    Quoted  in  Jour.  Obstetrics  and  Gyn.  of  Great  Britain,  October,  1009.- 
Beziehungen  dea  Geburtskanales  and  Geburtsobjekts  zur  Mechanik,  Leipsic,  Thieme,  1906. 


-Sellheim:  Die 


Disengagement. — Descent  continues  during  anterior  rotation,  as  also  does 
flexion  of  the  head.  Indeed,  flexion  is  exaggerated  by  the  resistance  of  the  pelvic 
floor,  the  forehead  being  pressed  upward  by  the  resistant  sacrosciatic  ligaments, 
the  tip  of  the  coccjtc,  and  the  levator  ani  (Fig.  214).  After  the  forehead  has  passed 
the  coccjTc,  and  the  nape  of  the  neck  has  come  to  lie  under  the  arch  of  the  pubis, 
deflexion  of  the  head  l^egins.  The  chin  leaves  the  chest,  the  occiput  rises  in  front 
of  the  pubis,  the  forehead  presses  out  the  soft  perineum,  and  the  head  is  delivered  in 
extension  (Fig.  215).  The  causes  of  extension  are  generally  agreed  upon.  The 
head  meets  an  inclined  plane — the  perineum.  The  fetal  axis  pressure,  or  the  general 
intra-iiterine  pressure,  forces  the  trunk  down  u]:)on  the  head,  acting  only  on  the 
sincipital  arm  of  the  heatl  lever,  since  the  occipital  arm  is  under  the  pubis.     The 


188 


PHYSIOLOGY    OF   LABOR 


parietal  bosses  strike  the  sides  of  the  levator  ani  near  the  rami  pubis,  and  are  held 
firmly  while  the  forehead  is  driven  down  and  forward  (Fig.  216).  The  perineum  is 
thus  displaced  downward  as  well  as  backward,  a  point  of  importance  in  considering 
lacerations  of  the  pelvic  floor  and  their  repair. 

External  Restitution. — After  the  head  is  delivered  it  slowly  rotates  in  a  direction 
opposite  to  that  taken  in  internal  anterior  rotation;  that  is,  in  O.L.  positions  the 
occiput  turns  to  the  left,  in  O.D.  positions  it  turns  backward  toward  the  right, 
side  of  the  mother.  The  movement  is  called  ''external  restitution,"  and  is  due  to 
the  untwisting  of  the  neck  and  to  the  impulse  imparted  to  the  head  by  the  internal 
rotation  of  the  shoulders.  External  restitution  or  rotation  does  not  invariably 
occur,  and  occasionally  the  occiput  turns  in  a  direction  opposite  to  that  which 
was  expected.     This  is  due  to  an  unusual  internal  rotation  of  the  shoulders. 

When  and  where  do  these  various  movements  take  place?     Descent  or  ad- 


FiG.  214. — Inckbased  Flexion  of  Head  at  Pehineum.     Ahhow  Indicates  Direction  of  Fobce. 


vancement,  or  translation  (Sellheim),  occurs  throughout  the  whole  process,  even 
when  the  head  is  rotating — a  point  to  bear  in  mind  when  imitating  nature's  method, 
as  in  a  forceps  delivery. 

Flexion  takes  place  at  the  inlet  of  the  pelvis,  but  may  not  until  the  head  has 
reached  the  pelvic  floor,  when  flexion  and  rotation  occur  almost  simultaneously. 
It  occurs  toward  the  end  of  the  first  stage  in  primiparse,  and  in  multiparae  in  the 
second  stage.  The  flexion  is  exaggerated  when  the  head  is  ready  to  disengage  from 
the  bony  outlet  of  the  pelvis,  and  this  occurs  about  the  middle  of  the  second  stage. 

Internal  anterior  rotation  takes  place  in  the  excavation  of  the  pelvis,  just  as 
the  head  comes  to  rest  on  the  pelvic  floor,  and  is  completed  when  the  head  has 
escaped  the  bony  pelvis;  though  often,  perfect  rotation,  bringing  the  small  fontanel 
absolutely  into  the  median  line,  may  not  occur  at  all,  the  head  being  delivered 
slightly  obliquely.  Absence  of  rotation  can  occur  only  when  the  child  is  small  and 
soft,  or  the  pelvis  very  large,  and  is  pathologic.     Internal  rotation  usually  begins 


-A 


mE    MECHANISM    OF   LABOR    IN    OCCIPITAL    PUESENTATION 


189 


in  primiparce  whon  tho  first  stasc  is  ondocl  and  is  comploted  l)oforo  tho  second  stage 
is  half  over.     In  multipara;  it  occurs  in  the  second  stage. 

Extension  occurs  after  the  forehead  has  passed  the  bony  outlet,  toward  the  end 
of  the  S(>c()iid  stage  of  both  priiuipara'  and  multipara,'. 

Mechanism  of  the  Shoulders.— When  the  head  becomes  visible  in  the  vulva, 
the  shouldei-s  engage  in  the  inlet,  the  bisacromial  diameter  usually  entering  in  the 
oblique  opposite  to  that  in  which  the  head  entered.  In  O.L.A.  one  finds  the  shoul- 
ders in  th(>  left  obliciue;  in  O.L.P.  they  enter  in  the  right  oblique.  In  O.L.A.  the 
anterior  shoulder  rotates  under  the  pubis  from  the  right  side  of  the  pelvis,  its 
direction  of  progression  being  opposed  to  that  which  the  head  underwent;  while  in 


Fig.  215. — Movement  of  Extension  and  Disengagement. 


O.L.P.  the  anterior  shoulder  follows  the  movement  of  the  head  from  the  left  behind 
to  the  pubis  in  front.  The  movements  imparted  to  the  shoulders  are  engagement, 
rotation,  and  disengagement.  General  intra-uterine  pressure  forces  the  child  down 
the  parturient  canal,  and  this  action  is  reinforced  Id}-  the  direct  pressure  of  the 
uterus  on  the  fetal  body.  The  anterior  shoulder  slides  dow^n  the  lateral  wall  of  the 
pelvis  until  it  reaches  the  pelvic  floor,  then  rotates  under  the  pubis.  Anterior  rota- 
tion of  the  shoulders  is  accomplished  by  the  same  factors  which  operate  on  the  head — 
the  shape  of  the  pelvic  floor,  the  direction  of  the  opening  in  the  pelvis,  and  the  elastic 
resistances  of  the  fetal  body.  Flexion  of  the  child's  trunk  is  necessary  to  accommo- 
date it  to  the  concavity  of  the  pelvic  canal.    The  child's  body  bends  best  laterally, 


190 


PHYSIOLOGY    OF   LABOR 


and,  therefore,  according  to  Sellheim's  law,  the  trunk  will  rotate  until  it  corresponds 
to  the  direction  of  the  curve  of  the  canal  through  which  it  has  to  pass  (Fig.  217). 
In  rare  cases  no  rotation  of  the  back  occurs,  the  shoulders  appearing  transversely, 


Fig.  216. — The  Factors  in  Extension  of  Fetal  Head  when  on  Perineum. 
Parietal  basse.?  meet  resistance  at  B  B.      There  is  a  tendency  for  A  to  come  down,  which  is  opposed  by  perineal  floor, 

giving  curve  A  A'. 


Fio.  217. — ZwKiFBi.'.s  Froze.n  Skction  of  a  W<j.ma?>.'   who  Died  aftkh  Dkliveuy  of  Head. 


THE    MECHANISM    OF    LABOU    IN    OCCIPITAL    PRESENTATION  191 

and  soinotinics  the  shoulders  rotate  to  the  ojjjjosite  oblique,  tlie  hack  ai)pearin}j;  on 
the  otlier  si(h'  to  that  in  wiiieh  it  was  exi)ecte(h  Dehver}'  of  tiie  shoulders  is  <juite 
typical.  Th(^  anterior  shoulder  steins  behind  the  j)ubis,  the  posterior  rolls  up  over 
the  perineum,  aft(>r  which  the  anterior  shoulder  comes  from  behind  the  pubis. 
If  the  perineum  is  much  torn,  a  reverse  mechanism  occurs.  Often  nature  needs 
a  little  aid  at  this  staji;e,  and  the  accoucheur  nnist  imitate  the  natural  modus  of 
delivery.  Trouble  with  the  shoulders  is  rare  unless  they  are  large,  but  lacera- 
tion of  the  i)erineum  frequently  results  from  carelessness  in  their  delivery,  as 
also  may  fracture  of  the  child's  clavicle — even  Erb's  paralysis.  (See  p.  813.) 
After  the  chest  is  born,  the  rest  of  the  child  follows  without  any  particular  mechan- 
ism. 

Over-rotation. — One  is  occasionally  surprised  to  note  that  a  labor  starting  out 
O.L.A.  becomes,  in  its  course,  an  O.D.A.,  and  external  rotation  follows  such  a 
mechanism.  In  those  cases  the  internal  rotation  was  excessive,  carrying  the  occiput 
])eyond  the  middle  line  to  the  opposite  side,  or  the  internal  rotation  of  the  shoulders 
was  reversed  or  excessive.  The  explanation  of  the  phenomenon,  after  removing  the 
question  of  error,  is  to  be  found  in  the  laws  governing  the  mechanisms,  and  one 


Fig.  218. — Zweifel's  Frozen  Section  of  a  Woman  who  Died  After  Deuvery  of  Head. 

usually  finds  that  the  child  was  small  or  the  parts  large  and  yielding,  the  factors  in 
the  production  of  a  perfect  mechanism  ])eing  weakened. 

What  One  Observes  of  the  Mechanism  of  Labor  in  O.L.A. — Careful  observa- 
tion of  the  course  of  labor  enables  us  to  closely  follow  the  mechanism,  to  determine, 
at  any  time,  its  rate  of  progress,  and  to  discover  any  variation  from  the  normal. 
It  is  the  knowledge  of  the  mechanism  of  labor  and  the  ability  to  recognize  and  correct 
abnormal  variations  that  mainly  distinguish  the  real  accoucheur  from  the  l)lind 
midwife,  male  or  female.  It  will  simplify  and  clarify  this  study  if  the  student 
will  follow  the  described  mechanisms  on  the  manikin  or  with  a  pelvis  and  fetal 
skull.  Abdominal  examination  furnishes  most  valuable  information,  is  less  danger- 
ous to  the  patient,  less  painful,  and  should  always  be  practised  first,  though  it  is 
often  necessary  to  supplement  it  by  internal  or  vaginal  ex]:)loration. 

At  the  beginning  of  uterine  contractions  the  uterus  is  more  globular  than  later, 
and  slightly  more  pendulous.  The  head  is  higher  up,  and  movable  above  the  inlet, 
especially  in  multiparip,  and  the  back  is  usually  far  to  the  side.  "When  the  con- 
tractions attain  regularity  and  severity,  the  uterus  lengthens,  the  head  becomes 
fixed  over  the  inlet,  and  the  back  shows  a  tendency  to  come  to  the  front,  or  go 


192  PHYSIOLOGY    OF   LABOR 

further  back  to  the  side,  the  latter  movement  depending  on  the  position — whether 
an  anterior  or  a  posterior  one.  Fig.  219  shows  the  hands  palpating  the  head  before 
it  engages  in  the  pelvis;  one  sees  how  the  fingers  can  move  the  head  from  side  to 
side  above  the  inlet.  Fig.  220  shows  the  hands  as  they  come  to  rest  on  the  head, 
after  it  has  engaged;  one  hand  feels  the  occiput  deep  in  the  pelvis,  to  the  left, 
behind  the  pubic  ramus;  the  other  hand  finds  the  sharp  forehead  on  the  right  and 
somewhat  behind  the  median  line.     When  flexion  is  marked,  as  in  generally  con- 


Fio.  219. — Moving  Head  fhom  Side  to  Side  Above  Inlet.     Head  not  Engaged. 
Arrows  show  direction  of  movements.    This  mancjeuver  may  also  be  carried  out  bimanually,  with  fingers  in  the 

vagina. 

tracted  pelves,  one  can  hardly  feel  the  occiput,  it  is  so  low  in  the  pelvis,  but  the  fore- 
head is  high  up  and  easily  palpated.  If  one  now  tries,  with  the  two  hands,  to  push 
the  head  from  side  to  side,  it  will  be  found  impossible:  the  head  is  fixed.  As  labor 
goes  on  and  internal  anterior  rotation  occurs,  the  occiput  sinks  behind  the  left  pubic 
ramus  out  of  reach  of  the  external  hand,  and  the  forehead  rises,  then  turns,  dis- 
appearing in  the  right  flank.  When  the  occiput  sinks  beyond  the  reach  of  the  fingers, 
the  head  is  engaged. 


THE    MECHANISM    OF    LABOR    IN    OCCIPITAL    PRESENTATION 


193 


The  back  at  first  is  directed  to  the  left  side,  but  as  labor  advances  it  rotates 
to  th(>  front.  One  can  follow  the  anterior  shoulder  as  it  goes  from  the  left,  behind, 
above,  to  tlie  middle  line  just  over  the  pubis.  The  movement  of  the  back  is  also 
depicted  by  the  course  of  tiie  fetal  heart-tones.  At  first  the  point  of  their  greatest 
intensity  is  about  tlie  level  of  the  navel,  on  the  left;  this  point  descends  and  comes 
to  the  median  line  until,  when  the  head  is  on  the  perineum,  the  heart  is  best  heard 
just  above  the  pubic  hair  margin. 

On  vaginal  exj)loration,  early  in  lal)or,  one  finds  the  cervix  closed  or  admitting 
only  one  or  two   fingers,  which  rendei's  the    diagnosis   veiy   difficult.     In   primi- 


FrG.  220. — PAt-p.vTixG  the  Engaged  Head. 


parse  the  head  is  often  engaged;  in  multiparce  it  usuallj^  lies  in  the  inlet,  but  freely 
movable,  floating,  or  "caput  ballitabile. "  The  finger  in  the  cervix  comes  upon 
the  soft  bag  of  waters,  and  through  this  feels  the  head.  Lying  across  the  os  is  the 
sagittal  suture,  running  medially  (synclitism)  or  nearer  the  promontory,  or  pubis 
(asynclitism),  and  at  the  end  of  the  suture,  in  the  left  anterior  pelvic  quadrant,  the 
finger  finds  the  small  fontanel.  At  the  other  end,  in  the  right  posterior  quach'ant, 
but  nearly  on  a  level  with  the  small,  lies  the  large  fontanel.  These  findings  indicate 
that  flexion  has  not  j^et  occurred.  Flexion  having  taken  place,  one  finds  the  small 
fontanel  lower  in  the  pelvis  and  nearer  its  center,  the  large  fontanel  higher  and 
13 


194 


PHYSIOLOGY    OF   LABOR 


harder  to  reach,  the  sagittal  suture  more  nearly  paralleling  the  axis  of  the  body,  and 
lying  almost  in  the  right  oblique.  That  fontanel  which  is  nearer  the  center  of  the 
pelvis  is  the  lower  one.    Internal  anterior  rotation  occurring,  the  small  fontanel  de- 


FiG.  221. — CouESE  or  Fetal  Heaht-tones  in  O.L.a. 


Fig.   222. — Head   Ready   for  Anterior   Rotation  in   O.L.A.     Viewed   from  Below. 


THE    MECHANISM    OF   LABOR   IN    OCCIPITAC    PRESENTATION 


195 


scencls  and  sweeps  around  the  left  anterior  quadrant  of  the  pelvis  until  it  lies  directly 
behind  the  pubis,  the  sagittal  suture  now  running  exactly  in  the  median  line  from 
before  backward  (Figs.  222,  223,  and  224).     Coincident  with  the.se  movements  the 

effaceinent  and  dilalulioii  of  tli<'  ccfvix  have  been  Inking  place,  and  usually,  by  the 


Fig.  223. — O.L.A.     Flexion  and  Anterior  Rotation  Begun. 


Fig.  224. — O.L.A.  Anterior  Rot.\.tion  Completed. 


Fig.  22.5.— Rot.vtion  in  O.L.A. 
Occiput  has  an  arc  of  only  45  degrees  to  travel. 


Fig.  226. — Rot.i.tion  in  O.D.P. 
Occiput  has  an  arc  of  135  degrees  to  travel. 


196 


PHYSIOLOGY    OF   LABOR 


time  the  head  comes  to  rest  in  the  perineal  gutter,  the  os  is  completely  dilated  and 
retracted  above  the  neck.  A  caput  succedaneum  begins  to  form,  and  in  long, 
tedious  labors  may  grow  so  large  that  it  makes  the  landmarks  on  the  skull  hard  to 
find.  Firm  pressure  or  massage  ■\\dll  obviate  the  difficulty.  Of  equal  importance 
to  the  determination  of  the  rotation  is  the  recognition  of  the  degree  of  engagement 
of  the  fetal  head — the  "  station  "  (Miiller) .  It  is  not  so  easy  to  determine  the  degrees 
of  advancement  of  the  head  along  the  birth-canal.  Older  Avriters  sought  to  decide 
this  point  by  pushing  the  head  up,  and  much  use  was  made  of  the  terms  "caput 


Fig.  227. — Course  of  Fetal  Heart-tones  in  O.D.P. 


ballitabile,  mobile,  and  ponderosum."  When  the  head  floated  alcove  the  inlet,  it 
was  called  "caput  ballitabile";  when  it  was  fixed  attheinlet,  "caput  mobile";  when 
deep  in  the  pelvis,  "caput  ponderosum."  A  head  that  is  even  visible  at  the  outlet 
may  be  pushed  up  out  of  the  pelvis,  and  a  head  that  is  not  engaged  may  be  fixed  so 
that  it  cannot  be  moved;  therefore,  one  may  not  be  guided  by  the  displaceability. 
The  head  is  engaged  when  its  largest  plane — that  is,  the  one  through  the  parietal 
bo.sses — has  passed  the  region  of  the  inlet.  How  may  we  determine  that  such  has 
occurred?  We  know  that  the  head  is  engaged  when,  first,  the  most  dependent 
portion  of  the  skull  (not  the  caput  succedaneum)  has  passed  a  line  drawn  between 
the  spines  of  the  ischia;  second,  when  two-thirds  of  the  sacrum  are  covered  by  the 
cranial  prominence,  that  is,  the  sacral  hollow  is  occupied  by  the  head;  third,  when 
the  finger  can  feel  only  one-fourth  of  the  pubis.     Of  these  three  criteria,  the  one 


TllK    MKCJIAMS.M    Ul"    LABOK    IN    OCCIPITAL    PRESENTATION  197 

measuring  tho  distanoo  of  tho  lu>a(l  al)ov('  or  bflow  tlio  intorspinovis  line  is  tlio  most 
valuabl(>  and  rcliahlc. 

Engagcniciit  varies  with  the  dif'terent  ])i-esentations  oi  the  liead.  It  is  pre- 
vented l)y  liighl}'  contracted  pelves,  tumors  blocking  the  inlet,  and  by  pendulous 
abdomen.  An  abnormally  large  head  engages  with  difficulty;  the  placenta  may  be 
in  the  way,  or  a  large  amount  of  liquor  amnii  (polyhydramnion)  may  confer  great 
mobility  on  the  fetus.  Whenever  the  head  does  not  engage,  the  cause  must  be 
sought  out,  and  (jiie  may  not  operate  until  the  degree  of  engagement  is  positively 
known. 

In  the  occipitodextra  anterior  position,  the  mechanism  of  labor  and  the 
findings  are  the  same  as  in  occipitolseva  anterior,  but  reversed. 


MECHANISM  OF  LABOR  IN  OCCIPITODEXTRA  POSTERIOR  POSITION 

One  essential  difference  exists  in  the  mechanism  of  O.D.P.  as  compared  with 
O.D.A. — the  occiput  has  to  rotate  through  an  arc  of  135  degrees,  three-quarters, 
of  a  half-circle,  while  in  O.D.A.  it  rotates  through  an  arc  of  45  degrees,  only  one- 
quarter  of  a  half-circle  (Figs,  225  and  226). 

Engagement  of  the  head  is  slower  because  the  broad  part  of  the  head  is  likely 
to  impinge  on  the  promontory  of  the  sacrum,  and  for  the  same  reason  flexion  is  not 
so  marked,  and  may  not  occur  until  the  head  is  well  down  on  the  pelvic  floor.  In- 
ternal anterior  rotation  takes  much  more  time — naturally,  since  the  occiput  has 
three  times  as  far  to  travel.  After  it  has  occurred,  the  mechanisms  of  all  positions 
are  identical.  The  factors  bringing  about  all  the  movements  are  the  same  in 
posterior  positions  as  in  anterior,  and  a  new  one  is  invoked.  It  is  believed  that  the 
shoulder,  striking  on  the  promontory  of  the  sacrum,  prevents  the  back,  and  there- 
fore the  head,  from  rotating  backward.  Sellheim  explains  anterior  rotation  by  his 
law  of  adaptability  of  a  body,  flexible  best  in  one  direction,  being  forced  to  accom- 
modate itself  to  the  curve  of  the  container.  Anterior  rotation  does  not  invariably 
occur — sometimes  the  occiput  rotates  to  the  hollow  of  the  sacrum  (3  per  cent,  of  the 
cases),  but  then  the  labor  is  pathologic.  This  phase  of  the  subject  is  considered  on 
p.  580. 

The  Findings  in  Occipitodextra  Posterior. — Abdominally,  the  back  is  felt  to 
the  right  and  posteriorly,  and  the  heart -tones  are  deeper  in  the  flank,  further  from  the 
navel.  During  labor,  both  gradually  come  anteriorly,  sinking  at  the  same  time  (Fig. 
227).  The  shoulder  is  on  the  right  side  of  the  median  hne,  and  turns  to  the  front, 
then  to  the  left  side  of  the  center,  as  labor  progresses.  The  forehead,  at  first,  is 
plainly  felt  above  the  left  ramus  of  the  pubis.  It  rises  a  little  higher,  due  to  flexion 
of  the  head,  then  it  sinks  lower  as  the  head  engages;  finally,  it  sweeps  backward, 
around  the  left  half  of  the  pelvis,  disappearing  at  the  side.  The  small  parts,  feet 
and  arms,  are  felt  anteriorly  around  the  umbilicus.  Internally,  at  the  beginning 
of  labor,  the  head  is  high  up,  the  sagittal  suture  in  the  right  oblique,  the  large  fon- 
tanel in  the  left  side  anteriorly,  the  small  fontanel  high  up,  and  at  the  right  sacro-iliac 
joint.  Flexion  is  less  marked  in  these  cases.  After  descent  is  started  the  flexion 
of  the  head  throws  the  small  fontanel  nearer  the  center  of  the  pelvis,  the  large  fon- 
tanel recedes,  and  the  sagittal  suture  becomes  more  vertical.  Should  flexion  fail, 
the  head  reaches  the  perineum,  the  small  and  large  fontanels  descend  in  nearly  the 
same  plane,  the  sagittal  suture  running  more  or  less  transversely  (Fig.  230).  After 
rotation  is  complete  the  findings  are  the  same  as  in  O.D.A. 

Labor  is  always  longer,  harder,  and  more  painful,  and  effacement  and  dilatation 
of  the  cervix  not  so  complete,  in  occipitoposterior  positions.  In  pathologic  cases 
the  powersof  labor  may  giveout  before  rotation  is  accomplished,  and  then  we  have  a 
condition  kno^\^l  as  ''arrest,"  of  which  more  later. 

In  O.L.P.  the  mechanism  of  lal)or  and  the  findings  are  the  same  as  in  O.D.P., 
but  reversed. 


198 


PHYSIOLOGY    OF   LABOR 


Fig.  228.  Fig.  229. 

Figs.  228  and  229. — Rotation  in  CD. P.       (Seen  from  below  and  from  the  side.) 


Fig.  2.30.  Fig.  231. 

Figs.  2.30  and  23L — It  is  now  called  O.D.T.      (If  rotation  stops  here,  it  is  called  transverse  arrest.) 


Fig.  232.  Fig.  233. 

Figs.  232  and  233. — Rotation  in  O.D.P.      (Now  it  has  become  CD. A.) 


riTAPTEU  XI  ri 
THE  MECHANISM  OF  THE  THIRD  STAGE 

Two  acts  make  up  the  delivery  of  the  i)lacenta:  separation  or  detachment  of 
the  organ  and  its  expulsion. 

It  is  not  probable  that  the  placenta  normally  separates  as  the  trunk  of  the  child 
leaves  the  uterus.  Observations  at  cesarean  sections  show  that  the  placenta  re- 
mains adherent  to  the  uterus  during  the  first  moments  of  retraction  of  the  muscle. 
The  uterine  wall  is  thick  everywhere  but  at  the  placental  site,  which  is  nearly  as 
large  as  it  was  before  delivery  (Fig.  234).  During  the  second  stage  of  labor  the 
placenta  may  shrink  somewhat,  to  accommodate  itself  to  the  diminishing  size  of 


Placenta 


Internal  03 


External  os 


Fig.  234. — Placent.v  Still  Attached  to  Uterus  at  Beginning  of  Third  Stage. 
Note  thin  uterine  wall  at  placental  site.     First  uterine  contraction  not  yet  taken  place. 


its  area  of  attachment,  but  after  the  child  is  out,  the  first  uterine  contraction 
causes  such  a  diminution  of  the  surface  area  that  separation  is  inevitable.  The 
first  break  in  continuity  allows  a  little  blood  to  escape  between  the  two  organs,  and 
the  next  uterine  contraction  forces  this  blood,  like  a  fluid  wedge,  between  the  layers 
of  the  decidua  serotina,  separating  the  placenta  in  the  smoothest  and  most  perfect 
manner  from  the  wall  of  the  uterus.  Since  the  placenta  is  more  adherent  at  the 
edges,  the  hemorrhage  l^ehind  it  will  lift  up  the  center,  as  is  depicted  in  Fig.  235. 
This  blood-clot  is  called  the  "  retroplacental  hematoma,"  and  varies  much  in  size, 
depending  on  the  method  of  extrusion  of  the  placenta.  When  too  brusque  man- 
ipulations are  made  on  the  uterus,  the  edge  of  the  placenta  will  separate  at  one 

199 


200  PHYSIOLOGY    OF    LABOR 

place,  allowing  the  retroplaeental  blood  to  escape  externally,  thus  producing  an 
abnormal  mechanism  of  the  third  stage. 

A  third  factor  in  the  separation  of  the  placenta,  but  a  minor  one,  is  the  loss  of 
the  intra-uterine  pressure.  There  is  now  nothing  to  hold  the  placenta  against  the 
wall  of  the  uterus. 

A  fourth  factor,  traction  on  the  placenta  by  a  too  short  cord,^ — 35  cm.,— or 
one  coiled  around  the  neck  of  the  child,  is  pathologic. 

Expulsion  of  the  placenta  begins  when  the  separation  is  complete,  or  nearly  so. 
The  uterine  contractions  force  the  placenta  against  the  internal  os,  and  finally, 
through  it,  into  the  dilated  cervix  and  upper  vagina.  From  this  point  another  force 
takes  up  the  work — the  abdominal  muscles.  Among  the  savages  and  ignorant 
people  various  methods  of  invoking  the  abdominal  pressure  are  employed,  as 
coughing,  sneezing,  blowing  into  a  bottle  or  the  fist,  pushing  on  the  belly,  or  squat- 
ting, as  at  stool.  The  accoucheur  directs  his  patient  to  bear  down,  which  failing,  he 
expels  the  placenta  by  pressure  on  the  uterus.     Few  authors  commend  pulling  on 


^'% 


\ 


Fig.  235. — Showing  how  Placenta  is  Raided  ur  by   Retroplacental  Hemorkhage. 
Specimen  kindly  loaned  by  Prof.  Pisca^ek,  of  Vienna. 

the  cord.     In  pathologic  cases  an  accumulation  of  blood  msiy  force  the  placenta  out 
of  the  uterus. 

During  the  delivery  of  the  after-birth  one  observes  two  mechanisms:  First, 
the  placenta  turns  inside  out  like  an  umbrella,  the  fetal  surface  comes  out  first,  the 
cord  leading  the  way,  the  membranes  containing  the  retroplaeental  hematoma  fol- 
lowing after.  This  is  called  Schultze's  method.  Second,  the  loAver  edge  of  the 
placenta  precedes,  the  whole  organ  sliding  down  the  side  of  the  uterus  in  the  vagina. 
This  is  called  Duncan's  method.  In  the  latter  cases  the  retroplaeental  hematoma 
is  small,  or  the  edge  of  the  placenta  may  have  been  inserted  low,  near  the  internal 
OS,  or  the  contractions  of  the  uterus  may  have  been  unusually  strong  from  the  start, 
quickly  separating  the  placenta  and  folding  it  together  ready  for  extrusion.  In 
opposite  conditions  we  notice  Schultze's  method.  Although  Baudelocque  described 
both  mechanisms,  they  have  been  assigned  the  above  names,  and  which  is  to  be 
considered  normal  or  more  frequent  for  a  time  occupied  the  discussion  of  authori- 
ties. My  own  observations,  with  the  cervix  exposed  by  broad  retractors,  prove 
that  a  pure  Duncan  method  is  rare,  a  combination  of  the  two  mechanisms  being 
the  rule,  but  that  the  placenta  emerges  from  the  vulva  most  often  like  an  inverted 
umV:)rella  (Figs.  242  and  245). 


THE    MECHANISM    OF   THE   THIRD    STAGE 


201 


Tlie  mcnibraiics  art'  lucfhauically  drawn  oil  the  wall  of  the  uterus  Ijy  the  de- 
scending placenta,  but  the  firm  contraction  of  the  muscle  also  helps  in  their  separa- 
tion.    They  are  also  detaciied  in  part  hy  the  retroplaeental  hematoma,  l»ut  when 


Fig.  236.  Fig.  237.  Fig.  238. 

Figs.  236,  237,  and  238. — Schultze's  Mechani.sm  of  Expulsion  of  Placent.^. 

this  is  extensive,  the  process  is  pathologic.  After  the  placenta  is  outside  of  the 
vulva,  the  membranes  follow  to  gentle  traction  the  weight  of  the  placenta,  or  by  their 
own  weight,  if  completely  separated.  Normally,  the  membranes — consisting  of 
the  amnion,  the  chorion,  the  decidua  reflexa,  with  portions  of  the  vera  and  part  of 


V 

Fig.  239.  Fig.  240.  Fig.  241. 

Figs.  230,  240,  and  241. — Duncan's  Mechanism  of  Expulsion  of  Placenta. 

the  decidua  serotina — are  expelled  still  adherent  to  each  other.  Where  the  head 
has  been  delivered  covered  Avith  a  "caul," — the  amnion, — a  separation  has  occurred 
between  the  chorion  and  amnion,  and  one  finds  the  latter  folded  around  the  cord, 


202 


PHYSIOLOGY    OF   LABOR 


attached  to  the  placenta  only  at  the  insertion  of  the  latter.  In  pathologic  cases 
(see  p.  772),  or  where  too  brisk  manipulations  have  been  carried  out  in  the  third 
stage,  the  placenta  is  delivered,  leaving  more  or  less  of  the  membranes  still  attached 
to  the  uterus.     These  portions  of  the  secundines  undergo  fatty  degeneration  and 


Fig.  242. 


Fig.  243. 


Fig.  244.  Fig.  245. 

Fio9.  242,  24.3,  244,  and  24.5. — Usttal  Mechanism  of  Expulsion  of  Placenta. 


are  cast  off  with  the  decidua  during  the  puerperium;    or,  rarely,  they  become  in- 
fected and  cause  puerperal  fever. 

Microscopically,  one  finds  that  the  separation  of  the  placenta  and  membranes 
occurs  in  the  glandular  or  ampullary  layer  of  the  decidua — sometimes  deeper, 
sometimes  more  superficially.    The  soft,  pink,  incomplete  layer  of  tissue  to  be  found 


THE    MECHANISM    OF   THE    TIIIUO    STAGE  203 

on  the  maternal  .surface  of  the  choi-ioii  is  dccidua  vera  and  roflexa,  and  one  can  often 
find  blood-vessels  in  it.  The  gray,  translucent  covering  of  the  placenta  is  decidua 
serotina,  and  the  broken-off  veins  and  arteries  of  the  placental  site  can  always  be 
demonstrated  in  it.  These  thin-walled  vessels,  the  glandular  spaces,  and  the  ab- 
sence of  fibrous  tissue  make  the  decidua  a  very  soft  structure,  and,  therefore,  separa- 
tion of  the  secundines  is  very  easy.  One  can  rub  the  decidua  off  the  uterus  with  a 
gauze  sponge.  In  pathologic  cases  the  decidua  serotina  does  not  form,  or  is  alj- 
sorlx'd  early,  and  the  chorionic  villi  burrow  down  into  and  between  the  muscle- 


\ '',  ;J- J'V 


'--^\li^!^  ^:^  :' _■    ,-:~^^:^^-' 


m 

■    ■    -"■<.5 


Fig.  246. — Thrombosis  in  Uterus  after  Abortion  of  Six  Weeks. 
Woman  twenty-six  years  old. 

fibers.     Dangerous  adhesion  of  the  placenta  results,  necessitating  its  operative 
removal.     (See  Placenta  Accreta.) 

Hemorrhage  from  the  large  sinuses  of  the  placental  site  is  controlled  by  the 
contraction  and  retraction  of  the  uterine  muscular  fibers  and  lamellae.  They  act 
like  "living  ligatures"  on  the  thin-walled  vessels  coursing  through  the  uterus.  The 
shifting  of  the  layers  of  muscle  and  shortening  of  the  bundles  of  fibers  displace,  com- 
press, twist,  and  bend  the  thin-walled  vessels,  so  that  they  are  no  longer  pervious. 
Thrombosis  in  the  sinuses  does  not  normally  occur,  but  occasionally  one  finds,  on 
the  surface  left  bare  by  the  placenta,  a  few  thrombi  occupying  the  open  mouths  of 
the  vessels.  Thrombosis  of  the  deeper  placental  site  is  pathogenic^ — it  may  lead 
to  embolism  and  it  invites  sepsis. 


SECTION  III 

THE  PHYSIOLOGY  OF  THE  PUERPERIUM 


CHAPTER  XIV 
LOCAL  CHANGES 

With  the  completion  of  the  third  stage,  labor  is  ended;  the  puerperal  state 
or  puerperium  has  begun;   the  woman  is  a  puerpera. 

The  puerperium  may  be  defined  as  that  period  which  extends  from  the  de- 
livery of  the  ovum  until  the  return  of  the  genitalia  to  the  non-pregnant  is  complete. 
Its  length,  therefore,  is  from  six  to  eight  weeks,  though  in  common  usage  the  puer- 


External  os 


Internal  os 


Internal  os 

Fio.  247. — Uterus  Directly  After  Labor. 
Frozen  section  of  a  primipara  who  died  one  hour  after  delivery,  from  hemorrhage  and  fatty  heart  (Stratz).     Usually, 

there  is  no  gut  in  front  of  the  fundus. 

perium  mean.s  tlie  time  the  woman  is  in  bed  after  the  labor.  As  has  been  repeatedly 
stated,  a  perfect  restitutio  ad  integrum  never  occurs  after  labor.  The  woman 
carries  the  evidences  of  child-bearing  all  her  life.  The  distinction  between  normal 
and  pathologic  conditions  during  the  puerperium  is  not  easy,  even  with  the  aid  of 
the  thermometer  and  of  bacteriology.     The  rapid  disintegration  of  the  uterus,  the 

204 


LOCAL   CHANGES 


205 


changes  in  the  endometrium,  and  in  the  open  vessels  at  the  placental  site,  are 
closely  akin  to  the  pathologic,  and  would  be  called  such  if  they  occurred  at  any  other 
time  or  i)lace.  It  is  the  same  approach  to  the  abnormal  that  renders  permanent 
structural  disease  so  prone  to  begin  during  tlie  puerperal  period. 

In  the  physiology  of  ijregnaney  we  learned  of  all  the  cliang(!S,  local  and 
general,  which  provided  for  the  growth  of  the  child  and  its  expulsion  from  the 
mother.  These  were  progressive"  changes.  In  the  physiology  of  the  puerperium 
we  will  study  the  retrogressive  changes,  local  and  general,  which  bring  back  the 


Fig.  248. — Height  or  Uterus  Postpartum.     The  Bladder  Ejiptt. 
L,  After  labor:  1,  First  day;  2,  second  day,  etc. 


organs  of  the  mother  to  their  original  condition,  and,  second,  those  progressive 
changes  in  the  breasts  which  enable  them  to  carry  further  the  function  begun  by 
the  uterus — the  nourishment  of  the  child.  The  retrogressive  changes  of  the  geni- 
talia are  grouped  under  the  general  heading  "Involution." 

Changes  in  the  Uterus.— Immediately  after  delivery  of  the  placenta  the  uterus 
sinks  below  the  level  of  the  navel  in  strong  anteversion  and  anteflexion,  resting  on 
the  promontory  behind  and  l>ing  against  the  abdominal  Avail  in  front  (Fig.  247). 
OAAang  to  its  previous  displacement,  its  ligaments  and  vaginal  attachments  are  so 
loose  that  the  fundus  may  easily  be  moved  to  any  part  of  the  belly, — even  as  high  as 


206 


THE    PHYSIOLOGY    OF   THE    PUERPERIUM 


the  liver,  or  may  be  pushed  clown  so  that  the  cervix  hangs  out  of  the  vulva.  The 
full  1  )ladcler  always  displaces  the  uterus,  and  usually  the  latter  rises  toward  the  right 
side.  The  uterus  now  resembles  a  flattened  pear;  it  is  15  cm.  long,  12  cm.  broad, 
and  8  to  10  cm.  thick,  l^eing  about  as  large  as  a  fetal  head,  and  it  weighs  about  two 
pounds.  On  vaginal  examination  immediately  after  labor  one  can  hardly  outline 
the  cervix,  it  is  so  soft  and  succulent,  hanging  down  from  the  hard  contracted  mus- 
cular fundus  in  folds,  like  a  cuff.  It  is  about  1  cm.  thick  and  6  or  7  cm.  long,  but 
may  be  stretched  to  10  or  11  cm.  The  internal  os  or  contraction  ring  firmly  closes 
the  uterine  cavity  and  marks  the  point  where  the  thick  fundus  goes  into  the  thin 


Fig.  249. — Utekus,  Fifth  Day  Postpartum  (from  Bumm). 


lower  uterine  segment  and  cervix.  Either  a  small  blood-clot  fills  the  cavity  of  the 
uterus  or  the  walls  lie  apposed.  At  the  placental  site  the  uterine  wall  is  thinner 
than  elsewhere  until  a  few  contractions  have  occurred ;  then  it  is  thicker,  and  one 
recognizes  the  location  of  the  placenta  by  the  roughened,  raised  surface.  This 
roughened,  raised  surface  is  normal,  and  must  not  be  mistaken  for  a  piece  of  ad- 
herent placenta.  Measurements  Ijy  Fehling  show  the  thickness  of  the  wall  to 
vary  from  33^  to  5  cm. 

Owing  to  the  development  of  the  elasticity  of  the  vagina  and  pelvic  floor,  and 
the  filling  of  the  rectum  and  bladder,  the  uterus  rises  in  the  abdomen  on  the  first 
day  of  the  puerperium;   but  from  then  on  one  observes,  from  day  to  day,  a  steady 


LOCAL    CHANGES 


207 


decrease  in  lieiftlit  above  the  pubis  and  in  all  its  diameters  (Fig.  248).  The  table 
from  Temesvary  gives  the  measurements,  which  were  taken  when  the  bladder  and 
rectum  were  empty  antl  when  tlie  uterus  was  lidd  up  against  the  abdominal  wall, 
i.  e.,  the  antcflcxiou  corfccted. 


Day 


IIeioht 
Pu 


ABOVB 
BIU 


After  (lolivory 10.91 

First  day 13.55 

2d 

3d 

4th 

5th 

6th 

7th 

8th 


12.45 
11. IG 
10.21 
!).29 
8.22 
7.61 
7.32 


Bkbadtii  at  Tubal 
i.nhkktion 


11.05  cr: 

12.27 

11.71 

10.93 

10.27 

9.66 

8.96 

8.32 

8.19 


Internal  os 


External 


Fig.  250. — Uterus,  Twelfth  Day  Postpartum  (Bumm). 


While  one  may  follow  the  descent  of  the  uterus  with  the  tape-measure,  for  prac- 
tical purposes  the  rule  of  the  fingers  is  sufficient.  On  the  first  day  the  uterus  is 
seven  or  eight  fingerbreadths  above  the  pubis ;  on  the  fifth  day  four  or  five,  and  cor- 
respondingly narrower  across  the  fundus;  while  by  the  twelfth  day  it  has  sunk  Idc- 
low  the  inlet  so  that  it  is  not  easily  palpable  from  the  abdomen  (Figs.  249  and  250). 


208  THE    PHYSIOLOGY    OF   THE    PUERPERIUM 

After  delivery  the  uterus  weighs  2i  jDounds,  or  1000  gm. ;  by  the  end  of  the 
first  week  it  has  lost  one-half — 500  gm.;  at  the  end  of  the  second  week  it  weighs 
350  gm.  (about  11  ounces);  while  in  the  eighth  week  it  again  is  the  small  organ  of 
two  ounces,  or  60  gm. 

This  rapid  diminution  of  size  is  brought  about  by  absorption  of  the  tissue-juices 
and  fatty  degeneration  of  the  muscle-fibers.  Sanger  showed  that  the  fibers  are 
not  all  nor  fully  destroyed,  but  the  protoplasm  undergoes  cloudy  swelling,  hyaline 
and  fatty  degeneration.  The  fat  is  removed  by  the  lymph-stream,  by  oxidation, 
by  the  action  of  a  fat-splitting  ferment,  and  partly  by  the  leukocytes.  That  fatty 
degeneration  of  the  muscle  protoplasm  is  not  the  only  method  nature  has  for  re- 
ducing the  uterus  is  indicated  by  the  demonstration  of  glycogen  (Broers)  and  pep- 
tone (Hofmeister)  in  the  muscle.  The  connective-tissue  fibers  also  undergo  hya- 
line fatty  degeneration  and  partial  absorption.  A  multiparous  uterus  is  usually 
thicker  and  more  fibrous.     Little  is  known  of  the  changes  in  the  nerves. 

The  uterine  vessels  are  compressed  by  the  contracting  uterus,  causing  the 
anemia  which  is  the  basal  factor  of  the  changes  described  above,  and  obliterating 
the  vessels  themselves,  with  hyaline  and  fatty  degeneration  of  their  walls  and 
occlusive  growth  of  the  endothelium  (E.  Ries) .  Thrombosis  occurs  in  the  walls  of 
the  deeper  veins  only  in  pathologic  cases,  but  a  superficial  thrombosis  is  not  ab- 
normal, and  may  occur,  according  to  Leopold,  even  in  the  latter  weeks  of  pregnancy. 
These  thrombi  are  organized  in  the  usual  manner  during  the  puerperium.  The 
placental  site,  after  the  placenta  has  left  it,  contracts  rapidly,  presenting  a  raised 
and  nodular  surface  about  three  inches  in  diameter;  by  the  fourteenth  clay  it  is 
the  size  of  a  silver  dollar,  and  in  six  weeks  may  still  be  recognized  by  its  elevated, 
though  not  roughened,  surface,  which  is  the  size  of  a  quarter. 

The  uterine  serosa,  in  spite  of  its  elasticity,  cannot  follow  the  receding  uterus. 
It  lies  in  fine  wrinkles  which  are  well  shown  in  Fig.  125,  p.  95.  They  disappear 
within  a  week.  Their  distinctive  grouping  shows  the  direction  of  the  contraction 
of  the  muscle-fibers. 

The  cervix,  after  labor,  hangs  down  like  a  soft  cuff,  succulent,  bruised,  some- 
times almost  black  with  suffused  blood,  edematous,  and  more  or  less  torn.  The 
author  has  never  failed  to  find  more  or  less  injury  to  this  organ,  even  after  natural 
and  easy  labors.  The  serous  infiltration  disappears  rapidly,  and  within  eighteen 
hours  the  cervix  forms,  quickly  shortens,  and  becomes  harder.  On  the  third  day 
two  fingers  still  pass  easily  into  the  uterus;  on  the  twelfth  day  one  finger  can  attain 
the  internal  os,  but  cannot  go  through  it;  while  in  the  fourth  week  the  os  is  a  small 
transverse  slit. 

Changes  in  the  Endometrium. — During  pregnancy  the  glandular  layer  of  the 
cleciclua  vera  and  reflexa  undergoes  a  fatty  degeneration.  The  separation  of  the 
placenta  and  membranes  takes  place  in  this  layer;  therefore,  when  the  uterus  is 
emptied,  its  mucous  surface  is  denuded,  the  connective-tissue  spaces  being  ex- 
posed all  over,  and,  at  the  placental  site,  almost  to  the  muscle.  The  interior  of  the 
uterus  is  one  large  wound,  with,  at  the  placental  site,  immense  veins,  containing 
superficial  thrombi,  opening  upon  it.  This  condition  explains  the  ease  of  infection 
and  the  severity  of  the  disease  if  it  once  gains  entrance.  An  invasion  of  the  decidua 
by  white  blood-corpuscles  takes  place,  forming  a  layer  of  granulation,  which  sepa- 
rates the  necrosing  parts  of  the  decidua  from  the  healthy.  At  first  the  endome- 
trium varies  from  2  to  5  mm.  in  thickness,  the  surface  is  rough,  with  shreds  of 
degenerating  decidua,  blood-clots,  and  bits  of  fetal  membrane.  By  the  third  day 
this,  as  the  result  of  fatty  degeneration,  has  softened  so  that  it  could  be  wiped  off 
with  the  finger,  but  nature  accomplishes  it  in  a  better  way.  The  granulation  wall 
separates  the  dead  from  the  living  tissues,  the  remaining  decidua  cells,  in  part, 
return  to  their  original  condition,  the  epithelium  from  the  stumps  of  the  glands 
which  lay  unaffected  among  the  muscle-fibers  and  which  now  crowd  closer  together 


LOCAL    CHANGES 


209 


as  the  utorus  shrinks,  prohfcnitcs  i-apidly,  grows  out  on  tlio  surface  of  the  endome- 
triuni,  and  covers  the;  new  mucous  nicinbrani^  Thus  the  larger  part  of  the  cikUj- 
metriuni  is  east  off,  regeneration  taking  place  from  the  connective-tissue  basis  of 
th(!  mucous  membrane  and  from  tiie  epithelium  of  the  dfjepest  portions  of  the 
utricular  glands  (I''ig.  2r)l).  It  closely  resembles  the  healing  of  a  granulating  sur- 
face on  any  nuicous  membrane. 


}J^"-A^ 


10 


Fig.  251. — Regenerating  Mucosa  on  the  Sixth  Day  of  the  Puerperium  (from  Bumm). 
1,1,  Upper  nocrotic  layer  of  docidua  invaded  by  leukocytes  and  being  cast  off;  2.  naked  decidua;  3,  new-form- 
ing epithelium;  4,  epithelium"  growing  out  of  a  gland-mouth;  5,  bank  of  granulation  tissue;  6,  6,  gland;   7,  7,  capilla- 
ries; S,  degenerating  and  rebuilding  decidua  cells  among  connective-tissue  fibers;  9,  9,  muscle;  10,  spindle-celled 
deepest  layer  of  decidua. 

At  the  placental  site  similar  processes  occur,  with,  in  addition,  the  thrombosis 
and  organization  of  the  open  mouths  of  the  vessels.  The  changes  here  are  much 
slower  than  in  the  vera. 

Changes  in  the  Vagina  and  External  Genitalia. — After  labor  the  vagina  may 

be  found  swollen,  blue,  bruised,  pouting  into  the  vulva;  but  it  soon  regains  most 

of  its  tonicity,  though  only  after  years  to  a  degree  approaching  normal.     The 

extravasated  blood  is  absorbed  in  a  week,  the  prolapse  of  the  walls  becomes  less, 

14 


210  THE    PHYSIOLOGY   OF   THE    PUERPERIUM 

though  the  anterior  wall  of  the  vagina  usually  remains  permanently  lower.  The 
elasticity  of  the  perineum  is  reestablished  with  surprising  rapidity;  perineal  tears 
that  looked  large  and  deep  are  small  the  next  day,  but  just  as  important,  however. 
A  peculiar  consistence  of  the  vagina  and  perineum  remains  for  weeks  after  delivery. 
The  tissues  are  distensible  to  only  a  certain  degree,  after  which  they  break  like 
card-board;  the  blood-vessels  are  friable,  and  operations  performed  during  the 
puerperium  are  likely  to  be  complicated  by  troublesome  capillary  oozing.  Many 
cases  of  rupture  of  the  vagina  sub  coitu  have  been  reported  as  occurring  in  this 
period,  and  bleeding  is  always  a  prominent  symptom.  The  vagina  and  mucous 
surface  of  the  vulva  have  a  deep-red,  velvety  appearance,  by  which  the  puerperal 
state  can  usually  be  diagnosed. 

The  pelvic  floor,  containing  muscle,  fat,  and  fascia,  is  infiltrated  with  bloody 
serum,  full  of  small  suggillations,  even  some  larger  blood  extravasations.  The 
muscle-fibers  are  often  torn  and  overstretched.  Absorption  of  the  blood  and 
serum  quickly  takes  place,  but  many  minute  and  larger  scars  are  left,  which  result 
in  atrophy  and  a  weakened  pelvic  floor. 

The  Puerperal  Wounds. — A  study  of  the  healing  process  of  the  wounds  made 
by  labor  forms  an  essential  part  of  the  duties  of  the  accoucheur.  The  hymen 
tears  in  every  labor,  and  its  relics  are  found  as  a  row  of  mucous  membrane  tags 
circling  the  vaginal  orifice  and  called  carunculce  myrtiformes.  Around  the  clitoris, 
the  labia  minora,  the  introitus  vaginae,  in  the  vagina,  in  the  cervix — especially  in 
primiparse — occur  larger  or  smaller  lacerations,  bruises,  and  scraped  surfaces. 
These  may  heal  by  apposition  and  primary  union,  or  by  granulation  and  suppura- 
tion. Lacerations  of  the  perineum  occasionally  heal  by  primary  union,  but  usually 
granulate  up  from  the  bottom.  Sometimes  the  skin  unites,  but  the  body  of  the 
perineum,  the  physiologically  important  part,  does  not  unite  well.  Lacerations 
of  the  vagina  usually  heal  readily,  but  with  scar  formation,  which,  if  marked,  will 
distort  the  base  of  the  bladder,  producing  incontinence  of  the  urine,  or  dislocate  the 
uterus,  producing  sterility  and  other  noxious  conditions.  Cervix  tears  occasionally 
unite  by  primary  union.  If  infected  they  do  not,  but  may  give  rise  to  cellulitis  in 
the  adjacent  broad  ligaments,  with  resulting  life-long  invalidism. 

In  the  absence  of  infection  these  wounds  heal  with  very  little  inflammatory 
reaction.  The  surface  is  covered  with  a  light-gray  exudate.  Underneath  this 
pink,  pointed  granulations  appear,  the  surface  cleans  off,  epithelization  rapidly 
occurs,  and  by  the  eighth  day  is  usually  nearly  completed.  Abnormal  wound  repair 
indicates  infection  somewhere  in  the  parturient  canal.  Swelling  of  the  labia, 
edema  around  the  wounds,  which  have  a  reddened,  angry  aspect,  greenish,  yellow- 
ish, even  dark  sloughing  of  the  surface  of  the  wounds,  pain,  fever,  and  illness,  indi- 
cate that  the  normal  process  is  being  interfered  with  by  infection. 

The  Lochia. — Another  striking  phenomenon  of  the  puerperium  is  the  appear- 
ance of  the  lochia,  a  discharge  from  the  genitalia  at  first  bloody,  then  sanguineous, 
then  purulent,  finally  mucoserous,  before  ceasing  entirely,  in  three  to  six  weeks. 
On  the  first  day  the  lochia  are  almost  pure  blood,  normally  not  mixed  with  clots — 
lochia  cruenta  or  rubra.  Clots,  unless  large  and  numerous,  are  not  significant. 
This  flow  is  followed  by  one  of  blood-stained  serum,  which  lasts  a  day  or  so,  after 
which  the  discharge  is  thicker,  of  a  maroon  color  and  creamy  consistence,  with  a 
characteristic  odor — lochia  sanguinolenta.  Gradually  the  bloody  admixture  grows 
less,  the  white  blood-corpuscles  increase,  the  lochia  resemble  cream, — lochia  alba  or 
purulenta, — until  at  the  end  (thirteenth  to  the  seventeenth  day)  there  is  only  a  slight 
mucoserous  discharge. 

The  odor  of  the  lochia  varies  from  day  to  day,  varies  with  the  patient,  some 
women  naturally  possessing  a  peculiar  odor  (even  with  the  menses),  and  with  the 
kind  of  bacteria  present  in  the  vagina.  Normally,  the  odor  is  not  very  offensive, 
being  faded  or  insipid,  like  old  meat,  or  strong,  like  perspiration.     If  the  lochia  are 


H- 


Fic.  2o2. — LoriiiA,  Thiiid  Day. 
1.   Blood-PcIIs   ruiiiKTous.      2.    Healthy  k'ukocytfs;    nuclei   coiitractetl   and    normal. 
3.    Few  bacteria. 


Fig.  253. — Lochia,  Fifth  Day. 
1.   Bacteria   in   abundance — one   kind   principally.     2.   Leukocytes  swollen,   nuclei 
swollen.     3.   Phagocytes.     4.  Blood-ccll.s  not  so  numerous. 


\.'<-:iitm        r;-:*.v-^^K>         'Cv^fln^      v-.'V<.^Hv-B>-'.*olik;:-    ' -*•  .  .  <V£! -.-.-.  ■ 


^,.^sjK.,   •• 


I 


IP 


Fig.  254. — Lochia  Alb.a.,  Eighth  Day. 
1.   Bacteria  less  numerous  and  pale  staining,  probably  dead.     2.   Leukocytes  more 
numerous  and  more  normal  in  appearance.     3.   Blood  less. 


LOCAL    CHANGES  211 

fetid,  or  have  a  fniit>',  pui-iilcnl  odor,  or  sharp  and  I'iting,  like  sanious  pus,  the 
pucrpcra  is  more  or  less  dan{i;ci-ously  diseased.  J)ec(jinposing  dots  or  nicTiihranes, 
a  forgcjtteti  piece  of  guu/e,  lend  tiie  lochia  the  foul  odoi'  of  decoinijosilion,  even 
when  the  general  condition  of  the  pueri)era  is  not  dis(|uieting.  The  other  char- 
acteristics of  the  odor  referred  to  indicate  that  the  puerpera  is  suffering  from  one 
of  the  severer  types  of  infection. 

The  lochia  cruenta  contain  blood,  shreds  of  nienibran(!  and  decidua,  and 
occasionally  fetal  remnants,  vernix  caseosa,  lanugo,  meconium,  etc. 

Lochia  sanguinolenta  contain  blood  in  a  state  of  solution,  wound  exudation, 
red  and  white  blood-corpuscles,  shreds  of  decidua  in  a  state  of  fatty  degeneration, 
mucus  from  the  cervix  and  vagina,  and  microorganisms  (P^ig.  252). 

Lochia  alba  are  full  of  decidual  cells — larg(>  mononucleated,  irregular,  round 
or  spindle-shaped  cells  in  process  of  degeneration,  leukocytes,  "lochiocytes, "  flat  and 
cylindric  epithelium,  fat  and  del^ris  from  the  uterus  and  the  puerperal  wounds, 
mucus,  cholesterin  crystals,  the  Trichomonas  vaginalis,  and  mjTiads  of  microorgan- 
isms (Fig.  254). 

The  Bddcriology  of  the  Lochia. — Even  in  normal  pucrpcrse  the  lochia  are  in- 
fectious, as  the  frequent  finger  infections  of  nurses  and  the  navel  infections  of 
children  show.  Kehrer  vaccinated  puerperse  on  the  thigh  with  their  own  lochia 
and  produced  abscesses.  Likewise,  inoculations  of  animals  with  normal  lochia,  in 
many  cases,  produced  sepsis  and  death.  Doderlein  found  that  the  uterus,  in  the 
first  few  days  after  labor,  was  sterile  in  83  per  cent,  of  250  cases  examined.  In 
the  others  were  found  the  streptococcus,  the  staphylococcus,  the  gonococcus, 
and  various  saprophytes,  aerobic  and  anaerobic.  The  vaginal  lochia  also  con- 
tain these  bacteria,  and  in  greater  freciuency  and  number  after  the  first  day 
of  the  puerperium.  The  uterus,  from  the  fourth  to  the  seventh  day,  shows  a 
bacterial  flora,  including  the  streptococcus  pyogenes  (Scheib).  In  the  succeeding 
week  the  uterus  gratlually  becomes  aseptic.  The  most  important  bacteria  found 
in  the  lochia  are  the  streptococcus,  the  staphylococcus,  and  the  bacillus  coli  com- 
munis.    (See  chapter  on  Puerperal  Infection.) 

In  spite  of  very  extensive  study  and  experimentation,  it  is  jTt  impossible  to 
distinguish  the  pathogenic  from  the  non-pathogenic  streptococcus.  Therefore  the 
streptococcus,  found  in  the  vagina  of  gravidse  and  puerperse,  must  be  regarded  as 
capable  of  developing  destructive  qualities  if  the  conditions  for  it  are  ripe. 

Since  there  is  no  doubt  of  the  presence  of  these  dangerous  germs  in  the  vagina, 
why  is  it  that  women  do  not  all  develop  fever  or  infection  during  the  puerperium? 

First,  because  the  bacteria  do  not  wander  upward  into  the  uterus,  where  the 
most  extensive  wounded  surface  lies,  until  the  third  or  fourth  day,  and  by  this 
time  the  protecting  granulation  wall  is  formed  in  the  endometrium.  The  stream 
of  lochia  from  above  tends  to  wash  them  out.  The  thick,  sc[uamous  epithelium 
of  the  vagina  also  acts  protectingly  against  an  invasion  by  bacteria.  If  a  care- 
less examiner,  or  indeed  any  manipulation,  breaks  through  this  protecting  wall  of 
granulations,  the  infection  of  the  underlying  blood-  and  lymph-vessels  is  inevitalile. 
Clinical  experience  has  taught  us  the  danger  of  such  interference. 

Second,  because  the  l^acteria  are  of  weak  virulence,  or — and  this  is  probably  a 
complement  to  such  a  statement — the  puerpera  possesses  natural  immunities 
against  infection.  When  her  general  health  is  broken, — as  by  hemorrhage  or 
eclampsia,  shock  from  operation, — or  if  the  local  resistances  are  lowered  from  severe 
injury,  the  bacteria  can  develop  their  virulence  and  invade  her  organism.  Anal- 
ogously, the  bacterium  coli  communis  in  the  intestine  and  the  bacillus  diphtherise  in 
the  mouth,  may  live  for  years  ^A-ithout  producing  disease.  Perhaps  part  of  this 
immunity  lies  in  the  presence  of  other  bacteria  in  the  vagina,  and  part  in  the  acid 
reaction  of  the  secretion  (after  the  sixth  day) ;  but  most  of  it,  probably,  is  in  the 
active  immune  bodies  of  the  living  tissues  themselves  (Stoltz,  Williams). 


212  THE    PHYSIOLOGY    OF   THE    PUERPERIUM 

The  Quantity  of  the  Lochia. — Hippocrates  estimated  the  amount  of  the  lochia  to 
be  about  1300  gm.;  later  authors  place  it  at  about  500  gm.,  three-fourths  of 
which  is  discharged  in  the  first  four  days.  Women  who  do  not  nurse  their  babies 
have  more,  nursing  women  less;  indeed,  in  the  latter,  involution  is  faster  and  more 
perfect.  These  conditions  are  attended  with  increase  of  the  lochia:  Primiparity; 
young  women;  women  who  usually  have  profuse  menses;  twins;  large  placenta; 
severe  operative  deliveries,  ^vith  bruising  and  injuries  of  the  genitalia;  retention  of 
parts  of  placenta  and  membrane;  too  full  meat  diet;  alcoholism;  hemophilia; 
general  atony.     A  strong,  robust  woman  has  more  rapid  reparative  processes. 

Source  of  the  Lochia. — The  lochia  are  very  complex,  containing  the  wound  dis- 
charges, a  serosanguineous  exudate  from  all  the  puerperal  wounds,  from  those  of  the 
endometrium,  the  lacerations  of  the  cervix,  indeed,  of  the  whole  parturient  canal. 
A  part  of  the  flow  conies  from  the  utricular  glands,  the  cervical  glands,  the  vaginal 
and  vulvar  glandular  organs. 

The  amount  and  quality  of  the  lochia  vary  from  day  to  day.  If  the  patient 
sits  up  early,  the  lochia  sanguinolenta  continue  longer  or  are  more  profuse.  Some- 
times the  red  lochia  persist  for  several  weeks,  or  they  may  reappear  on  the  occasion 
of  unusual  exercise;  or  the  lochia  may  cease  as  the  result  of  disease  (infection)  or  of 
obstruction  to  the  flow.  This  almost  always  causes  fever,  which  subsides  when  the 
drainage  is  reestablished.  The  normal  changes  in  the  color  and  consistence  of  the 
lochia  are  interfered  with  by  infection,  and  one  of  our  best  diagnostic  means  is  the 
investigation  of  the  puerperal  discharges.  The  lochia  contain  a  leukocyte  proteo- 
lytic ferment  (Jochman). 

Involution. — ^AU  the  foregoing  changes  are  part  of  the  function  of  involution, 
the  most  prominent  of  which  is  the  reduction  in  size  of  the  uterus.  The  reduction 
in  size  of  the  uterus  is  subject  to  many  variations.  In  women  who  do  not  nurse, 
the  reduction  in  size  is  slower.  Sepsis  stops  involution  or  slows  it^an  important 
sign.  On  the  other  hand,  involution  offers  a  barrier  to  infection — the  shedding  of 
the  decidua  resembles  the  cleansing  of  a  granulating  surface;  the  lochia  carry  off 
the  germs.     The  tightly  contracted  uterus  does  not  absorb  bacteria  nor  toxins. 

Involution  varies  in  different  women  and  in  the  same  woman  after  different 
confinements.  The  rate  of  decrease  is  not  even,  the  greatest  being  during  the  first 
six  days.  Sometimes  the  process  goes  beyond  the  normal,  the  uterus  at  the  tenth 
week  being  very  small — superinvoluted.  This  superinvolution  is  sometimes  called 
"lactation  atrophy."  It  occurs  only  in  women  who  nurse,  and,  in  such  cases,  the 
periods  do  not  reappear  during  lactation.  The  atrophy  reaches  its  maximmn  about 
the  fourth  month.  If  nursing  is  stopped,  the  uterus  is  regenerated  in  six  to  eight 
weeks.  This  phenomenon  is  probably  a  conservative  act  of  nature  against  too 
frequent  pregnancies.  If  the  nursing  is  continued  too  long,  actual  atrophy  of  the 
uterus  may  occur.  When  there  are  no  general  symptoms, — as  pain  in  the  back, 
nervous  disturbances,  anemia,  weakness, — and  if  the  uterus  does  not  grow  too  small, 
the  condition  is  not  abnormal,  and  the  uterus  will  regain  its  size  after  lactation 
ceases;  sometimes,  even  before  this.  Occasionally  (60  per  cent.),  about  the  third 
or  fourth  week,  there  is  a  slight  return  of  bloody  lochia.  This  is  usually  due  to  too 
much  activity  of  the  patic^nt,  and  the  blood  comes  from  the  placental  site;  perhaps 
a  superficial  clot  is  being  exfoliated.  A  piece  of  placenta,  thick  membranes,  sub- 
involution, infection  of  the  endometrium,  fibroids,  and  retroflexion  are  the  com- 
monest causes  of  profuse  and  abnormally  long-continued  lochia,  or  of  a  return  of 
bloody  discharge.  An  early  return  of  the  menses  occurs  in  43  per  cent,  of  nursing 
women,  h»ut  in  only  26  per  cent,  are  the  periods  regular.  Intervals  of  weeks  and 
months  are  noted,  as  are  also  great  irregularities  in  amount  and  duration.  If 
the  women  do  not  nurse,  the  menses  usually  return  in  six  weeks  and  continue  more 
or  less  regularly.     The  first  menstruation  after  delivery  is  likely  to  be  profuse. 

The  Abdominal  "Walls. — In  many  women  the   abdominal  walls  very  slowly 


LOCAL   CHANGES  213 

and  imperfectly  regain  their  previous  elasticity.  In  Ijut  a  few  the  tonus  is  well 
pres(?rve(l.  A  great  deal  dejjends  on  the  amount  of  distention  of  the  abdomen 
during  gestation  and  the  development  of  gas  in  the  Ijowels  after  labor.  Wearing 
tight  corsets  iluring  ])i'egiuiiu'y  ])rc(lisi)()scs  to  weakness  of  the  al)dominal  muscles. 
Attention  to  the  bowels  jjostpartum,  and  to  the  strengthening  of  the  nmscles,  will 
aid  in  preventing  what  the  women  call  "high  stomach."  Sometimes  the  belly  is  so 
weakened  that  the  recti  separate  and  the  uterus  comes  to  lie  between  them,  a 
state  which  the  women  call  "rupture,"  the  scientific  t(;rm  being  diastasis  recti. 

Changes  in  the  Breasts. — These  consist  in  the  estal^lishment  of  the  function  of 
lactation,  whereby  the  woman  is  put  in  position  to  continue  the  nourishment  of  her 
offspring. 

Nature  has  made  woman  an  exception  to  the  rule  of  other  mammals.  In  her 
the  secretion  of  milk  does  not  ])egin  until  the  second  or  third  day,  rarely  on  the  first 
day  after  birth.  In  animals  the  milk  is  present  in  the  glands  the  first  few  hours — 
even  during  labor.  This  delay  is  possibly  an  outgrowth  of  civilization,  in  that 
the  function  of  reproduction  is  not  allowed  such  full  play  as  formerly,  and  lactation 
especially  has  been  neglected  for  generations,  resulting  in  hypoplasia  of  the  glands. 

The  changes  about  to  be  described  occur  in  the  breasts  after  abortions  from  the 
fourth  month  on,  as  well  as  after  labors  at  term.  On  the  second  clay — or,  as  is 
usual  in  primiparae,  on  the  third  day — the  breasts  grow  harder,  the  veins  become 
prominent,  the  whole  organ  fuller  and  heavier;  the  patient  has  the  feeling  that  the 
secretion  of  milk  is  beginning  and  describes  a  prickling  or  Ijurning  sensation.  Soon 
the  swelling  reaches  a  considerable  degree,  and  the  individual  milk-ducts  can  ])e 
felt  as  hard  strings — the  lobes  of  the  breasts  as  hard  lumps.  The  gland  is  much 
fuller  with  blood  and  feels  hot  to  the  touch.  Rarely,  it  becomes  reddened  and 
sometimes  there  is  a  bluish  turgescence  of  the  surface.  The  milk  comes  into  the 
breasts  much  more  stormily  in  primiparae;  they  express  it  as  "shooting  in,"  and 
the  distress  caused  is  sometimes  very  severe. 

The  woman  says  the  breasts  feel  like  two  hot  weights  on  her  chest,  and  if  the 
little  extension  of  the  gland  which  sometimes  lies  in  the  axilla  is  involved,  the  pa- 
tient keeps  her  arms  outstretched  in  Consideral^le  discomfort,  if  not  pain. 

These  phenomena  are  attended  with  a  slight  flow  of  milk  from  the  breasts, 
even  if  the  baby  does  not  nurse.  At  each  nursing  the  milk  comes  'wdth  greater 
force,  but  after  twenty-four  hours  the  process  is  not  so  active,  though  there  may 
still  be  too  much  milk  for  a  week,  the  binder  being  always  more  or  less  wet  with  it. 
Lesser  degrees  of  activity  of  the  breasts  are  common,  even  agalactia,  al^sence  of 
lactation,  being  observed.  Even  though  the  breasts  show  tumor,  dolor,  calor,  and 
rubor,  the  phenomenon  has  nothing  to  do  with  inflammation;  the  patient  has  no 
temperature,  or,  at  most,  one-half  degree  F.  There  is  nothing  that  could  be  called 
"milk  fever." 

In  multiparse  the  secretion  begins  earlier,  sometimes  even  in  the  twelve  hours 
after  labor,  and  the  breasts  do  not  take  on  such  sudden  action,  but  lactation  begins 
more  gTadually,  and  seldom  do  the  breasts  swell  so  that  the  sldn  is  stretched  over 
them  tightly,  as  in  primiparie. 

The  enlargement  of  the  breasts  is  not  due  wholly  to  milk.  Only  a  small  part 
of  the  milk  is  formed  before  the  nursing,  most  being  made  while  the  child  is  suckling. 
The  distention  of  the  breasts  is  due  to  swelling  of  the  gland-cells  and  lymphatic 
engorgement — both  preparatory  to  the  formation  of  milk.  As  soon  as  the  child 
begins  to  nurse  the  gland-cells  break  down  into  fat-globules,  the  cells  produce  the 
milk  plasma  from  the  Ijonph  in  the  distended  hnnphatics,  and  active  secretion  is 
established  in  a  manner  somewhat  analogous  to  the  action  of  the  parotid  gland. 
Completely  established,  the  milk  secretion  becomes  regular.  The  breasts  fill  up 
and  are  emptied  in  sequence,  which  is  dependent  largely  upon  training.  If  the 
child  is  put  to  the  breast  to  nurse  at  regular  intervals,  the  organ  quickly  accom- 


214  THE    PHYSIOLOGY   OF   THE   PUERPEEIUM 

modates  itself  to  the  hours,  and  one  notices  that,  when  the  usual  sequence  is  in- 
terrupted, the  breast  will  begin  to  functionate  at  the  proper  time. 

The  first  milk  that  comes  resembles  the  secretion  that  may  be  pressed  out  of  the 
nipple  in  the  latter  part  of  pregnancy;  it  is  clear  or  only  slightly  cloudy,  sticky,  con- 
tains yellow  streaks,  and  is  called  "colostrum." 

The  colostrum  under  the  microscope  is  seen  to  be  made  up  of  fat-globules,  a 
water}'^  fluid,  and  the  so-called  colostrum  corpuscles  (Fig.  255).  The  fat-globules 
are  often  adherent  by  a  thin  substance  which  is  visible  after  staining  with  certain 
reagents.  The  colostrum  corpuscles  are  round,  ovoid,  or  stellate  cells  which  some- 
times show  ameboid  movement  and  have  one  to  three  nuclei,  which  color  with 
ammonia  carmin.  They  contain  numerous  fine  fat-globules.  Where  they  come 
from  has  been  disputed — they  are  believed  to  be  changed  gland  epithelium  or  leu- 
kocytes, mast  cells  which  have  gathered  up  fat-globules.  They  remain  four  to  six 
days,  and  reappear  if  there  is  stasis  or  inflammation.  In  addition,  lymphocytes  are 
found,  more  or  less  full  of  fat  drops;  indeed,  they  may  be  balled  together  so  that 
they  can  hardly  be  recognized  as  white  blood-cells.  Colostrum  contains  very  little 
if  any  casein,  but  nearly  15  per  cent,  lactalbumin  and  lactoglobulin,  with  much  fat. 
It,  therefore,  has  a  slightly  cathartic  action  on  the  new-born  babe.  One  sometimes 
finds  colostrum  in  the  breasts  during  menstruation,  sexual  excitement,  always 
during  pregnancy,  early  lactation,  and  during  the  weaning  process.  The  colostrum 
at  this  time  helps  the  resorption  of  the  milk. 

Human  milk  is  an  opaque,  slightly  yellowish  or  bluish-white  liquid,  with  a 
characteristic  odor  and  sweetish  taste.  Specific  gravity  varies  from  1026  to  1036; 
it  is  neutral  or  alkaline;  its  freezing-point  is  A=  —0.49  to  —0.63.  Microscopic- 
ally, one  sees  innumerable  fine  fat-droplets,  alike  in  size  if  the  milk  is  of  good 
quality,  and  occasionally  a  glandular  epithelial  cell  or  a  leukocyte. 

It  is  still  unsettled  whether  there  is  a  membrane  of  casein  around  the  fat-glob- 
ules or  not.  The  globules  float  in  a  thin,  almost  transparent,  serum  which  con- 
tains albumin.     Sometimes  bacteria  are  present. 

The  composition  of  human  milk  varies  from  day  to  day  and  from  hour  to  hour. 
It  contains  873^  per  cent,  water,  123^2  per  cent,  solids,  of  which  6.21  per  cent,  is 
milk-sugar,  3.78  per  cent,  fat,  2.29  per  cent,  proteicls  (lactoglobulin,  1.26  per  cent., 
and  casein,  1.03  per  cent.),  and  0.71  per  cent,  salts  (Konig).  Of  these  constituents, 
the  fat  is  subject  to  the  greatest  variations,  the  proteids  less,  while  most  constant 
are  the  sugar  and  salts.  In  round  figures,  milk  has  88  per  cent,  water,  2  per  cent, 
proteids,  4  per  cent,  fat,  and  6  per  cent,  sugar.  The  fat  of  the  milk  comes  from  the 
epithelium  lining  the  acini  and  alveoli.  When  the  proper  stimulus  reaches  these 
cells,  which  are  low,  cuboid,  with  one  nucleus,  they  enlarge,  the  nucleus  divides 
in  a  vertical  direction,  the  cell  becomes  colmnnar,  the  protoplasm  shows  fat-glob- 
ules, especially  near  the  lumen  of  the  acinus,  and  finally  the  cell  membrane  breaks, 
setting  free  the  formed  fat.  After  this  process  is  repeated  several  times  the  cell 
itself  is  cast  off,  its  place  being  taken  by  others  made  by  lateral  proliferation  (Figs. 
257  and  258).  It  is  possible,  but  not  proved,  that  the  epithelia  can  select  fat  out  of 
the  circulating  blood,  or  make  it  from  the  carbohydrates  ever  present  in  the  gland. 
The  casein,  since  it  does  not  exist  in  the  blood,  must  be  made  in  the  gland  itself,  as 
also  must  lie  milk-sugar  or  la(;tose.  Bottazzi  found  a  phosphoglycoproteid  in  the 
breast,  and  believes  that  through  the  splitting  of  this,  casein  and  lactose  result.  If 
there  is  stasis  of  milk  in  the  breasts,  lactose  appears  in  the  urine. 

The  fluid  parts  of  the  blood  do  not  reach  the  milk  by  filtration  or  exudation,  but 
are  secreted  from  the  blood  by  special  action  of  the  glandular  epithelium.  One 
must  accord  the  epithelium,  then,  the  most  important  function  of  making  the  milk. 

Enzymes,  or  living  ferments,  are  found  in  the  milk  and  give  it  vital  sustaining 
qualities,  which  are  not  to  be  discovered  or  imitated  by  the  finest  chemistry. 
Breast  milk  is  a  living  secretion,  and  contains  all  the  food  requirements  for  the  in- 


I.ciikor'vte 


Colostnim 
corpusclf! 

Epithelial 
cell 


Fig.  255. — Colostrum. 


Fig.  2."r,. — Milk. 


LOCAL   CHANGES 


215 


fant,  ready  for  immodiate  absorption,  and  also  tho  antibodies  to  infection.  Joch- 
man  found  a  proteolj-tic  ferment  in  the  colostrum.  It  is  a  clinically  demonstrated 
fact  that  breast-fed  children  resist  infection  of  all  kinds  infinitely  better  than  those 


^f 


91. 


^^. 


•  •4 


..; ' 


',—7      w 


^%M 


^9  **-. 


,.#» 


'\^ 


,«* 


^-^ 


f 


Fig.  257. — Fonctionating  Human  Breast. 


Fig.  25S.— M.VM.MARY  Gl.\.nd— L.a.ct.vting.     Stained  with  Osmic  Acid   (specimen  loaned  by  Dr.  Gideon  Wells). 

fed  artificially.  The  author  has  seen  such  children,  brought  to  the  hospital  in 
collapse,  revive  after  a  few  breast-feedings  as  if  a  strong  cordial  had  been  admin- 
istered.    Wassermann  has  proved  that  the  blood-serum  of  breast-fed  children  has 


216  THE    PHYSIOLOGY    OF   THE    PUERPERIUM 

stronger  bactericidal  power  than  that  of  those  fed  from  the  bottle.     The  quantity 
and  quality  of  the  milk  vsiry: 

First,  with  the  individual — nervous  women  are  not  as  good  wet-nurses  as  the 
phlegmatic. 

Second,  vrith  the  race — Japanese,  Jews,  Swedes,  Turks,  gypsies,  and  negresses 
usually  have  abundant  milk. 

Third,  ^^ith  development  of  the  body — a  small,  thin  woman  usually  gives 
more  milk  than  a  large,  muscular,  or  fat  woman;  the  same  rule  holchng  good  with 
cows.  Nor  does  the  size  of  the  gland  have  much  effect.  The  gland-lobes  may  be 
less  in  amount  than  the  fat  of  the  organ,  though  usually  a  well-developed  breast 
and  nipple  presage  a  good  milk  supply. 

Fourth,  nutrition  of  the  patient,  to  a  certain  degree — a  woman  in  good 
health  is  more  likely  to  give  sufficient  milk  than  a  sickly  mother,  but,  occasionally, 
one  sees  a  tuberculous  mother  with  a  fat,  healthy  baby. 

Fifth,  age  of  the  patient.  This  has  very  little  influence,  though,  before  the 
age  of  eighteen  and  after  forty,  the  milk  is  likely  to  suffer  both  in  quality  and 
in  quantity. 

Sb^th,  toward  the  end  of  lactation  the  milk  gets  poor  in  quality  and  less  in 
quantity,  though  there  are  exceptions. 

Seventh,  the  milk  of  the  two  breasts  varies  in  quantity  and  quality,  and  from 
clay  to  day,  and  at  different  times  of  the  day,  and  during  a  single  nursing.  The 
proteids,  fat,  and  sugar  increase  in  amount  with  the  emptying  of  the  breasts. 

Eighth,  hunger  decreases  the  amount  of  the  milk;  fat,  casein,  and  sugar 
decrease,  while  the  amount  of  albumin  increases.  These  facts  were  found  by 
Decaisne  during  the  siege  of  Paris. 

Ninth,  emotions  may  alter  quantity  and  quahty — it  is  said  that  extreme 
emotional  shock  may  so  alter  the  milk  that  it  will  give  the  child  colic,  diarrhea,  or 
even  convulsions;  that  nervous  shock  may  produce  agalactia  is  well  known. 

Tenth,  menstruation  has  a  distinct  effect  on  the  nursing  child — it  may  have 
colic,  or  cry  agreatdeal,  and  may  pass  green  stools,  vomit,  or  have  diarrhea;  though, 
chemically,  one  can  find  no  alteration  in  the  milk.  The  changes  last  only  a  short 
time. 

Eleventh,  pregnancy — the  milk  gradually  dries  up,  after  becoming  more 
watery.  Very  often  the  nursing  mother  observes  a  change  in  the  nutrition  of  the 
infant  and  ascribes  the  same  to  the  advent  of  a  new  pregnancy. 

Twelfth,  drugs  often  reappear  in  the  milk.  This  has  been  known  isince 
Hippocrates,  in  connection  with  cathartics.  One  may,  in  order  to  purge  the  infant, 
give  the  mother  the  cathartic.  Alcohol  is  said  also  to  pass  over,  and  cases  are  cited 
where  the  baby  got  drunk.  Opium  has  caused  narcosis  of  forty-three  hours  in  the 
baby.  Iron,  arsenic,  iodin,  lead,  and  mercury  are  well  known  to  pass  over.  Sal- 
varsan  may  thus  he  used  for  the  treatment  of  mother  and  babe. 

Briegerhas  shown  that  immunizing  doses  of  tetanus  antitoxin  pass  over  to  the 
infant.  The  writer  allowed  a  woman  with  diphtheria,  who  had  large  doses  of  anti- 
toxin, to  nurse  her  infant.  The  child  did  not  take  diphtheria,  though  Hofbauer 
claims  that  the  diphtheria  antitoxin  is  not  transmitted  to  the  child.  Vaccinia  is  not 
believed  to  pass  over.  The  only  drug  which  has  any  effect  on  the  amount  of  the 
milk  secreted  is  iodid  of  potash.     It  limits  the  output. 

Thirteenth,  disease  has  an  important  effect  on  the  milk.  Diarrheas  cause  a 
diminution;  in  cholera,  sometimes  complete  absence.  In  sepsis  the  milk  some- 
times dries  up,  which  is  a  bad  omen.  Bacteria  can  pass  into  the  milk  in  disease 
(Kehrer) .  Tuberculosis,  anthrax,  may  pass  over  without  any  ck^monstral^le  change 
in  the  gland.     In  mastitis  the  milk  may  contain  cocci  and  pus. 

Fourteenth,  irritation  of  the  nipples  causes  an  increase  of  the  secretion.  This 
is  demonstrated  clinically  in  many  ways — e.  g.,  by  placing  the  baby  to  the  breast 


LOCAL   CHANGES  217 

early,  the  milk  comes  earlier,  and  by  usinj;-  the  breast-pump  too  much  to  "relieve" 
the  l)reasts,  more  milk  is  produced.  It  is  i)ossiljle  to  start  lactation  in  a  non- 
puerperal woman,  even  in  young  girls,  by  properly  stinmlating  the  breasts.  Mas- 
sage of  the  breasts  and  cokl  l)aths  increase  the  milk  supply. 

Fifteenth,  certain  foods  are  saltl  to  increase  the  secretion,  as  tomatoes, 
oysters,  and  gruels.  My  experience  with  them  is  negative.  Licjuids  increase  the 
amount  of  milk,  and  a  rich  supply  of  proteids  in  the  diet  seems  to  augment  the  fat 
content.  Overfeeding,  however,  in  the  author's  experience,  only  occasionally 
improves  the  nursing,  and  then,  temporarily.  Later,  the  mother  puts  on  fat  and 
the  breasts  dry  up.  If  there  is  no  gland  tissue  in  the  breast,  no  amount  of  stimula- 
tion will  cause  it  to  secrete. 

Certain  foods  are  said  to  alter  th(^  milk  to  the  disturbance  of  the  child — e.  g., 
strawberries,  tomatoes,  beans,  and  acid  fruits.  It  does  seem  that  idiosyncracies, 
possessed  l)y  the  mother,  also  become  evident  in  her  offspring. 

Sixteenth,  multiparse  usually  have  more  milk  than  primiparse,  and  women, 
after  normal  labor,  are  less  likely  to  have  disturbed  lactation  than  those  who  have 
had  difficult,  operative  deliveries,  especially  if  attended  with  great  loss  of  l)lood. 

Seventeenth,  the  amount  of  milk  varies  Avith  the  demand.  Ordinarily  the 
breasts  give  600  to  800  gm.  per  day,  depending  on  the  needs  of  the  nurshng,  but 
Budin  has  recorded  cases  where  a  wet-nurse  produced  2500  to  2800  gm.  of  milk 
per  day,  for  a  long  period,  wdthout  injury. 

If  the  nursing  is  interrupted  from  any  cause,  it  may  be  resumed,  providing  the 
interval  is  not  too  long.  The  author  has  seen  the  secretion  of  milk  return  after  an 
absence  of  five  weeks,  and  cases  are  recorded  of  its  return  after  months. 

Lactation  has  a  not  unimportant  bearing  on  the  general  condition  of  the  woman. 
A  certain  amount  of  blood  and  fat  must  be  eliminated  after  pregnancy.  Part  of 
these  go  in  the  lochia,  part  in  the  excreta,  and  part  in  the  milk.  If  the  last  is  not 
excreted,  the  other  organs  must  remove  the  excess  and,  according  to  Kelirer,  con- 
gestion of  the  genitalia  is  likely  to  occur.  It  is  a  fact  that,  when  the  patient  does 
not  nurse,  the  lochia  are  increased,  and  the  involution  of  the  uterus  is  delaj'ed,  but 
this  is  generally  explained  by  the  absence  of  the  reflex  irritation  which  nursing 
causes  on  the  uterus.  The  act  of  nursing  causes  uterine  contractions  in  the  earlj^ 
puerperium,  which  are  a  prominent  symptom,  as  "after-pains, "  and  these  favor  the 
rapid  involution  of  the  uterus.  Positive  observations  are  not  on  record,  but,  in 
general,  it  may  be  said  that  a  woman  recovers  better  from  her  labor  if  she  nurses 
her  offspring.  Lehman  finds  slight  statistical  indications  that  the  neglect  of  lacta- 
tion favors  the  development  of  carcinoma  of  the  breast. 

Literature 

Budin:  Le  Nourisson,  Paris,  1901. — Duncan,  M.:  Researches  in  Obstetrics. — Fehling:  Die  Physiologie  und  Path,  des 
Wochenbettes,  2ded.,  1897. — Jochman:  .Arch.  f.  Gyn.,vol.  Ixxxix,  Bd.  3. — Knapp:  Winckel's  Handb.  der  Geb., 
vol.  ii,  1. — Lehman:  Inaug.  Diss.,  Munich,  1903. — Scheib:  Zeits.  f.  Heilk.  vol.  xxs'ii,  H.  23. — Stollz:  Die  Bak- 
teriologie  des  Genital-Kanales  in  der  Schwangerschaft  und  in  Wochenbett,  Graz.,  1903. — Temesvary:  Arch  f. 
Gyn.,  vol.  xxxiii. — Wassermann:  Deutsche  med.  Woch.,  1903,  No.  1. — Williams:  American  Journal  of  Obstetrics, 
1898,  vol.  xxxviii,  p.  449. — Wormser:  Arch.  f.  Gyn.,  vol.  Ixix,  H.  3. — Zangemeister:  Arch.  f.  Gj"n.,  1907. 


CHAPTER  XV 
GENERAL  CHANGES  IN  THE  PUERPERIUM 

It  is  surprising  how  little  the  general  condition  of  the  woman  is  affected  by  such 
a  severe  storm  as  is  even  a  normal  labor.  In  the  absence  of  infection,  most 
women  feel  quite  well  during  the  puerperal  period.  The  soreness  of  the  genitalia, 
due  to  the  \'idvar  wounds,  disappears  in  a  few  days,  the  soreness  of  the  muscles 
likewise,  and,  even  after  a  few  hours,  the  patient  feels  rested  from  the  severe  exer- 
cise of  delivery.  Women  unused  to  exertion  recover  less  quickly  from  the  strain. 
After  a  difficult  operative  delivery,  however,  and  after  a  severe  hemorrhage,  we 
find  the  symptoms  that  would  naturally  go  with  such  conditions,  and  the  occurrence 
of  surgical  shock  must  also  be  mentioned.  A  multipara  is  likely  to  be  annoyed  by 
after-pains.  These  are  painful  uterine  contractions  which  recur  more  or  less  regu- 
larly for  one,  two,  three,  or  even  six  days.  The  contractions  occur  especially  when 
the  child  nurses,  a  reflex  going  to  the  uterus  from  the  breasts,  or  when  the  uterus  is 
massaged,  but  especially  when  pieces  of  membrane,  of  placenta,  or  blood-clots  have 
been  left  in  the  uterus.  Women  who  have  had  endometritis,  metritis,  frequent 
abortion,  rapidly  successive  labors,  overdistention  of  the  uterus  by  twins,  poly- 
hydramnion,  or  very  quick  labors,  are  likely  to  suffer  more  with  after-pains. 
Primiparae,  because  the  uterus  remains  in  a  state  of  good  tonus,  are  less  likely  to 
suffer  with  them.  If  these  painful  contractions  reappear  after  they  have  once 
ceased,  it  is  indicative  of  something  wrong  in  the  uterus — either  infection  or 
retained  secunchnes,  a  fibroid,  etc. 

The  Nervous  System, — Puerperse  are  more  sensitive  to  irritations,  a  fact  which 
was  known  to  the  Romans,  and  they  placed  a  sign  before  her  door,  so  that  she  was 
not  disturbed — even  by  the  tax  collector.  The  reflex  excitability  is  increased. 
Recent  investigations  of  the  knee-jerk  show  that  in  pregnancy  this  reflex  is  more 
active  than  usual,  that  it  is  most  active  in  labor  at  the  height  of  a  pain,  while 
during  the  puerperium  the  excitability  gradually  passes  away.  Puerperse  hear 
more  acutely  and  are  more  sensitive  to  light  and  odors.  Though  many  writers,  and 
most  nurses,  believe  that  a  nervous  shock  can  cause  fever,  the  author  has  never 
observed  an  unequivocal  case  where  such  a  severe  emotional  storm  has  raised  the 
patient's  temperature.     (See  chapter  on  Puerperal  Infection.) 

The  Temperature. — Variations  in  the  temperature  of  puerperal  women  form  a 
most  important  index  of  her  health,  and,  together  with  the  pulse,  give  us  reliable 
information.  Although  attended  by  severe  muscular  exertion,  labor  does  not,  as  a 
rule,  raise  the  temperature  more  than  one-half  degree.  If  the  labor  terminates  in 
the  afternoon,  the  usual  rise,  at  this  time,  may  be  exaggerated;  but  in  normal  cases, 
a  parturient's  temperature  should  not  go  above  100.2°  F.  Even  this  makes  one 
suspicious  of  infection.  The  so-called  "physiologic  chill"  is,  in  the  author's 
opinion,  the  result  of  the  flooding  of  the  system  with  toxins  or  bacteria  from  the 
puerperal  wounds,  or  possibly  alien  proteids,  as  was  told  on  p.  127.  The  temper- 
ature may  rise  one-half  degree  after  labor,  but  falls  to  the  normal  within  twelve 
hours,  and  then  shows  the  physiologic  diurnal  variations,  but  these  do  not  exceed 
1°  F.  Many  authorities  admit  that  a  puerperal  woman  may  normally  have  fever. 
Fehling  considers  every  rise  above  101.1°  F.  pathologic;  Winckel  places  the  limit 
at  100.7°  F.;  Boxall,  of  London,  at  100°  F.;  Williams  at  100.4°  F.  It  is,  to  a  great 
extent,  arbitrary.     My  own  experience  is  that,  if  the  temperature  rises  above 

218 


GENERAL  CHANGES  IN  THE  PUERPERIUM  219 

99.0°  F.,  there  is  almost  always  some  cause  for  it^iisiiaiiy,  a  inild  infection.  This, 
then, — 99.0°  F., — is  given  as  the  limit  for  a  j)ueri)erium  which  may  be  called  nor- 
mal, but  it  is  not  meant  that  a  woman  showing  a  slighlly  higher  fever  nmst  be 
very  ill  or  in  danger.  In  such  cases  one  is  warned  to  more  careful  asepsis  in  the 
daily  technic  of  delivery  and  a  jjainslaking  study  into  the  cause  of  the  elevation 
in  each  individual  case. 

Primiparu^  show  higher  temperatures  and  greater  fluctuations  than  multi- 
parae,  because  in  them  there  are  more  wounds  and  greater  possibilities  for  the  ab- 
sorption of  toxins.  After  hard  operative  deliveries,  after  many  internal  examina- 
tions, the  temperature  is  often  higher  and  more  labile. 

There  i.s  no  sueh  thing  as  "milk  fever"!  Formei-ly,  in  the  non-antiseptic  era, 
almost  every  pueri)era  had  fever  on  the  third  day.  Since  at  this  time  the  breasts 
become  large  and  hard,  the  fever  was  ascribed  to  the  violent  coming  of  the  milk, 
and  the  real  cause,  the  infection  of  the  genitalia,  was  overlooked.  With  the  advent 
of  antisepsis  there  has  been  a  great  decrease  in  this  so-called  "milk  fever, "  and  large 
numbers  of  the  best  authorities  deny  its  existence.  Jaggard  said  he  had  never 
seen  a  case  where  there  was  fever  and  no  other  cause  to  be  found  than  simply  the 
coming  of  the  milk.  I  have  seen  primiparse  with  the  breasts  standing  out  hard  and 
firm,  the  axillary  lobe  of  the  gland  so  swollen  that  the  patient  had  to  keep  the  arms 
from  the  sides,  and  yet  the  temperature  was  98.6°  F.  Infection  of  the  breasts  is 
another  thing.  "Milk  fever"  is  a  misnomer  that  should  be  abolished  from  ob- 
stetrics. It  too  often  forms  the  cover  for  severe  puerperal  infections,  and  many 
w^omen  have  lost  their  lives  because  of  neglect  of  the  real  disease. 

The  reason  usually  given  that  the  puerperal  w^oman  should  have  some  fever  is 
this:  The  products  of  the  regressive  metamorphosis  of  the  uterus  and  all  the  geni- 
talia being  absorbed,  must  be  oxidized.  This  increased  oxidation  causes  the  in- 
crease in  the  body  heat.  But  nature,  by  increasing  the  perspiration  and  other 
excretions,  keeps  the  temperature  nearly  normal.  The  slight  rise  of  temperature 
right  after  delivery  is  probably  a  mild  infection.  The  older  -^Titers  called  it  fibrin 
ferment  fever. 

The  temperature  of  the  puerperal  woman  is  subject  to  fluctuations  on  slighter 
causes  as  compared  with  the  non-puerperal  woman. 

Constipation  is  said  to  give  rise  to  temperature,  which  goes  do'v\'n  when  the 
bow'els  are  emptied.  This  fever  is  probably  due  to  obstruction  to  the  flow  of  lochia, 
which  is  overcome  wdien  the  rectum  is  emptied,  but  may  be  due  to  al^sorption  from 
the  intestine.  It  is  safest,  as  soon  as  your  puerperse  have  fever,  to  think  of  infection 
first.  A  full  bladder  may  act  similarly,  but  it  is  wdse  to  bear  in  mind  the  frequency 
of  ureteropyelitis  in  puerperio.  While  fever  may  arise  from  the  bowels,  as  from 
enteritis,  I  have  never  been  fully  convinced  that  constipation  itself  will  cause  it. 

The  Pulse. — In  the  second  stage  of  labor  the  pulse  is  strong,  rapid,  perhaps 
irregular ;  but  during  the  third  stage  it  calms  down  and  is  normal  throughout  this 
time,  unless  there  is  a  severe  hemorrhage,  w^hen  it  becomes  small  and  fast.  Im- 
mediately after  lal)or  the  pulse  is  soft ;  soon  it  has  a  high  tension,  especially  in  mul- 
tiparee,  but  the  blood-pressure  then  sinks  slowly  to  below  normal  or  about  normal. 

A  very  high  tension  slow"  pulse  must  be  regarded  as  a  warning  of  eclampsia. 
In  general,  the  pulse  during  the  puerperium  runs  from  68  to  80,  which  is  about 
normal,  though  higher  rates  are  sometimes  found,  even  in  healthy  women. 

A  peculiar  phenomenon  is  sometimes  oliscrved  in  healthy  puerpera?.  The  pulse- 
rate  may  be  as  low  as  40  a  minute,  and  some  observers  have  found  30,  but 
this  is  very  rare.  It  occurs  after  labors  at  term  more  than  after  early  abortions; 
in  multiparce  more  often  than  in  primiparse;  in  phlegmatic  women  oftener  than  the 
neurotic;  in  lean  oftener  than  fat  women.  The  author  has  found  a  pulse  of  below 
60  in  only  10  per  cent,  of  his  cases.  Other  authors  give  16.2  per  cent.  (Hemeys) 
and  63  per  cent.  (Olshausen).     The  cause  is  not  kno^^^l.     Lynch  gives  the  litera- 


220  THE    PHYSIOLOGY    OF   THE    PUERPERIUM 

ture.  There  are  many  theories,  of  which  the  most  plausible  are:  Fehling's — ^the 
sudden  diminution  of  the  intra-abdominal  tension  irritates  the  vagus  reflexly; 
Schroder's — the  heart,  which  hypertrophies  during  pregnancy,  now  need  not  work 
so  hard;  Olshausen's — the  fat,  which  is  absorbed  from  the  uterus,  slows  the  heart. 
Further,  the  horizontal  position,  the  quiet  of  the  patient,  the  less  amount  of  food, 
the  gTeat  excretion  of  liquid  in  milk,  lochia,  sweat,  etc.,  may  conduce  to  the  slow 
pulse.  It  is  of  great  prognostic  significance.  A  slow  pulse  indicates  that  every- 
thing is  going  along  nicely. 

A  very  rapid  pulse  in  the  puerperium,  in  the  absence  of  fever,  points  to  hem- 
orrhage, recovery  from  severe  hemorrhage,  or  some  heart  disease.  Not  seldom  a 
rapid  pulse  draws  attention  to  the  condition  of  the  heart,  but  one  must  be  careful 
in  the  diagnosis  of  heart  disease  during  pregnancy  and  the  puerperium,  because 
murmurs  are  common  (70  per  cent.),  and  a  displaced  heart  simulates  hypertrophy. 
The  pulse  is  more  labile  during  the  puerperium  than  the  temperature.  It  warns 
much  quicker  of  the  advent  of  sepsis  or  other  puerperal  complication,  but  is  less 
reliable.  It  fluctuates  with  the  after-pains  and  with  any  little  excitement — as 
visitors  and  nursing  the  baby.  The  usual  relation  between  temperature  and  pulse 
obtains  here  as  elsewhere. 

The  Blood. — There  is  a  decrease  in  the  amount  of  blood  (Sengel),  which  had 
increased  during  pregnancy,  an  evidence  of  the  loss  during  labor  and  especially  if 
delivery  was  accompanied  by  much  hemorrhage.  The  hemoglobin  is  dispropor- 
tionately reduced.  The  lochia,  sweat,  and  other  excreta  tend  to  impoverish  the 
blood  in  the  first  week,  so  that  in  the  first  days  after  labor  there  may  be  a  decrease 
of  both  reds  and  whites.  During  labor,  the  leukocyte  count  varies  from  9000  to 
34,000,  with  an  average  of  18,000,  the  increase  being  in  the  polynuclear  neutrophiles. 
The  eosinophiles  are  often  absent.  The  reds  vary  from  4,000,000  to  5,500,000. 
After  labor  the  leukocytosis  rapidly  disappears,  even  within  twenty-four  hours,  but 
usually  it  requires  several  days  for  the  count  to  come  down  to  the  normal  limits — 
7500  to  15,000,  which  is  somewhat  higher  than  in  the  non-puerperal  state.  The 
normal  proportion  of  the  various  whites  is: 

Neutrophiles 60  to  75  per  cent. 

Lymphocytes 25  per  cent, 

Eosinophiles 2  to    5  per  cent. 

These  proportions  vary  from  day  to  day.  About  the  fifth  day  one  occasionally 
observes  a  slight  eosinophilia,  which  is  more  marked  after  the  birth  of  twins,  of 
macerated  fetuses,  and  in  gonorrheal  cases.  Infection  alters  the  blood-picture. 
(See  p.  852.) 

The  respiration  is  not  much  altered  in  frequency,  but  responds  more  readily 
to  disturbances.  The  chest  being  free,  expands  more  easily  than  during  preg- 
nancy, the  type  of  breathing  being  costal  and  diaphragmatic.  The  vital  capacity 
is  increased  after  the  third  day.  On  percussion  one  finds  a  deeper  resonance.  The 
heart  dulncss  sinks  a  little. 

The  Skin. — All  the  functions  of  the  skin  are  more  active,  the  sweat-glands 
particularly.  After  labor,  when  the  patient  is  well  covered  up,  she  breaks  out  with 
a  full,  warm  sweat,  but  this  is  rarely  so  profuse  as  to  require  a  change  of  bed-linen. 
It  is  favored  by  the  warm  covers  and  the  administration  of  warm  drinks.  That 
there  is  a  sweating  peculiar  to  puerpcra  is  not  true,  but  the  perspiration  has  a 
peculiar  odor,  which  varies  in  health  and  disease.  During  the  lying-in  there  is  a 
tendency  to  perspiration,  especially  in  sleep,  but  it  is  less  in  the  latter  days,  probably 
because  of  the  establishment  of  the  milk  secretion  and  the  free  lochia. 

The  laity  have  great  fear  that  the  patient  takes  cold  at  this  time.  This  is  the 
outgrowth  of  the  old  belief  that  puerperal  fever  comes  from  catching  cold,  a  view 


Fig.  259. — Bladder  Three  Hours  After  Delivery. 
Note  edema  of  trigoiuim  and  hemorrhages. 


GENERAL  CHANGES  IN  THE  PUERPERIUM  221 

still  hold  arnonp;  the  iiiidwivcs,  and  in  llicir  jx-acticc  it  is  iiol  unusiud  to  find  the 
windows  closed  and  the  patient  covi'red  witli  iieavy  hluiikets,  even  in  surnnier. 

Alilt'eld  says  that  there  is  some  connection  between  the  ai)])earance  of  the  sweat 
and  the  contraction  and  retradion  of  the  uterus  after  labor. 

The  Kidneys  and  Urinary  Apparatus. — Relieved  suddenly  from  the  increased 
intra-ai)doniinal  ])ressure  Ijy  the  delivery  of  the  child,  the  kidneys  become  active. 
In  the  tiiird  staj^e  il  is  not  rare  to  find  the  l^ladder  full  and  even  overfilled,  making 
an  obstacle  to  the  delivery  of  the  placenta. 

In  the  first  twelve  hours  there  is  usually  retention  of  urine,  which  sometimes 
may  be  enormous  and  cause  ischuria  paradoxa.  This  is  due  to  the  lack  of  elasticity 
of  the  bladder,  inability  to  urinate  in  the  horizontal  position,  the  swelling  of  the 
vulva  and  urethra,  kinking  of  the  urethra  (Olshausen),  reflex  spasm  of  the  sphincter 
from  stitches  in  the  ptu-incum,  and  injury  to  the  bladder  trigonum  and  urethral 
orifice,  with  edema.  Still,  quite  a  few  puerperas  pass  urine  spontaneously.  In 
many  cases  it  is  ncn-essarj^  to  use  the  catheter.  As  a  rule,  patients  pass  urine  three 
times  daily,  much  less  often  than  in  the  later  months  of  ])regnancy. 

Cystoscopic  examination  of  the  bladder  after  labor  shows  the  effect  of  the  bruis- 
ing sustained  during  the  expulsion  of  the  child.  The  trigonum  and  urethral  orifice 
are  edematous  and  strewn  with  minute  blood  extravasations.  The  epithelium 
desquamates  and  lies  on  the  mucous  membrane  as  a  grajash  film.  After  prolonged 
deliveries  and  hartl  operations,  the  bladder-wall  is  much  crushed,  and  in  the  cysto- 
scope  we  see  the  above  effects  much  more  marked  (Fig.  259) .  The  ureteral  orifices 
are  not  easily  found,  but  the  ureters  are  very  easily  palpable,  l)eing  usually  somewhat 
enlarged.  The  laceration  of  the  urogenital  septum,  and  of  the  connective  tissue 
around  the  base  of  the  bladder,  allows  the  anterior  wall  of  the  vagina  to  prolapse, 
carrying  the  urethra  and  neck  of  the  bladder  with  it. 

The  urine  collected  just  after  delivery  frequently  contains  a  little  albumin, 
white  blood-corpuscles,  a  few  reds  and  scattered  hyaline  casts.  In  twelve  hours 
the  latter  disa]:)pear.  The  amount  of  urine  for  the  first  eight  daj'S  is  300  to  400 
c.c.  more  than  that  of  the  non-pregnant  woman,  but  is  not  much  more  than 
that  of  the  pregnant  woman  in  the  latter  months  (Kehrer). 

The  specific  gravity  varies  from  1010  to  1025,  according  to  the  amount  of 
urine.  The  urea  varies  from  2.6  per  cent,  to  1.6  per  cent.,  being  highest  on  the  third 
day,  the  excess  being  ascribableto  the  increased  metabolism  of  lactation — the  change 
of  the  albuminoids  into  fat.  It  is,  therefore,  less  in  women  who  do  not  nurse.  The 
proportion  of  salts,  phosphates,  and  sulphates  does  not  vary  much  from  the  normal 
— perhaps  the  salt  output  is  increased. 

Milk-sugar  occurs  in  80  per  cent,  of  puerperal  urines  (von  Xoorden).  It  is  de- 
rived from  the  breasts.  Blot  first  called  attention  to  this  physiologic  lactosuria.  It 
is  greatest  during  the  establishment  of  lactation,  absent  during  its  proper  functionat- 
ing, and  appears  again  during  the  weaning  process.  The  average  is  0.2  per  cent., 
but  this  may  be  increased  to  1  per  cent,  by  feeding  with  albuminoids  .and  carbohy- 
drates. 

Peptone  has  been  found  in  the  urine  by  Fischel  from  the  second  to  the  tenth 
day,  and  is  ascribed  to  the  absorption  of  products  of  albuminoid  degeneration 
going  on  in  the  uterus.  Albuminuria  occurs  in  40  per  cent,  of  the  cases  of  labor,  l)ut 
this  cUsapi)ears  before  the  third  day.  If  it  does  not,  or  if  alliumin  reappears,  its 
cause  must  be  sought  out.  Nephritis,  pyelitis,  ureteritis,  cystitis,  post- anesthetic 
effects,  eclampsia,  and  sepsis  must  be  considered.  To  avoid  confusion  from  the 
admixture  of  lochia,  only  catheterized  specimens  may  be  used. 

Lactic  acid,  acetone,  pepsin,  and  toxins  have  been  found  in  the  urine  of  puer- 
perse. 

The  Intestinal  Tract. — The  puerperse  are  very  thirsty  and  drink  much,  but 
the  appetite  usually  is  poor  for  the  first  three  daj'S.     Loss  of  fluids  during  labor,  and 


222  THE    PHYSIOLOGY    OF   THE    PUERPERIUM 

in  the  lochia,  urine,  and  sweat,  explains  the  thirst.  After  labor,  the  belly  is  flat, 
even  slightly  concave,  but  soon  a  moderate  tympany  appears.  In  thin  women  the 
uterine  tumor,  the  large  and  small  intestines,  with  their  peristalsis,  the  liver,  spleen, 
and  kidneys  are  verj^  easih^  palpable,  and  one  may  use  the  opportunity  for  investiga- 
tion of  these  organs. 

A  moderate  tympany  is  normal  in  the  puerperium ;  it  is  due  to  slight  intestinal 
paresis,  and  accompanies  the  usual  constipation.  Rarely  do  the  bowels  move  spon- 
taneously in  the  first  few  daj^s  of  the  puerperium.  The  causes  of  the  obstipation 
are:  The  bowels  usually  have  been  emptied  by  cathartics  before  labor;  the  woman 
eats  little,  and  the  excretion  of  fluids  is  so  rapid  that  the  intestinal  contents  dry 
up;  the  abdominal  and  perineal  muscles,  because  of  overstretching,  cannot  do  their 
work;  a  patient  usually  has  difficulty  in  defecating  while  lying  on  the  back;  and 
the  pain  in  the  parts  may  inhibit  the  action. 

Older  writers  believed  that  constipation  could  cause  puerperal  infection.  That 
constipation  alone  may  cause  fever  I  have  some  doubts,  but  in  these  cases  the  fever 
would  come  from  the  intestinal  canal,  not  from  the  genitalia.  A  brisk  purge  may  be 
followed  by  a  fall  of  temperature  in  a  case  of  real  puerperal  infection,  and  one  may 
be  misguided  into  ascribing  the  fever  to  the  intestines,  when,  in  reality,  the  purge 
simply  stirred  up  the  pelvic  circulation,  emptied  the  lower  bowel,  provided  good 
drainage  for  the  lochia,  and  perhaps  increased  the  local  and  general  leukocytosis  so 
that  the  infection  was  taken  care  of.  The  author  does  not  believe  that  constipa- 
tion or  errors  of  diet  (another  popular  fancy  and  fallacy)  can  cause  puerperal 
infection. 

The  weight  of  the  patient  undergoes  marked  changes  in  the  first  months 
after  labor..  According  to  Gassner,  the  average  weight  of  238  women,  on  the 
day  after  labor,  was  124  pounds.  In  the  first  two  weeks  they  lost  about  9 
pounds,  or  8  per  cent,  of  their  weight — Baumm,  6.58  per  cent.  The  loss  is  greater 
in  multiparse,  greater  in  large  women,  and  after  full  term  than  premature  labor, 
also  greater  after  twins.  This  loss  of  weight  is  due  to  the  moderate  amount  of 
food  taken  and  the  great  amount  of  excreta — the  sweat,  the  urine,  but  especially 
the  lochia  and  the  milk.  The  women  look  thin,  pale,  and  washed  out  after  getting 
up,  and  need  a  tonic  diet.  The  weight  is  regained  in  four  to  six  weeks,  many  women 
putting  on  excessive  fat.  Nowadays,  since  we  do  not  starve  the  women  so  much  in 
the  puerperium,  these  losses  are  not  so  marked,  but  the  custom  of  feeding  puer- 
peree  very  lightly  still  exists  in  many  places. 

Literature 

Carton:  Annales  de  Gynecologie,  1903,  vol.  ii,  p.  163. — Grdfenherrj:  Arch.  f.  Gyn.,  1908,  vol.  Ixxxv,  Heft  2. — Ha}il: 
Ibid.,  vol.  xlvii,  Heft  3. — Lynch:  "Bradycardia  in  Puerperio,"  Surg.,  Gyn.  and  Obstet.,  May,  1911.  Literature. 
— r.  Xoorf]eii:Viit\\.  des  StoffwechseLs,  1900. — Sengel:  "The  Blood  in  Pregnancy,  Parturition  and  Puerperium," 
X.  Y,  Med.  Jour.  1903,  vol.  Ixiii,  p.  od.—Wild:  Arch.  f.  Gyn.,    vol.  liii.  Heft  2,  p.  363. 


SECTION  iV 

THE  HYGIENE  AND  CONDUCT  OF  PREGNANCY  AND  LABOR 


CHAPTER  XVI 
THE  CHILD 

Few  women,  in  rearing  a  daughter,  consider  the  possibiUty  of  her  future  preg- 
nancy and  lal)or,  and  niak(^  the  attempt  to  prepare  her  for  their  successful  accom- 
phshment.  Many  women  beUeve  that  while  the  child  is  in  utero  it  can  be  influenced 
by  the  mental  occupation  of  the  mother;  thus,  for  example,  if  she  desires  a  musical 
child,  she  should  study  music  assiduously  during  pregnancy.  Then,  too,  most 
intelligent  mothers  try  to  live  a  hygienic  life  during  gestation  and  do  those  things 
which  seem  to  promise  normal  healthy  offspring.  Some  few  intelligent  parents 
try  to  arrange  the  most  auspicious  circumstances  at  the  time  of  procreation  of  their 
children,  but,  beyond  such  desultory  efforts,  very  little  attention  is  paid  to  the 
science  of  Eugenics.  Indeed,  to  be  well  born  one  must  go  back  man}-  generations, 
but  it  is  certainly  demanded  that  a  beginning  should  be  made  at  once,  to  provide  for 
posterity'.  Only  in  the  human  animal  are  the  laws  of  successful  procreation  defied. 
The  influences  of  heredity,  of  disease,  of  character,  of  environment,  are  all  set  at 
naught,  and  the  propagation  of  the  species  left  to  chance,  to  lust,  or  to  convenience. 

Incontestable  evidence  exists  to  prove  that  the  children  of  alcoholics  are  often 
weak,  puny,  imbecile,  or  epileptic.  Insanity,  the  tendency  to  drug  addictions, 
venereal  disease,  hemophilia,  nephritis,  and  other  affections,  or  a  predisposition  to 
the  same,  are  undoubtedly  transmitted,  and  their  effects  may  be  discovered  even  in 
the  third  generation.  As  far  as  the  obstetrician  is  concerned,  these  fa^ts  carry 
weight  as  matter  to  be  included  in  his  history -taking  in  individual  cases,  for  they 
will  shed  light  on  many  complications  occurring  in  the  course  of  pregnancy  and 
parturition,  and  indicate  what  measures  to  pursue  in  preventing  and  treating  such 
complications  (Ballantyne).  After  a  girl  is  born,  however,  much  may  be  done  to 
correct  an  evil  ancestry  and  to  prevent  diseases  which  would  affect  her  procreative 
ability.  A  well-developed  child  requires  at  least  thirty-six  weeks  of  uterogestation. 
Prematurely  born  girls  not  seldom  show  skeletal  and  genital  infantilism,  the  latter 
causing  dysmenorrhea  and  sterility  and  neuroses,  the  former,  contracted  pehns 
with  dystocia  (abnormal  labor).  Another  cause  of  infantilism,  not  generally 
recognized,  is  intestinal  disturbances,  especially  infection,  during  the  first  two  years 
of  life.  Atrophy  of  the  intestinal  glands  leads  to  permanent  hj-poplastic  changes  in 
the  whole  system.  Since  bottle-fed  children  are  most  likely  to  suffer  from  such 
infections,  the  obstetrician  will,  all  the  more,  seek  to  enforce  breast-feeding,  wdth  the 
future  of  the  baby  in  view. 

The  new-born  child  is  very  easily  infected,  and  vulvitis  and  vaginitis  not  seldom 
occur.  That  such  may  lead  to  subsequent  pelvic  disease  is  beyond  question. 
IVIastitis  in  the  new-born  girl  may  result  in  complete  destruction  of  the  mammary 
gland,  with  resulting  agalactia  in  the  puerperium.  Rachitis  in  very  early  life  is 
not  uncommon,  and  it  may  distort  the  pelvic  bones.  While  the  resulting  deformity 
only  in  severe  cases  produces  an  absolute  disproportion  between  the  child  and  the 

223 


224  THE  HYGIENE  AND  CONDUCT  OF  PREGNANCY 

pelvis,  milder  degrees  of  pelvic  distortion  cause  abnormalities  in  the  mechanism  of 
labor  which  not  seldom  cost  the  life  of  the  mother  or  the  babe,  and  often  leave 
serious  injury  to  both. 

The  acute  infectious  diseases — scarlatina,  diphtheria,  anterior  poliomyelitis, 
etc. — not  seldom  leave  permanent  traces  on  the  child,  as  nephritis,  hepatitis,  and, 
in  the  last  instance,  paralysis,  with  shortening  of  the  leg  and  consequent  distortion 
of  the  pelvis. 

These  few  examples  are  given  to  indicate  the  scope  of  prophylaxis  in  early  life, 
from  an  obstetric  point  of  view,  and  much  can  be  done  by  a  wise  hygiene  to  preserve 
the  growing  girl  from  the  evils  of  disease,  environment,  and  heredity. 

PUBERTY 

At  this  time,  when  mighty  changes  are  going  on  in  the  internal  and  external 
genitalia,  the  foundation  of  permanent  disease  may  be  laid.  It  is  beyond  question 
that  the  crowding  of  the  child's  mind  with  studies  and  accomplishments,  the  pre- 
mature social  duties,  together  with  inappropriate  reading  and  company,  and  a  lack 
of  outdoor  exercise  and  sports,  tend  to  develop  the  mind  at  the  expense  of  the  body, 
particularly  the  sexual  organs,  which  require  so  much  of  the  girl's  vitality  at  this 
period.  Dysmenorrhea,  hypoplasia  of  the  uterus,  later,  chlorosis,  are  some  of 
the  results  of  these  evils.  Early  womanhood  also  requires  proper  hygienic  conduct 
if  one  wishes  to  develop  a  healthy  nervous  system  and  a  normal  reproductive  func- 
tion. Of  transcendent  importance  is  the  proper  instruction  of  the  growing  girl  in 
the  principles  of  sex  and  reproduction.  Only  in  this  way  will  it  be  possible  to  save 
the  girl  from  ignorantly  performing  secret  practices,  e.  g.,  masturbation,  to  restrict 
the  spread  of  venereal  disease,  the  number  of  illegitimate  births  and  criminal  abor- 
tions. It  is  impossible  to  go  deeper  into  this  important  subject  here,  but  that  the 
obstetrician  is  concerned  in  this  matter  goes  without  saying,  and  by  wise  counsel, 
at  this  particular  time,  he  may  save  the  girl  from  permanent  invalidism,  even  from 
death  in  childbirth  (Surbled). 

MENSTRUATION 

Unfortunately,  most  women  cannot  take  sufficient  care  of  themselves  during 
this  monthly  illness,  but  many  who  could  do  so  are  very  careless  with  themselves. 
Examples  of  great  neglect  are  common.  Immoderate  dancing,  exposure  to  cold 
with  thin  clothes,  sexual  excitement,  hot  baths  taken  to  bring  on  the  period,  all 
cause  catarrhal  conditions  of  the  uterus,  which  predispose  to  abortion,  adherent 
placenta,  and  postpartum  hemorrhage. 

THE  HUSBAND 

The  part  played  by  the  husband  in  obstetric  complications  has  never  been 
properly  noticed.  If  he  is  unusually  large  and  heavy  boned,  he  may  procreate  chil- 
dren too  large  for  his  wife  to  bear.  Venereal  disease  communicated  to  the  wife  is  so 
common  that  obstetricians  reckon  with  it  all  the  time.  Under  this  heading  may  be 
mentioned  the  local  inflammations  of  the  female  urinary  tract,  cystitis,  ureteritis, 
pyelitis,  surgical  kidney;  vulvitis,  endometritis,  with  adherent  placenta,  postpartum 
hemorrhage,  subinvolution,  etc.;  pyosalpinx  with  gonorrheal  and  streptococcic 
(often  fatal)  peritonitis;  syphilitic  macerated  fetus,  with  maternal  hemophilic  ten- 
dencies ;  gonorrheal  ophthalmia  of  the  new-l:»orn,  and  other  fetal  disease.  These  need 
only  to  be  indicated  to  show  that  the  husband  is  directly  concerned  in  our  discussion. 

Too  frequent  intercourse  during  pregnancy  often  causes  abortion,  premature 
labor,  and  even  abruptio  placentae.  One  important  fact,  and  it  will  be  again  re- 
ferred to,  is  that  coitus  in  the  latter  weeks  of  pregnancy  may  cause  infection  of  the 
uterus,  which  shows  itself  during  and  after  delivery  as  a  sometimes  fatal  puerperal 

fever. 
s 


CHAPTER  XVII 
HYGIENE  OF  PREGNANCY 

Women  call  the  doctor  and  cnsaf^c  liiiu  for  their  confinement  earlier  now  than 
formerly,  earlier  among  the  better  classes  than  the  poorer,  earlier  In  the  city  than 
the  countr>',  cai'lier  in  the  United  States  than  in  most  other  lands.  Many  advan- 
tages arise  from  this,  in  that  it  ma}'  enable  the  doctor  to  learn  the  traits  or  constitu- 
tion of  his  patient,  watch  for  any  symptoms  of  disease,  and  prepare  her  properly  for 
the  labor.     It,  therefore,  should  be  encouraged  in  practice. 

Many  and  varied  questions  will  be  asked  of  the  accoucheur,  and  it  will  be  found 
convenient  to  supply  each  patient  with  a  folder  containing  instructions  for  her  to 
follow  and  other  common  information.  In  a  general  way  the  gravida  should  not 
change  her  usual  mode  of  life  unless  the  physician  knows  that  some  of  her  habits 
arc  bad. 

Dress. — The  dress  should  be  simple  and  warm.  Even  in  summer  woolen  under- 
clothing is  to  be  worn,  but  of  the  lightest  weight,  and  heavier  in  winter.  This 
rule  must  be  specially  enforced  in  cases  of  nephritis.  All  the  clothes  should  hang 
from  the  shoulders  by  suspenders  or  corset-waist,  and  heavy  skirts  not  worn ;  better, 
warm  drawers,  closed,  to  prevent  infection  from  street  dust. 

Low-heeled  shoes  ^vith  broad  toes  are  best.  The  pregnant  woman  throws  her 
head  and  shoulders  back,  in  order  to  keep  her  balance.  This  makes  an  angle  in  the 
small  of  the  back  (see  Fig.  133,  p.  109)  and  gives  the  patient  a  pecuhar  gait,  which 
did  not  escape  the  eye  of  Shakespeare,  who  called  it  the  "pride  of  pregnancj'-. " 
Elevation  of  the  heels  tlirows  the  body  still  more  forward;  the  woman  must  throw 
head  and  shoulders  further  back,  which  causes  pain  in  the  loins  and  stretching  of  the 
abdomen. 

There  should  be  no  circular  constriction  at  any  part  of  the  body,  which  mean>s 
that  corsets,  tight  waistbands,  round  garters,  may  not  be  worn.  The  Latin  term 
for  the  condition  of  pregnancy  was  "incincta, "  without  a  girdle,  and  had  refer- 
ence to  the  custom  of  laying  off  the  girdle  as  soon  as  pregnancy  was  determined. 
In  multiparas  with  a  tendency  to  pendulous  abdomen,  and  in  most  primiparte 
toward  the  end  of  pregnancy,  a  light-weight,  woven  abdominal  supporter  will  be 
found  very  comfortable.  Most  women  prefer  one  of  the  maternity  waists  on  the 
market.  The  Patterson  supporter  and  the  Kabo  INIaternity  Corset  are  the  best 
types.  The  corset  is  particularly  injurious  during  pregnancy,  because  it  forces  the 
uterus  and  child  down  into  the  pelvis  and  against  the  lower  abdominal  wall,  causing 
congestion  of  the  pelvic  veins  and  weakness  of  the  abdominal  muscles.  Too  tight 
corsets  also,  l^y  restraining  the  expansion  of  the  uterus,  cause  deformities  of  the 
child;  for  example,  clul>foot,  wTy-neck.  Women  who  wish  to  conceal  pregnancy 
by  tight  lacing  may  do  themselves  or  the  fetus  even  fatal  damage. 

Diet. — Simple,  not  strict,  rules  govern  the  diet.  The  amount  of  meat  and 
broths  should  be  small — not  more  than  four  ounces  of  meat  or  its  equivalent  in  fish 
or  eggs  per  day.  Starches  fried  in  fat  and  rich  pastry  should  be  avoided.  Cereals, 
vegetables,  and  fruits  should  l3e  eaten,  especially  fruit,  to  loosen  the  bowels.  Water 
is  taken  freely,  at  least  five  full  glasses  daily — sterilized  or  filtered.  ]Milk  and, 
especially,  buttermilk  are  commended.  Alcohol  is  to  be  forbidden,  first,  because 
of  the  danger,  exaggerated  during  pregnancy,  of  contracting  the  liquor  habit;  sec- 
ond, because  of  its  demonstrable  bad  effect  on  the  offspring,  a  fact  which  was  known 
15  225 


226  THE    HYGIENE    AND    CONDUCT    OF   PREGNANCY 

in  Biblical  times.  Samson's  mother  abstained  from  wine  during  her  pregnancy. 
A  child  begotten  by  a  drunken  father  may  be  dull,  stupid,  or  diseased,  an  obser- 
vation made  by  Diogenes. 

Fat  women  may  restrict  the  liquids,  but  never  so  much  that  the  daily  amount 
of  urine  is  reduced  below  32  ounces,  and  a  moderate  general  decrease  of  the  diet 
is  permissible  for  them. 

Coffee  in  moderate  amounts  is  not  forbidden.  Some  popular  books  advise  a 
special  diet  to  reduce  the  bone  salts  of  the  fetus — a  pernicious  recommendation, 
because  the  mother's  health  vnW  suffer  before  the  infant  is  affected,  and  in  all 
probability  fetal  rickets  would  result  if  an  effect  were  possible. 

In  general,  a  woman's  ordinary  habits  need  be  little  disturbed.  She  should  not 
overeat,  thinldng  she  must  feed  two.  Special  rules  govern  the  diet  in  women  who 
have  contracted  pelves  (Prochownik's  diet),  renal  disease,  or  diabetes. 

The  Bowels. — Constipation  is  the  rule  during  pregnancy,  and,  if  neglected,  may 
lead  to  most  serious  consequences.  A  long-standing  habit  cannot  be  cured  at  this 
time,  wherefore  drugs  must,  usually,  be  resorted  to.  The  following  is  the  treatment 
pursued  by  the  author : 

First,  the  patient  should  make  it  an  unfailing  habit  to  go  to  stool  at  a  certain 
hour  each  day.  The  best  time  is  shortly  after  breakfast.  Should  no  movement 
occur — and  straining  is  not  permitted — the  action  of  the  rectum  may  be  provoked  by 
a  glycerin  suppository  or  an  enema.  A  desire  to  go  to  stool  at  any  time  must  not 
be  resisted.  A  sufficient  amount  of  exercise  must  be  taken.  Abdominal  massage 
is  not  permissible  during  gestation. 

Second,  every  morning  just  after  rising  and  every  evening  just  before  re- 
tiring the  patient  should  drink  a  glass  of  cool  water  and  eat  some  fruit — an  apple  or 
an  orange.     Between  meals  water  is  to  be  drunk  freely. 

Third,  her  diet  should  contain  fruit  and  vegetables  in  abundance,  especially 
spinach,  peas,  beans,  barley,  tomatoes,  corn,  and  foods  of  this  kind.  They  give 
something  for  the  bowels  to  act  on,  but  one  cannot  use  so  much  of  them  as  in  the 
non-pregnant  state.  Tea  is  forbidden,  but  coffee  in  moderate  amount  allowed. 
Prunes,  figs,  and  dates  are  to  be  eaten,  with  care  to  chew  them  very  fine,  as  they  may 
cause  inchgestion.  A  little  system  in  this  helps  a  great  deal,  probably  by  sug- 
gestion. Let  the  patient  begin  with  one  prune  a  day,  then  one  more  each  day  up  to 
ten  or  fifteen,  gradually  decreasing  the  number  as  the  need  disappears.  Agar  is 
being  given  lately. 

Fourth,  let  the  patient,  every  night  before  retiring,  inject  into  the  rectum 
4  to  6  ounces  of  ordinary  olive  oil,  leaving  it  there  all  night.  In  cases  of  spastic 
constipation  this  is  a  valuable  remedy. 

Fifth,  drugs  are  withheld,  as  far  as  possible,  and  active  cathartics  entirely. 
Cascara,  in  bitter  extract,  administered  in  capsules,  gives  the  best  results,  the  dose 
being  increased  gradually  and  decreased  as  the  desired  effect  is  obtained.  One  may 
alternate,  every  month,  with  a  saline  aperient,  and  of  the  many  on  the  market,  the 
author  has  found  Pluto  water  best.  Medicines  are  discontinued  as  soon  as  the 
patient  is  taught  to  do  without  them.  A  good  prescription  for  atonic  constipation 
attended  \\dth  flatulence  is  the  following: 

1\.  Fluidext.  cascarse  sagradse 30 

Tr.  rhei  aromatici 30 

Tr.  nucis  vomica; 20 

Elixir  taraxaci  com.,  N.  F q.  s.  ad  120 

M.  et  S. — A  half  teaspoonful  after  meals,  t.i.d. 

If  the  patient  has  hemorrhoifls,  aloes  may  be  substituted  for  the  cascara. 

The  Kidneys. — It  is  generally  conceded  that  the  kidneys  are  the  most  vulner- 
able point  in  the  body  during  pregnancy.     One  surely  obtains  very  valuable  informa- 


HYGIENE    OF    PREGNANCY  227 

tioii  of  the  <i;ciicral  iuct:il)()lisiii  tVoiii  the  urine,  and  its  frccimnt  examination  is  a 
duty  of  tlie  acc-oucheur.  The  woman  is  direcled  l(jsend  him  a  tourwnmcc  Ijottlcful 
of  th(!  morninjj;  urine  every  three  weeks  until  the  seventh  montli;  then,  every  two 
w(!oks,  and  if  there  is  an}^  suspicion  of  nephritis  or  toxemia,  every  day.  She  is  also 
(hrected  as  often  to  measure  the  amount  ))assed  in  twenty-four  hours.  This  must 
he  not  less  than  50  ounces.  Tests  are  made  for  albumin,  sugar,  specific  gravity, 
urea,  and  for  casts.  For  i)ractical  purj)oses,  finer  examinations  are  not  necessary. 
Alhumin  is  significant  if  found  by  the  usual  tests.  The  author  has  made  these 
urinalyses  for  years,  and  has  been  rewarded  in  discovering  and  forestalling  many 
cases  of  probable  eclampsia  and  toxemia  (see  Eclampsia). 

Exercise. — Violent  exercise,  of  course,  is  to  ])&  avoided.  It  is  not  possiV)le  to 
build  up  a  strong  muscular  system  during  pregnancy.  That  should  have  Ijeen 
don(!  before.  To  be  avoided  are  jolts,  running,  sudden  motions,  lifting  great 
weights,  going  np  and  down  stairs  quickly,  horseback  riding,  cycling,  riding  over 
rough  roads,  golf,  tennis,  dancing,  and  swimming.  Sea-bathing  is  adopted  by  some 
women  to  ]:)ring  on  abortion.  To  be  encouraged  are  walks,  up  to  two  miles,  in  the 
sunlight,  preferably  not  at  night,  and  carriage  drives.  Housework  is  desirable, 
unless  too  strenuous. 

Railway  travel,  the  automobile,  and  ocean  voyages  had  better  be  avoided,  and 
if  travel  is  necessary,  the  most  comfortable  accommodations  must  be  secured. 
Much  depends  on  the  individual,  since  many  gravida  do  the  most  remarkal^le 
things  and  suffer  nothing,  while  others  miscarry  from  the  slightest  provocation. 
If  a  woman  has  a  known  tendency  to  abort,  she  must  be  very  careful,  and  had 
better  even  go  to  bed  at  the  usual  time  of  her  menstrual  periods.  A  general  mas- 
sage is  often  useful,  care  being  taken  to  avoid  the  breasts,  the  abdomen,  and  varicose 
veins. 

The  patient  may  go  to  the  theater,  but  must  avoid  crowds,  for  fear  of  getting 
into  a  crush.  She  must  avoid  gatherings  in  close  rooms,  especially  ^\^th  stove  heat, 
because  the  fetus  is  very  susceptible  to  coal-gas. 

Coitus  During  Pregnancy. — This  is  a  subject  on  which  much  has  been  MTitten, 
and  deservedly,  because  it  is  of  great  importance.  Many  women  have  a  distaste 
for  intercourse  during  this  time;  in  others  the  desire  is  increased,  rarely  to  nympho- 
mania.    There  are  many  reasons  for  forbidding  coitus  during  gestation: 

First,  the  danger  of  abortion,  which  is  caused  Ijy  the  impact  of  the  penis 
against  the  cervix,  and  the  great  congestion  of  the  parts  during  the  act.  Xo  doul^t 
the  frequency  of  miscarriage  in  the  newly  married  is  due  to  this  cause. 

Second,  the  nervous  shock  is  not  well  borne  by  a  woman  whose  nerve  energy 
is  already  overtaxed.  It  aggravates  the  leukorrhea,  and  often  increases  the  nausea 
and  vomiting.  In  some  cases  the  presence  of  the  husband  incites  an  attack  of 
vomiting,  and  removal  of  the  patient  from  home  may  be  necessary. 

Third,  animals  do  not  copulate  when  the  female  is  pregnant,  and,  while  the 
habits  of  other  animals  do  not  guide  man,  in  many  cases  it  would  be  vnse  for  him  to 
follow  their  instincts. 

Fourth,  the  danger  of  infection.  This  is  a  real  danger,  the  author  knowing 
t)f  two  cases  where  fatal  sepsis  resulted  from  coitus  just  before  labor-,  and  several 
other  cases  where  severe  puerperal  fever  was  in  all  likelihood  the  result  of  this  per- 
nicious practice.  The  danger,  of  course,  is  greater  in  multiparae  in  whom  the  cervix 
is  patulous. 

Other  reasons  that  have  been  given  are  more  or  less  fanciful — for  example, 
that  it  makes  the  child  sensual,  that  it  weakens  it,  that  the  wife  will  lose  respect  for 
her  husl)and.  The  danger  from  coitus  is  greatest  in  the  first  three  months,  when 
usually  the  fact  of  pregnancy  is  not  always  sure,  and  in  the  last  three  months,  when 
the  abdominal  tumor  is  large  and  the  element  of  infection  more  prominent.     It  is 


228  THE    HYGIENE    AND    CONDUCT    OF   PREGNANCY 

wise  to  restrict  the  practice  to  the  intervening  months,  or,  better,  advise  against  it 
entirely. 

Parvin  devotes  some  space  to  this  subject,  and  refers  to  the  distaste  of  coitus  in  the  wife  as 
one  of  the  signs  of  pregnancy  mentioned  by  Susru-fa.  African  tribes  and  other  savages  forbid  it, 
the  Chinese  and  Indians,  hkewise.  Tlie  Talmud  forbids  it  conditionally.  Swift,  in  liis  terrible 
satire  on  the  human  race,  in  "Gulliver's  Travels  Among  the  Houyhnhnms,"  says  that  "this  is 
such  a  degree  of  infamous  brutality  as  no  other  sensitive  creature  arrives  at,"  that  is,  "that  the 
Slie-yahoo  admits  the  male  wliile  she  is  pregnant." 

The  ancient  Irans,  Medes,  and  Persians  punished  the  man  heavily  for  such  an  act;  he  re- 
ceived 2000  lashes  and  was  compelled  to  carry  3000  loads  of  heavy  and  light  wood  to  the  fire, 
sacrifice  1000  small  animals,  kill  1000  snakes,  1000  land  lizards,  2000  water  lizards,  and  3000 
ants,  and  build  30  bridges  over  flowing  water  (Ploss). 

Bathing. — Cold  and  liot  baths,  Turkish  and  Russian,  hot  sitz-baths,  and  ocean 
bathing  are  to  be  avoided,  because  of  the  danger  of  exciting  uterine  contractions. 
Tepid  baths,  with  cool  spongings,  may  be  taken  freely.  They  aid  the  kidneys  in  the 
work  of  excretion  and  preserve  the  person  from  odor.  During  pregnancy  the  skin 
secretes  more.  Sea-salt  baths  at  home  are  good,  but  if  the  patient  feels  exhausted 
afterward,  they  are  to  be  stopped.  A  light  general  massage  after  the  bath  is  very 
grateful  to  the  patient.  For  the  profuse  sweating  which  is  sometimes  an  annoying 
sj-mptom,  a  bath  followed  by  a  brisk  rub  with  a  "salt  towel"  is  useful.  A  "salt 
towel"  is  made  by  wringing  a  bath-towel  out  of  a  strong  brine  and  drjdng  it. 

Among  the  poor  there  is  a  notion  that  bathing  during  pregnancy  is  dangerous. 
Is  it  possible  that  old  experience  discovered  some  harm  in  it?  We  know  that  the 
full  tub-bath,  during  or  near  labor,  may  cause  infection,  through  the  polluted  water 
gaining  entrance  to  the  vagina.  Therefore  the  author  advises  his  patients,  in  the 
latter  weeks  of  pregnancy  and  in  labor,  to  employ  only  the  shower. 

Vaginal  douches,  unless  indicated  by  disease,  are  not  to  be  used.  Only  mild 
antiseptics  may  be  employed,  tepid,  and  given  under  low  pressure,  12  to  18  inches. 
One  of  the  best  medicaments  is  potassium  permanganate,  gr.  v  ad  Oij.  Existing 
gonorrhea  must  be  treated  thoroughly,  to  avoid  conjunctivitis  in  the  new-born  and 
puerperal  accidents  in  the  mother. 

Mental  Occupation. — Most  women  have  sufficient  to  do  in  their  household, 
and  the  question  of  an  especial  obstetric  literature  does  not  come  up.  Occasionally 
the  accoucheur  will  be  asked  to  recommend  a  book  on  the  subject  of  the  care  of  the 
mother  during  pregnancy.  There  are  many  on  the  market,  some  of  the  best  being 
"Wife  and  Mother,"  by  Pye  Henry  Chevasse,  and  one  by  Fry,  on  Maternity.  The 
author  questions  the  wisdom  of  giving  gravidse  books  which  describe  the  anatomy 
and  physiology  of  the  function.     She  should  be  advised  to  avoid  them. 

Some  women  believe  that,  by  reading  fine  literature,  the  child  will  be  intellectual, 
by  studying  music,  musical,  by  practising  the  arts,  artistic.  Since  these  enjoy- 
ments do  no  harm,  but  rather  keep  the  mind  away  from  injurious  thoughts,  the 
woman  may  be  humored  in  the  idea,  though  the  physician  may  express  a  gentle 
disbelief  in  the  notion.     This  brings  us  to  the  subject  of — 

Maternal  Impressions. — By  this  term  is  meant  those  impressions  on  the  mind 
or  body  of  the  child  in  utero  which  result  from  a  similar  impression  on  the  mind  or 
body  of  the  mother.  The  belief  that  if  a  pregnant  woman  should  see  an  ugly  or 
terrifying  object  it  would  be  reproduced  in  the  offspring  dates  from  remotest  an- 
tiquity, and  is  spread  all  over  the  world,  even  in  darkest  Africa.  The  Biblical  story 
of  Jacob  and  the  "speckled  and  spotted  kine"  proves  its  existence  in  the  civilized, 
and  the  practices  of  the  savages  in  many  parts  of  the  world  show  that  the  notion 
existed  among  the  uncivilized,  peoples  for  ages  (Ploss).  Novelists  (Goethe,  Scott, 
Dickens,  O.  W.  Holmes,  Shakespeare,  Sterne,  Hawthorne)  have  used  the  idea  as  a 
pet  theme,  and  many  names  great  in  medicme  and  allied  sciences  could  be  quoted  in 
its  support.     A  few  are  Van  Swieten,  Boerhaeve,  Morgagni,  Rokitansky,  Burdach, 


IIYfJIEXE    OF    PREGNANCY  229 

Stoltz,  Liobrccht,  Dolassus,  M()iitefi;f;i;i,  MoiitfAoniory,  Tyler  Smith,  Fordycc 
Barker,  Busey,  and  Parviu.  Nevertlu-less,  iiKjst  of  tlie  later  writers  call  the  belief 
a  superstition,  absurd  and  harmful.  Blondel  (London,  1727)  fought  against  the 
theory.  It  must  be  admitted  that  the  belief  in  the  effect  of  the  mother's  mental 
state  on  tiie  infant  canucjt  l)e  proved  b\'  appeal  to  physical  laws,  but  we  cannot 
always  prove  our  meiUcal  l)eliefs  in  this  way.  We  admit  the  influences  of  heredity, 
which  we  cannot  as  yet  explain. 

The  arguments  against  the  theory  are,  first,  there  is  no  nervous  connection 
between  the  mother  and  the  fetus.  Virchow  himself  could  find  none.  Second, 
the  ciiild  is  completely  formed  at  the  end  of  the  sixth  week,  a  time  that  pregnancy 
is  usually  not  recognized,  and  in  most  of  the  cases  reported  the  causative  mental 
shock  occurred  much  later  in  gestation.  Third,  all  the  monstrosities  observed  in  the 
human  are  found  in  the  lower  animals,  and  in  much  greater  number.  Many,  many 
women  see  ugly  or  striking  scenes  during  pregnancy  and  anxiously  ask  the  doctor  if 
the  baby  is  "marked,"  but  their  fears  arc  seldom  realized.  It  would  seem  then 
that,  with  our  present  scientific  knowledge,  the  belief  in  the  effect  of  the  mother's 
mind  on  the  physical  well-being  of  the  child  is  absolutely  unfounded.  How  can 
we  explain  th(^  innumerable  cases,  many  reported  by  trustworthy  physicians,  where 
the  deformity  of  the  child  reseml:»led,  in  most  striking  manner,  that  of  the  alleged 
shocking  experience  of  the  mother?  Very  probably  by  coincidence,  if  pure  in- 
vention be  excluded. 

That  a  violent  emotion,  experienced  by  a  nursing  mother,  can  so  affect  the 
milk  that  the  nursling  gets  sick  from  it,  even  having  convulsions,  is  a  fact  attested 
by  honest  observers.  That  great  mental  excitement  can  produce  abortion  is  a  daily 
experience.  A  patient  of  the  author,  in  her  fifth  month,  was  much  frightened  by  fire 
in  an  adjoining  dwelling  and  aborted.  The  fetus  was  tangled  in  its  cord,  the  left 
leg  being  constricted  in  a  hard  knot.  The  author  performed  the  autopsy  on  an 
otherwise  healthy  but  macerated  fetus  weighing  nine  pounds.  During  a  severe 
thunderstorm,  a  week  previously,  the  mother  had  taken  fright,  the  child's  move- 
ments became  excessively  violent,  and  then  ceased.  The  labor  was  normal.  A 
h(>morrhage  in  the  placenta,  due  to  circulatory  disturbance  in  the  uterus,  wall 
explain  the  first  case,  but  there  was  no  suspicion  of  abruptio  placentae  in  the  second. 
These  facts  show  that  an  impression  on  the  mother's  mind  is  transmitted  to  the 
uterus,  but  they  do  not  explain  how  the  destructive  action  on  the  fetus  is  produced. 
Hemorrhages  into  the  chorion  may  interfere  ^^dth  the  nutrition  of  the  embryo,  even 
causing  its  death.  Lesser  degrees  of  interference  may  alter  the  gro'VA'th  of  the  em- 
bryo, producing  a  monster,  since  we  know  that  the  various  cells  of  the  morula  are 
endowed  with  unequal  resistance  to  external  influences.  ^Monstrosities  have  been 
produced  by  chemical  action  on  segmenting  eggs  (see  Teratology).  If  the  emotions 
are  not  purely  nervous,  Ijut  partly  chemical  in  action,  "would  it  be  absurd  to  believe 
that  toxins,  produced  by  acute  and  chronic  emotional  conditions  of  the  mother, 
passed  through  the  placenta,  as  other  chemicals  do,  and,  exerting  a  selective  action, 
as  many  toxins  do,  affected  the  delicate  nerve-cells  of  the  growing  eml^ryo?  We 
know  that  physical,  mental,  temperamental,  and  emotional  traits  in  either  parent 
are  transmitted  to  the  offspring.  How  is  the  germ  plasm  affected  in  the  first  place, 
that  it  can  carry  these  delicate  l^ut  permanent  impressions?  The  scope  of  this 
work  does  not  permit  going  deeper  into  the  subject,  nor  have  our  means  of  investi- 
gation been  all  tried  on  its  solution.  Perhaps  modern  biochemistry  will  explain  it. 
The  author  has  not  seen,  in  the  many  cases  of  supposed  maternal  impression 
reported  to  him,  even  a  plausible  connection  between  the  nervous  shock  and  the 
deformity  of  the  child,  and  has  not  the  least  ground  for  believing  that  such  a  tera- 
togenic connection  could  exist.  Xor  have  his  ordinary  observations  discovered 
any  relation  between  the  mind  of  the  mother  and  the  babe  that  could  not  be  ex- 
plained by  the  laws  of  herecUty  as  we  at  present  understand  them,  but  that  such  an 


230  THE  HYGIENE  AND  CONDUCT  OF  PREGNANCY 

influence  may  go  from  one  to  the  other  should  not  be  ruled  out  as  absurd  and  in- 
discussable. 

When  the  gravida  asks  the'question,  "Could  anything  I  have  done  or  seen  affect 
my  l^aby?"  a  question  that  is  so  often  put  in  great  trepidation  by  the  expectant 
mother,  the  physician  can  conscientiously  answer,  ''No,  in  the  present  state  of  our 
scientific  knowledge  there  is  no  basis  for  such  fears."  He  can  say,  too,  that  a  quiet, 
well-ordered  mind  conduces  to  a  normal  pregnancy  and  healthy  offspring,  which 
Plato,  in  the  Seventh  Book  of  Laws,  recommended. 

Care  of  the  Breasts. — The  breasts  require  care  even  from  early  infancy.  The 
number  of  women  unable  to  nurse  their  babies  is  enormous,  and  the  evil  effects 
are  noticeable  in  our  infant  mortality  tables.  The  number  of  women  able  but  un- 
willing to  nurse  is  small  and  growing  smaller  every  year.  It  is  a  great  misfortune 
if  a  woman  cannot  nurse  her  infant.  The  prevention  of  mastitis  neonatorum  has 
already  been  mentioned.  Especially  in  the  growing  girl  do  the  mammis  and 
nipples  need  care,  and  when  they  develop  at  puberty,  provision  for  this  growth  by 
proper  dress  should  be  made.     Pressure  and  injury  must  be  avoided. 

Some  women,  during  pregnancy,  require  some  form  of  bust  supporter  to  hold 
up  the  large,  heavy,  pendent  breasts.  This  supporter  often  forms  a  part  of  the 
''maternity  waist."  During  her  bath  the  patient  exercises  care  not  to  hurt  the 
glands.  The  fine,  branny  scales  which  accumulate  on  the  nipple,  if  allowed  to 
remain,  form  moist  crusts  and  lead  to  cracks,  fissures,  blisters,  and  infection.  The 
nipples  should  be  washed  frequently  with  a  good  soap,  dried,  and  anointed  with 
solid  aibolene,  cocoa-butter,  or  any  sterile  fat.  In  blonds,  red-haired  women,  and 
others  mth  tender  nipples  a  lotion  that  is  very  slightly  astringent  may  be  used : 

Py .    Glycerite  of  tannin 15 

Spir.  lavandulse  comp 30 

Aquae  destil 80 

After  this  has  dried  in,  the  nipples  are  to  be  anointed  with  the  unguent.  No 
strongly  astringent  washes  or  alcohol  may  be  used.  They  harden  the  nipple,  which 
then  cracks  under  the  sucking  efforts  of  the  child.  The  skin  of  the  nipple  must  be 
made  soft  and  pliable. 

Inverted  nipples  (a  reversion  to  an  embryonal  type)  can  seldom  be  improved 
by  treatment.  If  the  nipple  is  undeveloped,  or  pressed  in  by  improper  dress, 
gentle  attempts  may  be  made  to  draw  it  out  with  the  fingers  during  the  last  six 
weeks  of  pregnancy. 

Preservation  of  the  Figure. — Naturally  and  properly,  women  are  desirous  that 
the  fiuiction  of  child-bearing  should  not  leave  the  person  in  an  ungainly  shape — ■ 
for  example,  with  protuberant  abdomen.  The  most  common  complaint  is  that  the 
patient  develops  a  "high  stomach"  after  labor. 

It  may  be  remembered  that  the  Roman  women  had  abortions  performed  so 
that  they  need  not  suffer  the  disfigurement  produced  by  child-bearing.  Certain 
changes  in  the  body  are  the  necessary  consequences  of  childbirth,  and  beautify  the 
figure,  although  some  women  do  not  look  at  it  in  this  light.  Such  are  the  rounding 
of  the  hips,  broadening  of  the  bust,  the  more  mature  and  matronly  appearance. 
It  is  natural  for  some  women  to  put  on  fat  after  delivery,  and  nothing  done  before, 
during,  or  after  confinement  will  prevent  it.  An  excessive  accumulation  is,  how- 
ever, amenable  to  the  usual  treatment  for  obesity. 

For  the  prevention  of  "high  stomach"  or  extreme  prominence  of  the  lower  ab- 
domen much  may  be  done.  The  condition  is  caused  by  weakness  of  the  abdominal 
muscles,  or  even  by  a  separation  of  the  recti  muscles — when  the  woman  is  said  to 
have  a  "rupture."  As  the  result  of  either,  the  intestines  fill  with  gas  and  fall 
forward;  sometimes  the  kidneys  become  movable,  or  even  the  liver  descends.  The 
muscles  give  way  under  the  stretching  produced  by  the  growing  uterus,  and,  of 
course,  will  give  away  sooner  if  there  are  twins  or  an  unusually  large  child,  or  if  the 


HYGIENE    OF    PREGNAN'CY  231 

walls  are  weak.  If  corsets  are  worn  during  pregnancy,  they  add  to  the  strain  on 
the  lower  alxlonicii,  and  thus  favor  muscular  weakness.  High-heeled  shoes  are 
another  factor.  Overstraining  during  lal)or  and  inattention  to  the  bowels  after 
labor  are  also  causative.  To  prevent  the  muscular  insufficiency,  one  must  begin 
with  the  girl.  She  should  develoj)  herself  as  does  the  boy,  with  active  sports — 
rowing,  swimming,  climbing,  etc.  When  a  young  woman,  she  should  not  "lace" 
and  thus  paralyze  the  abdomen.  Healthy  exercise  of  the  whole  body  should  form 
part  of  her  daily  routine.  The  abdomen  may  need  some  support  during  the  last 
three  months  of  pregnancy,  which  may  be  obtained  by  one  of  the  maternity  corsets 
recommended.  A  special  abdominal  binder  may  sometimes  Ijc  needed,  especially  in 
multiparse  with  already  weakened  walls  or  with  twins,  polyhydramnios,  etc.  After 
the  birth  of  the  child  the  nurse  should  see  that  the  bowels  are  regularly  emptied 
and  that  gas  does  not  accumulate  in  the  intestines.  The  binder,  after  labor,  does 
not  prevent  ''  high  stomach, "  and  while  the  Avi-iter  recommends  it  (see  Treatment  of 
the  Puerperium) ,  the  most  benefit  obtained  from  it  is  when  the  patient  first  leaves 
the  bed..  To  bring  the  abdominal  walls  back  to  their  original  tonus  the  nurse  may, 
after  the  uterus  has  sunk  into  the  pelvis,  give  them  a  daily  five-minute  massage. 

To  prevent  the  overstretching  of  the  skin  and  the  formation  of  the  linear  or 
strise  gravidarum,  our  efforts  are  not  very  successful,  but  the  writer  recommends 
skin  massage  with  albolene  or  fat.  Several  such  remedies  are  much  vaunted  in 
newspaper  advertisements. 

Women  whose  legs  become  swollen  and  full  of  immense  varicose  veins  should 
wear  rul^l^er  stockings.  Varicosities,  when  large  and  extensive,  are  a  congenital 
defect  and  unprevental)le. 

General  Instructions. — In  general,  the  obstetric  case  is  to  be  treated  as  a 
major  surgical  case.  The  woman  is  requested  to  report  any  symptom  that  annoys 
her,  especially  headache,  edema  of  the  extremities,  bleeding  from  any  part  of  the 
body,  constipation,  diminished  urine,  nausea  and  vomiting.  It  is  wise  for  the 
physician  to  see  her  occasionally  during  pregnancy,  and  judge  for  himself  if  her 
condition  is  satisfactory.  Women  complain  that  their  accoucheurs  do  not  take 
enough  interest  in  them — a  charge  which  is  true.  Instructions  are  to  be  given 
regarding  the  advent  of  labor,  how  the  patient  may  decide  that  it  is  at  hand,  and 
cordial  encouragement  should  be  offered  her,  since  she  awaits  the  event  with  much 
anxiety  and  trepidation. 


THE  PREPARATION  FOR  THE  ASEPTIC  CONDUCT  OF  LABOR 

Unless  the  woman  is  to  go  to  a  maternity  for  delivery,  the  same  preparations 
must  be  made  at  home  as  for  a  major  surgical  operation  at  home.  Thousands  of 
mothers  and  children  die  every  year  because  of  the  lack  of  such  preparation,  and 
of  the  spirit  that  animates  it.  The  principles  of  asepsis  and  antisepsis  are  not  com- 
phcated  nor  hard  to  apply.  They  are  only  two:  ever>i;hing  that  is  to  come  in 
contact  with  the  puerperal  wounds  must  be  absolutely  sterile;  second,  the  external 
genitalia  and  introitus  vaginne  must  be  thoroughly  disinfected.  If  these  two  prin- 
ciples are  deeply  ingrained  in  the  accoucheur's  mind,  the  methods  of  carrjang  them 
out  will  suggest  themselves.  The  ponderous  and  complicated  system  of  asepsis 
practised  in  hospitals  is  not  possible  nor  necessary  in  the  home;  but,  on  the  other 
hand,  the  ideals  of  asepsis  are  not  met  by  a  basin  of  bichlorid  solution  and  a  roll  of 
absorbent  cotton. 

A  list  of  the  utensils  (a  copy  of  the  author's  being  reproduced  herewdth) — 
dressings,  cottons,  brushes,  etc. — needful  for  confinement  is  to  be  supplied  each 
patient,  with  instructions  how  to  prepare  same,  so  that,  when  the  time  comes, 
everything  is  in  readiness  for  an  aseptic  and  correct  accouchement.  The  nurse 
engaged  for  the  case,  two  weeks  before  the  day  set  for  labor,  goes  to  the  patient's 


232  THE  HYGIENE  AND  CONDUCT  OF  PREGNANCY 

home  and  sterilizes  a  supply  of  towels,  sheets,  cotton  sponges,  gauze,  umbilical 
pads,  vulvar  pads,  and  binders.  The  woman  herself  may  be  instructed  in  these 
matters.  In  the  cities  there  are  nurses  who  make  a  specialty  of  such  preparations. 
Among  the  poorer  classes  the  physician  may  have  to  carry  everything  necessary  for 
an  aseptic  labor  with  him. 

LIST  OF  ARTICLES  NEEDED  FOR  LABOR 

Three  hand-basins  of  graniteware. 

Two  hand-brushes,  \Yooden  backs. 

One  new  two-quart  douche-bag. 

An  Ideal  bed-pan. 

Rubber  sheeting  enough  to  cover  the  bed,  and  a  piece  a  yard  square. 

Twenty  yards  bleached  dairy  cloth  or  gauze. 

Two  pounds  of  sterile  absorbent  cotton. 

Five  yards  borated  gauze  in  sealed  jar. 

One  hundred  bichlorid  of  mercury  tablets. 

Four  ounces  of  lysol. 

Four  ounces  of  boric-acid  crystals. 

One  ounce  of  camphorated  oil. 

Four  ounces  of  solid  albolene. 

A  bundle  of  new  newspapers. 

The  basins,  brushes,  and  douche-bag  are  carefully  sterilized  in  dust-proof  bags. 
One  pound  of  the  cotton  is  made  into  pledgets  or  sponges  of  convenient  size,  packed 
into  glass  jars,  and  sterilized.  The  other  pound  is  made  into  large  vulvar  pads, 
covered  with  gauze.  These  are  sterilized  in  packages  of  six.  The  newspapers  are 
sterilized  by  steam  with  the  pledgets  and  pads,  or  by  baking  in  the  oven,  and  serve 
many  purposes — for  example,  to  wrap  up  basins,  towels,  sheets.  Mason  jars,  etc., 
that  have  been  sterilized  before  labor,  to  place  under  the  patient  during  labor,  and 
to  lay  on  tables  and  chairs  to  avoid  marring  them.  A  sterile  newspaper  wrapped 
in  a  sterile  towel  makes  a  good  bed-pad  during  delivery.  After  everything  has  been 
sterilized,  the  packages  are  labeled  and  put  away  in  a  clean  drawer  or  trunk. 
Maternity  outfits  containing  all  the  needed  utensils,  gauzes,  dressings,  pads,  sheets, 
towels,  etc.,  already  sterilized,  and  neatly  packed  in  sealed  containers,  are  sold  by 
surgical  supply  houses.  At  the  time  of  labor  the  accoucheur  finds  things  all  pre- 
pared and  ready,  a  most  comforting  feeling.     Well  prepared  is  half  the  battle. 

RULES  FOR  PREGNANT  WOMEN 

(This  set  of  rules  is  printed  on  the  reverse  side  of  the  slip  giving  the  hst  of  articles  needed  for  labor.) 

1.  Consult  your  physician  as  soon  as  you  suspect  pregnancy. 

2.  Dress  warmly,  with  wool  next  the  skin.  Avoid  circular  constriction  at  any  part  of  the 
body.  As  soon  as  pregnancy  is  determined,  lay  off  corsets;  wear  a  maternity  waist  and  bust 
supporter. 

3.  Take  plenty  of  mild  exercise  in  the  open  air,  especially  walking,  stopping  short  of  fatigue. 
Avoid  violent  motions,  golf,  tennis,  swimming,  long  trolley  or  automobile  rides,  etc. 

4.  Take  no  hot  or  cold  baths;  in  the  last  two  weeks  no  tub-baths;  use  the  shower  and  spong- 
ing. Take  no  douches  unless  ordered,  and,  especially  in  the  last  month,  allow  nothing  to  touch 
the  internal  genitalia. 

5.  The  bowels  must  move  every  day. 

6.  Eat  your  usual  amount  of  food,  restricting  the  meats  or  their  equivalents,  fish  and  eggs, 
to  four  ounces  a  day.     Drink  freely  of  water,  milk,  and  buttermilk. 

7.  Keep  the  breasts  free  from  pressure.  Bathe  the  nipples  once  a  week  with  tincture  of 
green  soap  and  anoint  them  daily  with  sterilized  albolene. 

8.  Send  a  four-ounce;  spticimen  of  the  morning  urine  for  examination  every  three  weeks; 
after  the  seventh  month,  every  two  we(>ks. 

9.  During  the  eighth  month  a  careful  examination  must  be  made,  and  near  term  another. 

10.  Report  to  your  physician  when  you  are  troubled  with  nausea,  vomiting,  headache, 
swelling  of  the  feet  or  eyelids,  or  other  abnormal  symptoms.  Report  also  any  marked  reduction 
in  the  amount  of  urine,  and  if  there  is  hemorrhage,  however  slight,  from  any  part  of  the  body. 

11.  When  labor  pains  begin,  or  if  the  waters  break,  or  if  the  show  of  blood-stained  mucus 
appears,  call  your  nurse  and  notify  the  accoucheur. 

The  Physician's  Examinations. — It  is  wise  for  the  accoucheur  to  make  a 
complete  general  and  pelvic  examination  of  every  woman  when  she  engages  him  to 


HYGIENE    OF    PREGNANCY 


233 


take  care  of  her  during  confinement.  He  may  discover  a  contracted  p(;Ivi.s,  an  ex- 
tra-uterine pregnancy,  an  ovarian  tumor,  or  other  contUtion  wiiich  may  Ije  removed 
at  this  time  safely  for  the  patient,  wiiile  if  left  for  chance  discovery,  the  favorable 
period  may  have  i)assed  l)y.  Further,  he  must  make  sure  that  the  wonvdn  is  preg- 
nant, to  spare  himself  mortifying  surprises.  The  woman  will  not  object  to  the 
examination  if  its  necessity  is  explained.  A  card  or  history  sheet  should  l^e  filled 
out  at  this  first  visit,  which  should  contain  a  complete  medical  history  of  the  pa- 
tient. This  may  bear  on  the  obstetric  side  of  the  case.  The  card  used  by  the  author 
is  reproduced  on  p.  247,  Fig.  279.  The  urinalyses,  the  results  of  examinations, 
and  items  of  interest  during  the  course  of  pregnancy,  are  recorded  on  the  card. 


Fig.  260. — Baudelocque-Breiskt  Pelvimeter. 
Very  slightly  modified  by  the  author. 

Every  week,  at  a  time  set  apart  for  the  purpose,  the  physician  looks  over  these  cards 
and  gets  in  touch  with  the  individual  patients.  If,  for  example,  the  record  shows 
that  no  urinalysis  has  been  made  for  a  long  time,  the  patient  should  be  reminded  of 
such  a  necessity. 

When  the  call  to  a  labor  comes,  the  card  should  be  taken  to  the  case.  The 
young  practitioner  is  ad\dsed  to  use  the  history  sheet,  reproduced  in  the  Appendix, 
in  the  early  j^ears  of  his  practice.  It  has  not  the  advantage  of  convenience  of  the 
card,  but  it  is  more  detailed  and  more  complete.  It  A\ill  develop  habits  of  thor- 
oughness and  broaden  his  mind.     In  later  years  he  wall  be  too  busy  to  fill  out 


234 


THE  HYGIENE  AND  CONDUCT  OF  PREGNANCY 


detailed  records,  then  the  card  will  afford  him  sufficient  space  for  the  important 
and  necessary  entries.  The  keeping  of  accurate  and  complete  records  is  a  duty 
wliich  the  physician  owes  his  patient,  his  profession,  and  himself. 

Some  time  during  the  eighth  month  the  patient  should  be  thoroughly  exam- 
ined. Tliis  examination  is  best  made  in  a  maternity  on  the  delivery  bed,  with  the 
patient  undressed.  It  can  be  conducted  at  the  patient's  home  or  even  at  the  physi- 
cian's office,  though  not  as  thoroughly.  While  the  greatest  attention  is  paid  to  the 
pelvis,  the  heart  and  lungs  should  be  studied,  with  a  view  to  discover  any  defects 
that  might  jeoparcUze  the  pregnancy  or  the  patient  in  labor.  The  size  and  con- 
sistence of  the  breasts  and  the  configuration  of  the  nipples  are  studied  with  a  view 
of  determining  the  woman's  ability  and  j&tness  for  lactation.     Far  from  objecting, 


Interspinous, 
26  cm. 


Intertrochan- 
teric, 31  cm. 


Fig.   201.— The  External  Measttremexts.     Showing  Where  to  Place  Pelvimeter. 

the  patient  will  approve  of  such  care  and  thoroughness  in  the  study  of  her  case,  and 
it  will  give  her  increased  confidence  in  her  accoucheur.  After  the  chest,  including 
the  breasts,  has  been  examined  and  the  information  noted  on  the  history  sheet  or 
card,  the  patient  is  arranged  lengthwise  on  the  bed  or  table,  the  abdomen  bared, 
the  chest  and  extremities  being  appropriately  draped  with  sheets,  and  all  the  in- 
formation that  may  be  gained  by  abdominal  examination  is  sought  and  recorded. 
One  notes  the  size,  shape,  and  consistence  of  the  uterus,  the  position  and  size  of  the 
fetus,  its  heart-tones,  and  the  presence  of  abdominal  tumors  beside  the  uterus. 
The  external  pelvic  measurements  are  now  taken,  using  a  pelvimeter  (Fig.  260). 
The  following  are  the  most  useful: 

1.   The  distance  between  the  spines  of  the  ilia,  always  taking  the  outer  lip. 
The  distantia  spinarum  iliorum,  or  Sp.  I.  =  26  cm. 


HYGIENE    OF   PREGNANCY 


235 


2.  Tlic  distance  between  llic  crests  ol"  the  iliu,  taking  llic  (jutor  lip,  the  dis- 
tantia  cristuruni  iliorum,  or  Cr.I.  =  29  cm. 

3.  Between  tiie  j^reut  troelumters,  distantia  bitrochanterica,  or  Bi.T.  =  31  cm, 

4.  From  the  depression  under  the  last  lumbar  spine  to  the  anterior  surface  of 
the  pul)is — conjugata  externa,  diameter  Baudelocquii,  or  D.B.  =  20  cm. 

5.  The  circumference  of  the  pelvis,  90  cm. 

6.  The  oblifiues,  fi-om  <he  ri<i;ht  i)osterior  superior  spine  of  the  ilium  to  the 
left  anterior  sujx'rior,  ol)li(|ua  dextru,  0b.D.  =  22  cm.;  and  the  corresponding 
oljlique  of  tlie  other  side.     Ob.L,  =  2132  cm. 


Fig.  262. — Taking  Interspinous  Diameter. 


Fig.  26.3. — Taking  BAtrDELOCQrE"s  Di.vmeter. 


The  author  takes  the  obliques  only  in  cases  where  there  is  scoliosis  and  other 
evidence  of  pelvic  asymmetry.  Fig.  262  illustrates  the  manner  of  taking  the 
external  diameters.  Baudelocque's  cUameter  is  best  obtained  when  the  patient  is 
erect,  as  in  Fig.  263,  but  one  can  get  it  with  the  patient  lying  on  the  side,  with  the 
upper  leg  straight,  the  lower  drawii  well  up  against  the  belly.  The  posterior  branch 
of  the  pelvimeter  is  placed  in  the  dimple  under  the  last  lumbar  spine.  This  point 
IS  one  inch  above  a  line  drawai  between  the  two  posterior  superior  spines.  On  the 
posterior  aspect  of  the  pelvis,  in  well-formed  women,  is  a  diamond-shaped  depression 


236 


THE  HYGIENE  AND  CONDUCT  OF  PREGNANCY 


formed  by  the  dimples  of  the  posterior  superior  spines  of  the  ilia,  the  lines  formed 
by  the  gluteal  muscles  and  the  groove  at  the  end  of  the  spine.  It  is  called  the 
rhomboid  of  INIichaelis,  and  is  seen  on  beautiful  statues — for  example,  the  Capito- 
line  Venus  (Fig.  264).  The  point  for  the  calipers  is  near  the  apex  of  the  rhomboid. 
Variations  in  the  shape  and  size  of  this  landmark  give  us  valuable  information  in 
deformed  pelves.  Anteriorly,  the  knob  of  the  pelvimeter  comes  to  rest  on  the 
most  prominent  portion  of  the  bony  pubis.  It  is  wise  to  take  Baudelocque's 
diameter  three  times  and  use  the  average  of  the  three  measurements. 


Fig.  204. — The  Rhomboid  of  Michaelis. 


Fig.  205. 


-DeLee's  Internal  Pel- 

VIMETEE. 


The  circumference  is  taken  with  the  tape  lying  between  the  crests  of  the  ilia 
and  the  trochanters  on  each  side,  and  in  a  plane  perpendicular  to  the  long  axis  of 
the  body.  Naturally,  in  fat  women  the  circumference  does  not  give  valuable  in- 
formation. Indeed,  the  value  of  the  external  measurements  is  but  relative.  Only 
marked  deviations  from  the  normal  indicate  a  contraction  of  the  pelvis,  and  one 
must  rely  on  the  internal  examination  for  more  positive  information. 

Baudelocque  believed  that,  by  deducting  8  cm.  from  the  external  conjugate, 
the  length  of  the  vera  could  be  obtained.  This  is  not  true,  because  the  thickness  of 
the  bones  and  their  conformation,  produce  differences  of  even  53^  cm.  (Skutsch  and 


HYGIENE   OF   PREGNANCY 


237 


o 


i^^ 


o=dt 


^^^^^^q— -— 3 


Fig.  266. — A  Few  of  the  M.\^-t  Internal  Pelvimeters. 
Copied  from  Skutsch. 


238 


THE  HYGIENE  AND  CONDUCT  OF  PREGNANCY 


Goenner).  The  author  possesses  a  pelvis  with  an  external  conjugate  of  18  cm.  and 
a  C.V.  of  14  cm.,  and  another  with  an  external  conjugate  of  21  cm.  and  a  C.V. 
of  93^  cm.  If  a  woman  has  a  conjugata  externa  of  less  than  18  cm.,  the  probabil- 
ities are  strong  that  the  inlet  is  also  narrowed. 

For  the  same  reason  the  other  measurements  are  unreliable.  The  author  has  a 
pelvis  with  an  intercristous  diameter  of  21  cm.  and  an  internal  transverse  of  133^ 
cm.  The  relation  between  the  interspinous  and  intercristous  diameters  is  of  more 
importance,  for  when  the  interspinous  diameter  is  equal  to,  or  greater  than,  the 
intercristous,  we  suspect  a  flat  pelvis.  (See  Chapter  LIV.)  The  author  insists  on 
internal  pelvimetry  in  all  cases,  excepting  only  those  women  who  have  had  one  or 
more  large  children  without  the  sHghtest  difficulty. 

The  internal  measurements  are  taken  with  the  hand  and  a  special  internal 
pelvimeter  (Fig.  265).     These  are  essential: 


Fig.  267. — Diagram  to  Show  the  Effect  of  a  High  Pubis  on  the  Length  op  the  CD. 
Dotted  line  shows  shortening  due  to  a  thick  pubis  or  exostosis.     Red  line  shows  effect  of  long  pubic  symphj'sis. 


1.  The  conjugata  diagonalis,  C.D.  =  i23/^  cm. 

2.  The  distance  between  the  spines  of  the  ischia,  bispinous,  Bi-sp.  =  ii. 

3.  The  distance  between  the  tuberosities  of  the  ischia,  Bi-isch.  =  11  cm. 

4.  The  distance  from  the  end  of  the  sacrum  to  the  ligamentum  arcuatum 
pubis;  sacropubic,  S.P.  =11  cm. 

Of  the  scores  of  instrumental  methods  of  measuring  the  conjugata  vera 
directly,  since  the  first  by  the  elder  Stein  (1772)  up  to  the  latest  by  Biligky 
(1909),  not  one  has  proved  practical  (Fig.  266).  Their  application  is  too  pain- 
ful and  difficult.  We  still  obtain  our  best  information  l^y  measuring  the  conju- 
gata diagonalis  and  deducing  from  it  the  length  of  the  C.V.  Even  though 
we  can  measure  the  height  of  the  pubis,  and  thus  know  the  length  of  two  sides 
of  the  triangle,  it  is  impossible  to  learn  the  arc  of  any  of  the  angles  of  the  tri- 
angle subtended  by  the  symphysis.  Trigonometry,  therefore,  cannot  help  here — 
we  must  d(,'pend  on  estimates.  Examination  of  large  numbers  of  pelves  shows  that 
if  one  deducts  \]/2  cm.  from  the  length  of  the  C'.D.,  one  obtains  the  length  of  the 
C.V.     If  the  pubis  is  very  high,  6  cm.  or  more  (Fig.  267),  one  must  deduct  2  or  2^^ 


IIVCIKXK    Ol'    I'HKGXANCY 


239 


cm.  If  the  upper  border  ot"  the  puhis  iiu-Hnes  more  tlian  usual  toward  tlic  sacrum 
or  is  v(!ry  thick,  or  if  there  is  an  exostosis  of  the  posterior  surface  of  tlie  symphysis, 
l)oth  of  wiiich  last  occur  in  rachitic  pelves,  2  or  even  3  cm.  may  have  to  be  deducted 
from  the  length  of  the  CD.  (Fis-  2(5S). 

The  transverse  diameter  of  the  jx'lvis  decreases  from  al)ove  downward.  At 
the  level  of  the  inlet  it  measures  12  to  13  cm.;  in  the  region  of  the  spines,  11 
cm.;  anterior  to  the  spines,  113^^  to  12  cm.;  at  the  outlet,  between  the  tuberosities, 
11  cm.  Ill  practice,  it  is  only  exceptionally  possible  to  measure  the  transverse  of 
the  inlet  directly.  \Vh(ni  labor  has  been  in  progress  for  a  time,  the  vagina  becomes 
so  soft  and  distensible  that  one  can  spread  the  branches  of  the  internal  pelvimeter, 
pictured  in  Fig.  265,  until  they  touch  both  sides  of  the  pelvis,  enabling  one  to  read 
off  the  measurement  on  the  scale  with  mathematical  accuracy.  Late  in  pregnancy 
it  is  easy  with  this  instrument  to  measure  the  distance  between  the  spines  of  the 
ischia.  The  distance  between  the  tul^erosities  is  not  so  easily  gotten,  because  of  the 
thick  padding  of  fat  over  these  bones.     One  must  add  1  to  2  cm.  to  the  measure- 


FiG.  268. — Di.\GRAM  Showing  Effect  of  Ixcreased  Ixclixatiox  of  Pubis  ox  Lexgth  of  C.V. 


ment  obtained  ^\'ith  the  pelvimeter.  While  the  external  measurements  give  only 
equivocal  information,  considerable  dependence  may  be  placed  on  internal  men- 
suration, and  this  will  increase  with  added  experience. 

Technic  of  the  Internal  Examination.— During  the  early  part  of  the  eighth 
month  is  the  most  favorable  time  for  pelvic  mensuration  in  genei'al  practice.  Dur- 
ing lal)or  one  may  have  the  advantage  of  anesthesia.  The  patient  must  lie  across 
the  bed  or  on  a  table,  with  the  hips  hanging  well  over  the  edge,  to  enable  the  examiner 
to  sink  liis  elbow.  Her  person  must  be  ckaped  with  a  sheet,  but  the  genitalia  are  to 
be  exposed.  For  examination,  at  this  period,  the  genitals  need  not  be  shaved,  but 
they  should  be  washed  "uith  water  and  soap,  following  this  with  a  liberal  use  of 
antiseptic  solution,  1  :  1500  bichlorid  or  1  per  cent,  lysol.  Rubber  gloves  are  worn 
by  the  author  as  a  precaution  against  S3'philitic  infection,  for  the  sake  of  personal 
cleanliness,  to  preserve  the  skin  from  the  corrosive  action  of  antiseptics,  and  to 
render  the  examination  less  painful  to  the  patient.  The  internal  pehimeter  is 
sterilized  l^y  boiling  in  a  1  per  cent,  soda  or  borax  solution.  On  inspecting  the  vulva, 
one  will  note  an}'  suspicious  discharge,  abscess,  varicose  veins,  the  extent  of  previous 


240 


THE  HYGIENE  AND  CONDUCT  OF  PREGNANCY 


lacerations,  etc.,  after  which  two  fingers  are  inserted  between  the  widely  separated 
labia,  deeply  into  the  vagina.  It  is  well  to  study,  in  each  case,  the  topography  of  the 
levator  ani,  which  can  be  easily  done  by  pressing  the  fingers  down  on  either  side  of 
the  vagina.  The  powerful  broad,  sling-like  muscle  of  a  primipara  contrasts  strongly 
with,  the  thick,  cord-like  muscle  of  a  multipara.  The  condition  of  the  vagina  is 
noted.  If  there  is  a  granular  condition  of  the  mucous  membrane  which  might 
suggest  gonorrhea,  a  smear  should  be  taken  with  a  view  of  preventing  ophthalmia 
neonatorum  and  sepsis  postpartum.     Next,  the  cervix  is  studied  to  learn  whether 


Fig.  269. — Taking  Distance  Between  Spines. 


it  is  long,  tapir-nose-like,  or  short  and  broad;  whether  patulous,  as  in  multiparse,  or 
closed;  whether  normal,  smooth,  and  soft,  or  diseased,  thick,  knobby  (ovula  Na- 
bothi),  catarrhally  inflamed,  or  eroded.  Then  the  lower  part  of  the  uterus  is  pal- 
pated and  the  y)resence  of  the  head  determined,  at  the  same  time  discovering  any 
tumor  which  may  block  its  entrance  into  the  pelvis.  The  fingers  now  pass  around 
the  bony  walls  of  the  pelvis  to  obtain  a  mind  picture  of  the  capacity  and  configura- 
tion of  the  excavation.  It  requires  years  of  practice  for  the  accoucheur  to  be  able 
to  form  correct  mind  j^icturcs  of  these  things,  but  they  must  be  learned.  The  height 
of  the  pubis,  its  inclination  into  the  inlet,  the  presence  of  an  exostosis  on  its  posterior 


HYGIENE    OF    PREGNANCY 


241 


surface,  the  curve  of  the  rami  pubis,  the  height  of  the  sacrum,  the  shape  of  the  sac- 
rum, the  movability  and  shap(>  of  the  coccyx  are  determined  in  tlie  order  mentioned. 


Fig.  270. — Direct  Measurement  of  Anteroposteriok  Diameter  of  Outlet. 

Possible  only  at  term.     Anesthetic  usually  necessary. 

Next  the  bispinous  diameter  is  taken  with  the  pelvimeter.     The  instrument  is 
closed  and  passed,  with  the  scale  upward,  along  the  finger  until  it  has  passed  the  grip 


Fig.  271. — Taking  the  Conjugata  Diagonalis. 


of  the  levator  ani,  then  the  blades  are  spread  until  one  knob  comes  to  rest  on,  or  just 
in  front  of,  the  spine  of  the  ischium  (Fig.  269).     Being  assured  that  the  patient's 
16 


242 


THE  HYGIENE  AND  CONDUCT  OF  PREGNANCY 


hips  are  horizontal,  the  blades  are  spread  in  the  horizontal  plane  until  they  are 
arrested  by  the  bony  walls  of  the  pelvis,  and  at  this  instant  the  amount  of  separation 
is  read  off  the  scale.  This  measurement  will  cause  little  pain  if  the  vagina  is  soft 
and  dilatable  (which  is  usual  at  this  time),  and  if  the  examiner  proceeds  slowly  and 
gently.  If  the  vagina  is  diseased,  it  is  more  tender.  Under  no  circumstances  may 
force  be  used,  as  a  tear  of  the  vagina  might  occur.  If  the  blades  easily  spread  to 
10  cm.  and  there  seems  to  be  room  beyond,  it  is  not  necessary  to  insist  on  the  full 
measurement.  In  a  contracted  pelvis  it  is  easier  to  obtain  the  distance.  To  take 
the  sacropubic  diameter  from  the  inside  is  not  always  possible  without  anesthesia, 
and  less  often  in  primiparse  in  whom  the  perineum  rises  high.  Fig.  270  shows 
how  it  is  done.  One  knob  is  steadied  by  the  outside  hand  against  the  ligamentum 
arcuatum  at  the  side  of  the  clitoris,  while  the  other  knob  is  pressed  against  the  end 
of  the  sacrum,  being  guided  into  place  by  the  fingers  in  the  vagina.  One  may  mea- 
sure the  sacropubic  diameter  with 
the  fingers  in  the  same  manner  as  one 
obtains  the  diagonal  conjugate.  Now 
the  instrument  is  removed  and  the 

J  examiner    takes    the    conjugata   di- 

i^M       agonalis  (Fig.  271). 
^^^^^  m^_  Sinking  the  elbow  and  resting  it 

Sfl^aH^^M..  against  the  knee,  the  examiner  gently, 

Wff^^^^^st  ^^^  with  force,  presses  the  middle  fin- 

^B^^BV^^  ger-tip  against  the  promontory  of  the 

^^^Hwy  sacrum.    It  may  be  necessary  to  keep 

^^^\^  up  a  steady  pressure  against  the  peri- 

C\/7\^^^^^  neum  for  several  minutes  before  the 

rigid  muscles  will  relax.  As  soon  as 
the  tip  of  the  promontory  is  felt,  the 
hand  is  raised  against  the  ligamen- 
tum arcuatum.  A  bit  of  cotton  car- 
ried on  the  index  of  the  other  hand  is 
now  pushed  along  the  index  of  the 
examining  hand  until  it  rests  at  the 
point  where  the  examining  hand  is 
touched  by  the  ligamentum  arcu- 
atum. After  making  sure  that  the 
middle  finger-tip  was  actually  resting 
on  the  promontory  at  the  time  the 
bit  of  cotton  reached  the  under  edge 
of  the  pubis,  the  cotton  is  carefully 
steadied  in  its  place  by  the  outside  hand  while  the  internal  hand  is  removed  from 
the  vagina.  With  a  tape-measure  or  any  pelvimeter  one  now  obtains  the  length 
of  the  conjugata  diagonalis  (Fig.  272).  After  guessing  at  the  inclination  of  the 
pubis  and  allowing  for  its  height,  one  deducts  13^  or  2  or  more  cm.,  and  thus 
approximates  the  length  of  the  C.V. 

Several  methods  may  be  practised  in  obtaining  the  bituberal  or  biischiatic 
diameter.  Schroder  made  marks  on  the  skin  of  the  ])uttocks  to  show  the  location 
of  the  inner  surface  of  the  tuberosities  and  measured  the  separation  of  the  marks. 
An  assistant  may  measure  the  distance  between  the  two  thumbs  so  placed  on  the 
tubers  that  the  finger-nails  represent  their  inner  surfaces.  Two,  three,  four,  or  five 
knuckles  of  the  hand  may  be  pressed  in  })etween  the  l)ones,  and  the  distance  across 
them  later  measured  with  a  tape.  Williams'  pelvimeter  may  be  used  or  the  internal 
pelvimeter  shown  above.  The  closed  knobs  are  inserted  between  the  bones  and 
separated  until  they  are  arrested  (Fig.  273).  It  is  necessary  to  press  the  tissues  well 
against  the  l)one  and  to  add  1  to  1  '2  f-'ii-  tf)  the  reading  for  the  thickness  of  the  fat. 


Fig.  272.- 


-Me.\suring   Length   op   CD.   with   Author's 
Pelvimeter. 


HYGIENE    OF   PREGNANCY 


243 


The  sacropubic  diameter  may  also  be  taken  from  tlie  outside  l)y  Breisky's 
method  (Fig.  274).  One  knob  of  the  pelvimeter  re.sts  under  the  arch  of  the  pubis, 
the  other  is  i)ressed  against  the  saerocoecygeal  joint,  1  cm.  being  deducted  from 
the  reading  to  obtain  the  result. 

Finally,  the  examiner  can-fully  palpates  the  accessible^  bony  portions  of  the 
pelvis.  The  fingers  of  each  hand  are  laid  on  the  descending  rami  of  the  pubis  and 
the  acutencss  of  the  angle  of  the  arch  thus  easily  d(>terminofl  fFig.  275).     Thickness 


Fig,  273. — Taking  Distance  Between  Tuberosities. 


of  the  bones,  asymmetry  of  the  two  sides,  a  beak-shaped  pubis  (osteomalacia,  rickets, 
see  Chapter  LIV),  are  thus  discovered  (Fig.  276).  As  the  last  manoeuver,  the  hand 
is  laid  flat  on  the  sacrum,  the  middle  finger  pressed  firmly  into  the  genital  crease,  to 
conform  to  the  curve  of  the  bone.  On  remo\ang  the  fixed  hand,  the  external  con- 
figuration of  the  sacrum  can  be  seen  at  a  glance  (Figs.  277  and  278). 

A  study  of  the  general  makeup  of  the  gravida  ^^^ll  tell  us  a  great  deal.     Tall, 
muscular  women  seldom  have  contracted  pelves,  and,  if  they  do,  the  tn^e  is  usually 


244 


THE  HYGIENE  AND  CONDUCT  OF  PREGNANCY 


masculine.  Short,  petite  women  may  have  generally  contracted  pelves.  A  woman 
that  limps,  or  is  hunchbacked,  or  has  crooked  legs,  may  have  a  distorted  pelvis. 
Evidences  of  rickets  should  always  be  sought  in  the  rachitic  rosary,  the  square, 
large  head,  enlargement  of  the  epiphyses,  bow-legs,  curvature  of  the  spine,  etc. 

IMucli  more  could  be  written  on  pelvic  mensuration,  but  little  that  is  practical.  Rontgen 
photograph}^  (Budin)  has  failed  to  give  accurate  results,  as  far  as  mensuration  is  concerned,  but  it 
does  give  some  idea  of  the  shape  of  the  pelvic  cavity.  (See  Chapter  LIV.)  CUseometry  is  a  method, 
devised  by  Neuman  and  Elirenfest,  for  taking  the  inclination  of  the  pelvis.  The  cUseometer 
invented  by  them  gi^-es  fairly  satisfactory  readings,  but  the  information  is  of  httle  practical  value. 
They  also  devised  an  instrument  built  on  the  lines  of  the  ordinary  pantograph,  with  a  spirit-level 
for  obtaining  accurate  outlines  of  the  entire  pelvic  parietes.  While  the  results  are  usable,  the 
application  of  the  instrument  is  quite  painful  and  compUcated,  precluding  its  employment  as  a 
routine. 


Fig.  274.- 


-Measuring  Sacropubic  Diameter.     Bkeisky's 
Photograph,  Chicago  Lying-in  Hospital. 


Method. 


All  this  information  is  to  be  carefully  entered  on  the  history  sheet  or  card  (Fig. 
280) .  If  the  physician  conducts  his  examination  systematically,  he  will  not  overlook 
any  points  and  have  the  disagreeable  necessity  of  putting  the  patient  back  on  the  table. 
On  discovering  anything  unusual  in  the  pelvis,  soft  parts,  or  child,  the  examination 
takes  on  extra  interest,  and  special  attention  will  have  to  be  directed  to  the  part. 
A  discussion  of  these  special  subjects  will  be  found  under  the  appropriate  headings. 
A  careful  consideration  of  all  the  information  obtained  enables  the  accoucheur  to 
make  his  diagnosis  of  the  case,  the  prognosis  of  the  labor,  and  any  recommendation 
for  treatment  at  this  time,  all  of  which  are  noted  on  the  card.  Too  much  emphasis 
cannot  be  laid  on  the  importance  of  making  a  careful  pelvic  mensuration  in  preg- 
nancy. It  may  discover  a  contracted  pelvis  and  permit  us  to  induce  labor  while 
the  child  is  small,  or  prepare  for  cesarean  section  or  other  operative  delivery  at  term. 
It  will  explain  many  anomalies  in  the  mechanism  of  labor,  and  it  will  save  many 
mothers'  and  children's  lives. 

Visit  Before  Labor. — It  is  not  wise  to  allow  the  gravida  to  go  into  labor  with 
an  abnormal  pn'scntation.     Sliortly  before  the  date  set  for  confinement  (see  p. 


HYGIENE    OF   PREGNANCY 


245 


26  for  the  (Icteniiiuatioti  of  tliis  (hilc),  the  accoucheur  should  call  on  tho  woman, 
inquire  into  her  f^cncral  condition,  and  make  an  abdominal  examination  to  deter- 
mine the  position  and  presentation  of  tiie  eliild.  To  av(jid  repetition,  the  methods 
of  diagnosis  of  presentation  and  position  will  Ix;  considered  in  full  in  the  conduct  of 


Fig.  275. — Palpating  Pubic  Arch. 


lalior.  After  this  point  is  settled  the  heart  of  the  infant  should  be  auscultated. 
It  is  possible  to  diagnose  fetal  heart  disease  before  delivery.  A  question  usually 
put  to  the  accoucheur  is  one  regarding  the  sex  of  the  child.  This  cannot  be  told 
before  delivery.      Frankenhauser  claimed  that  the  girl's  heart  was  more  rapid 


Fig.  276. — Variously  Shaped  Arches  Obtained  in  Practice. 
1,  Normal.     2,  Broad — as  in  flat  pelves.     .3,  Narrow — as  in  male  pelves.     4,  Osteomalacic  beaked  pelvis. 


than  the  boy's,  so  that  if  the  fetal  heart-tones  were  persistently  below  135  per  minute, 
a  male  child  could  be  predicted.  The  author  has  paid  special  attention  to  this 
point,  and  has  found  that,  as  a  rule,  the  girl's  heart  beats  a  little  faster  than  the  boy's, 
but  that  much  depends  on  the  size  of  the  infant — the  larger  the  child,  the  slower  the 


246  THE  HYGIENE  AND  CONDUCT  OF  PREGNANCY 

heart.     If  the  child's  heart  beats  persistently  above  140  per  minute,  one  will  be 
correct  in  the  prediction  of  a  girl  three  out  of  five  times;   if  below  135  persistently, 


Fig.  277. — Outlining  the  Sackum. 
12  3  4 


Fig.   278. — S.\c'k.vl  Outlines. 
1,  Xormal  curve.     2,  Rachitis.     3,  Rachitis.     4,  Rachitis.     5,  Ankylosis  of  coccyx. 

one  may  expect  a  boy  with  the  same  slight  degree  of  confidence.  The  patient  is 
advised,  however,  that  the  doctor  is  only  guessing.  There  are  no  other  means  of 
distinguishing  the  sex  before  labor. 


HYGIENE   OF   PREGNANCY  247 

The  physician  satisfies  himself  tliat  the  woman  is  in  the  best  possil)le  physical 
condition  to  undergo  the  strain  of  deUvery,  and  this  is  a  matter  not  Ughtly  settled. 


PREGNANCY.  ^     .j.  ^  ^  ^-^^-o^^t^^e.     ^y^-/^/^. 

Mrs.       i^Out*tM^^     C^.M.'lAy^^C^^  Ad.  /<^tf     cSAJ^yCtjt^o^  ^k\.^.  JZ^/^ 

Date  ^aA..  //-/O   Ref.  by    ^.  ^^-  /^  Ack    Nurse  >^c.««5^:,       ^^'-U^  Tel.  ^.    ^Z" 

Age  ^fufil.  Para-7r~Born    ^.  /".  p")?/  Fam,  Hist   ^o'-^Zc^  /'yif^  ff=i'2uiu4ntU^^ 

Prev.  Hist.     /<-'^<:t.4y(s.^^  ,        /X-i^'yt,^  .        Ay~t.^^<~c£^t>0..<U 

U^n^\.W\i^.  ayt'^ 3 -/tA^,       0~^Ca...iAA.  ,    3  -  ^  t>^»^.^,^l^  ,  Married>^  years 

Prev.  Pregnancies    7~-   ^<--<*-'«-<'^-<-^t^  -        i^<-&Lju.^X-e^»^    ,-<i..-C   /^. 

Abortions,  Cause      '^ 
Prev.  Labors    T"  'U-a.^T..<^o.J^  -  -^^^  .^  f ,    /<^     J~^ii/£:?^-djl^  . 

Puerp.    ^-«si-t-<-o-«^  -   &^K3  e.'^^i^ yt-<j ^L^C6l^<L,   -    ^^Ccc^^^a-^  -^^^-"^    -4^  t</^  . 

Last  Menses  (Normal?)    ;S€^i^-^^-^/^»^  Conception  ?  Quickening  1=^*^/**^ 

Urinalyses 

Datej//?-//0      (7)^.  S.G.^<?/7  U^sts     ^-' Datev/^;^/^         (51||J  S.G. /-^/i  U^asts   <» 

Date    3/Aj<^//0     (3'(S).  S.G./0/</u'^Xlsts  >C<a^  2^.       Date  A.  S.  SO.  U.  Casts 

Date  /?y'^///0     (A^S  G./^/^u':Casts    ^7-<'(?.'^.  Date  A.S.  S.G.  U    Casts 


Fig.  279. — Obverse  of  .\  Filled  Pregnancy  C.a^rd. 


It  means  an  inquiry-  into  the  state  of  tlie  kidney's,  the  liver,  the  heart,  the  blood,  and 
the  mental  faculties. 

He  selects  the  best,  that  is,  the  most  commodious  and  lightest,  room  in  the 


EXAMINATION  Date  VCuO/^     Pf  /  O 

Stature  ^Uf^^u.i^  Height      'S~  —  Rachitis     O 

Lungs     i^.   J?-  ^<^.^  Heari^. 

Breasts       f^^<^  .    ^if-*>^t~ /jiur^t^  Nipples    <^  /*Wft.  > 

Sp.  I.      I      Cr.  I.      I     Bi.-T.     I      D.  B.      I     Ob:  R.    |     Ob.  L.     I     'Circ.      |     CD.     [  C.  V.      I    Bi.-Spt    I      8i-lsch.     |      S.  P.      i       Sac. 

Vaginally  ^^Wa/£  e^a/i-Crtk.  7eaA     ifC^e^  .  i^L>^m  /x,  ^u^a-C/vu^-  'LS.'i^.  ^^^^V^'^^'^ 
Diagnosis    6^  ^yri^,    ^'U.^t-t.oi^.jiJ  -'1^iB^^<^-z^  ^  -  .^/ey^,^|l^'t^zy■t!^^  ,.<x-a-  /i^^^^t-^^"^*^  <a/>'2^52t<  . 


Fig.  280. — Reverse  of  .\  Filled  Pregnancy  Card. 


house,  and  one  that  is  close  to  the  water-supply,  for  delivery,  provides  for  sufficient 
artificial  light,  a  proper  talile  for  possible  operation,  and  satisfies  himself  that  there 
are  towels,  sheets,  cotton,  basins,  etc.,  all  sterilized,  ready  for  the  event. 


248  THE  HYGIENE  AND  CONDUCT  OF  PREGNANCY 

At  this  visit,  unless  previously  instructed,  the  woman  is  told  how  to  decide  that 
labor  has  begun,  and  when  to  call  the  accoucheur  and  nurse,  and  what  physician  to 
summon  in  the  event  of  an  emergency,  when  the  regular  attendant  is  not  obtainable. 
She  is  advised  not  to  take  tub-baths,  to  keep  the  bowels  very  free,  to  limit  the  meat 
in  her  diet,  and  to  drink  a  great  deal  of  water. 

The  Engagement  of  the  Nurse. — An  accoucheur's  success  in  obstetrics  depends 
largely  on  the  nurse.  A  careless  nurse  can  undo  his  best  work.  After  the  diagnosis 
of  the  time  of  labor  is  made,  the  nurse  is  engaged  and  holds  herself  in  readiness  for 
a  call  for  that  time.  The  phj^sician  should  select  the  nurse,  the  woman's  preferences 
in  the  matter  being  consulted  only  when  they  agree  with  his.  A  good  nurse  possesses 
these  qualifications:  She  should  be  neat,  clean,  strong,  healthy,  and  in  love  with 
her  work;  she  should  be  a  gTaduate  of  a  training-school  where  she  has  had  special 
obstetric  training,  and  she  should  be  well  acquainted  with  the  methods  of  her 
physician;  she  should  be  sympathetic  and  agreeable  to  the  patient,  and  withal 
loyal  to  the  accoucheur;  she  should  not  be  a  tale-bearer,  should  not  quarrel  with 
the  servants  in  the  house,  but  should  be  tactful  in  all  her  actions.  Such  nurses  are 
in  gTeat  demand,  and  it  is  well  for  each  obstetrician  to  have  several,  specially  trained 
for  his  own  needs,  at  his  service.  Unless  the  accoucheur  has  a  staff  of  such  nurses, 
it  is  advisable  for  him,  if  he  wishes  to  avoid  mistakes  and  meddlesome  interference 
on  their  part,  to  provide  a  list  of  printed  instructions  regarding  the  care  of  the 
mother  and  babe  during  labor  and  puerperium.  The  author  refers  his  nurses  to  a 
book  ^ratten  by  him,  "Obstetrics  for  Nurses,"  and  thus  avoids  a  great  deal  of  de- 
tailed ex^Dlanation. 

INSTRUCTIONS  FOR  THE  OBSTETRIC  NURSE 

Ten  days  to  two  weeks  before  the  date  of  expected  labor,  visit  the  patient  and  prepare  the 
materials  needed  for  confinement.  See  that  everything  on  tlie  hst  of  articles  needed  (p.  232)  is 
at  hand. 

Basins,  bed-pan,  brushes,  douche-bag,  and  all  utensils  are  carefully  sterihzed  by  steam; 
the  Kelly  pad,  by  soap  and  water  and  soaking  in  1:1000  bichlorid  for  three  hours;  the  douche- 
bag  is  to  be  boiled. 

Prepare  one  dozen  towels,  three  sheets,  two  pairs  very  long  stockings,  or  special  leggings, 
two  pillow-cases,  two  night-go-mis,  two  physician's  gowns,  two  quart  Mason  jars  of  gauze  sponges, 
two  quart  Mason  jars  of  cotton  sponges,  two  pads  of  cotton  covered  with  gauze,  one  yard  square, 
one  receiver,  and  sufficient  \'xilvar  pads  and  umbihcal  cord  dressings  for  the  mother  and  babe 
during  the  puerperium.  These  are  all  packed  in  appropriately  sized  bundles,  securely  covered 
\\'ith  towels  or  newspapers,  distinctly  labeled,  then  sterihzed.  All  these  tilings  are  carefully  laid 
away,  protected  from  dust,  for  the  time  of  labor. 

In-struct  the  patient  how  to  determine  when  labor  is  at  hand,  and  what  to  do  until  you  or 
the  doctor  arrives. 

During  Labor. — When  you  are  called,  see  that  the  accoucheur  is  at  once  notified. 

See  that  there  is  a  supply  of  hot  and  cold  sterile  water. 

Prepare  the  patient  as  follows:  Give  colonic  flushing  of  warm  soapsuds;  shave  genitalia; 
full  shower-bath;  scrub  torso  with  soap  and  water,  pa^-ing  special  attention  to  the  genitalia;  rinse 
and  wash  thoroughlyfrom  ensiform  to  knees  with  1:1500  bichlorid.     Put  on  sterile  night-gown. 

Do  not  examine  the  patient  internally  nor  give  vaginal  douches  without  permission. 

Keep  an  accurate  record  of  pulse,  temperature,  and  all  the  occurrences  during  labor  and  the 
puerperium. 

See  that  the  patient  takes  light  nourishment  during  the  first  stage. 

Provide  quiet,  cheer,  and  fresh  air  for  the  patient.     Allow  no  gossip. 

See  that  the  bladder  is  emptied  every  four  and  the  rectum  every  twelve  hours,  asking  the 
accoucheur  for  orders  regarding  them. 

When  the  second  stage  draws  near,  dress  the  bed  and  the  patient  with  the  sterile  articles. 

Be  ready  to  assist  the  accoucheur  in  caring  for  the  feces  which  may  escape  from  the  anus 
(basin  of  1:1-500  bichlorid  and  large  cotton  sponges). 

Have  sterile  scissors,  tape,  and  artery  clamp  ready  for  the  cord,  and  gauze  pledgets  for  wiping 
the  eyelids  and  throat.     Antiseptic  for  the  eyes. 

As  soon  as  the  child  is  severed,  wrap  it  warmly  in  the  receiver  and  put  in  a  warm,  safe  place. 
Look  at  it  occasionally  for  hemorrhage  from  the  cord  or  choking. 

Receive  the  placenta  in  a  basin  covered  with  a  sterile  towel,  and  be  sure  to  present  it  to  the 
accoucheur  for  his  inspection. 

During  the  Puerperium. — Treat  the  genitalia  as  an  open  surgical  wound.  Change  the 
pads  when  soiled,  douching  the  external  genitals  with  1::W00  Inchlorid  each  time.  Give  no 
vaginal  douches  without  orrlers.     See  that  the  patient  urinates  within  eight  hours  after  delivery. 

Give  her  one  ounce  of  castor  oil  on  the  morning  of  the  second  day  after  delivery.  Get  further 
instructions  from  the  accoucheur. 


HYGIENE    OF   PREGNANCY  249 

Support  the  brea-sts  and  alxloiiicii  with  hf^ht  hinders. 

Rc'ijort  to  the  accoucheur  sleeplessness,  temperature  above  99.5°  F.,  pulse  over  100,  head- 
ache, lieniorrhaKc,  .severe  after-pains,  ahdoniinal  (listention  or  pain,  dysuria,  fetid  or  abnormal 
lochia,  infe(!ted  perineum,  cracked  nipples,  engorged  breasts,  and  anythinj^  unu.sual. 

The  diet  is  to  be  liquid  for  twelve  hours,  then  light. 

Take  temperature,  pul.se,  and  respiration  at  7  a.  m.,  4  and  i)  i*.  .m. 

(^onsult  the  acccjucheur  re{i;ardin(j;  the  time  to  ^jet  patient  out  of  bed. 

CauI';  ok  Cuili). — See  that  the  eyes  are  cared  for  according  to  tiie  accoucheur's  practice. 
Anoint  the  child  with  albolene,  lul)  all  off,  then  disinfect  and  dress  the  cord  with  dry  sterile  gauze. 
Change  only  when  soiled. 

Wash  eyelids  and  nostrils  once  daily  with  extreme  gentleness.  A  half-bath  daily  until 
navel  is  cicatrized,  then  a  full  l)ath  or  an  oil  rub. 

Take  temperature  and  pulse  \.  m.  and  p.  M.     Weigh  daily.     Record  everything. 

Give  10  drops  of  castor  oil  on  morning  of  second  day. 

Let  infant  nurse  every  four  hours  until  milk  comes,  then  every  three,  beginning  at  7  a.  m. 
Let  nur.se  once  after  10  p.  m.  until  three  weeks  old,  then  train  to  sleep  the  night  tlirough. 

Report  to  the  accoucheur  temperature  above  99. .5°  F.,  ab.sence  of  bowel  movements  or  urine, 
con\iilsions  or  nervous  symptoms,  \-omiting,  redness  of  eyes  or  navel,  hemorrhage  from  any  place. 

In  general,  the  breasts,  the  genitalia,  and  the  navel  of  tlie  infant  must  be  regarded  as  open 
wounds  and  treated  invariably  \\ith  extreme  surgical  cleanUncss. 


ANTENATAL  THERAPEUTICS 

Closely  allied  to  the  subject  of  eugenics  is  the  special  care  of  the  woman  and 
her  babe  during  pregnancy,  with  a  view  of  producing  healthy  and  mature  offspring. 
All  that  has  l^een  previously  said  in  this  chapter  really  has  this  object;  but  if  one 
bends  his  mind  to  the  matter,  one  will  agree  with  Ballantyne  that  there  exists 
here  a  field  still  sparsely  settled,  very  vast,  and  intensely  alluring.  We  seek  to  dis- 
cover and  counteract  the  effects  on  the  fetus  of  syphilis,  tuberculosis,  hemophilia, 
alcoholism,  and  other  chemical  poisons,  lead,  arsenic,  phosphorus,  tobacco,  etc. 
We  seek  to  discern  the  causes  of  abortion  and  premature  labor  and  to  avoid  them ; 
also  to  learn  to  cure  those  diseases  which  necessitate  the  artificial  interruption  of 
pregnancy — for  example,  hyperemesis  gravidarum,  chorea,  placenta  prsevia,  etc. 
We  seek  to  trace  the  occurrence  of  fetal  monstrosities,  but  have  not  advanced  at  all 
in  this  direction,  even  in  the  cases  of  those  women  who  have  such  a  hereditary  dis- 
position. 

In  practice  among  the  well-to-do  the  children  are  larger  and  stronger  than 
among  the  very  poor,  though  the  difference  is  not  as  great  as  one  would  expect. 
Studies  of  the  factory  workers  in  Europe,  where  the  proportion  of  the  operatives 
that  are  pregnant  women  is  larger  than  with  us,  have  proved  that  their  children  are 
more  likely  to  be  premature,  puny,  inidersized,  or  weakly.  Certain  cities  have 
arranged  to  give  the  pregnant  woman  a  respite  from  work  for  six  weeks  before 
delivery  and  four  weeks  afterward,  and  France,  Italy,  and  Switzerland  are  consider- 
ing bills  making  such  relief  from  toil  obligatory,  Austria  and  Germany  have  passed 
such  laws  and  have  rendered  their  application  possible  by  providing  the  financial 
aid  such  women  need  when  they  stop  working.  In  Paris  there  are  homes  for  women 
in  the  last  weeks  of  pregnancy,  and  experience  has  shown  their  good  effect  upon  the 
new-born  children  and  the  mothers.  But  our  maternities  should  do  this  and  more 
— they  should  be  open  for  the  reception  of  ill  pregnant  women,  or  those  with  ill 
fetuses,  with  a  view  of  the  thorough  scientific  study  and  investigation  of  the  chseases 
of  gestation  and  of  the  unborn  fetus,  and  the  discovery  of  means  of  prevention,  cure, 
or  amelioration.     This  is  the  "  prematernity  "  of  Ballant  jTie. 

Literature 

DaUantyne:  Antenatal  Pathologj-,  1902. — Barbaud-LeFevre:  La  Puberte,  Paris,  1S97. — Budin:  Varnier,  Fabre,  Leopold, 
190S. — Forel:  The  Sexual  Question,  1908.  What  a  Young  Girl  Should  Know. — Fry:  Maternity,  1907. — Goenner: 
Zeit.  f.  Geb.  u.  Gyn.,  vol.  xliv. — Panin:  Obstetrics,  1S95,  pp.  219  and  225. — Pinard:  Annales  de  Gj-n.,  1S9S. — 
Ploss:  Das  Weib  in  der  Natur  und  Volkerkunde,  vol.  i,  p.  602;  Das  Weib,  he.  cil.,  p.  600  et  seq. — Skutsch:  Die 
Beckenmessung.  Monograph.  Gives  historj-  and  illustrations  of  instruments,  1886. — Surbled:  La  Vie  a  Deux, 
Paris,  1901. 


CHAPTER  XVIII 
THE  DIAGNOSIS  OF  PREGNANCY 

Certainty  in  the  diagnosis  of  pregnancy  cannot  always  be  attained,  but  a  high 
degree  of  probabiUty  can  be  reached.  This  most  common  condition,  which  any 
matron  thinks  she  could  diagnose  with  ease,  may,  after  skilful  application  of  all 
the  means  of  investigation,  assisted  by  long  experience,  and  studied  with  a  view  to 
careful  judgment,  escape  discovery  or  be  mistaken  for  something  entirely  different. 
While  we  \\dll  admit  that  error  may  not  always  be  avoided,  it  is  also  true  that  blun- 
ders are  more  often  due  to  carelessness  in  making  the  examination,  and  lack  of 
consideration  of  all  the  facts  learned  by  it,  than  to  ignorance.  Socrates  said  that 
in  studying  ourselves,  we  should  ''lay  aside  prejudice,  passion,  and  sloth,"  an  axiom 
which  could  well  apph^  to  the  diagnosis  of  pregnancy. 

Sometimes  the  diagnosis  may  be  made  very  quickly,  but  the  accoucheur  is 
warned  to  guard  his  statements,  because  the  people  believe  the  fact  of  pregnancy 
should  be  very  patent  and  will  discredit  the  physician  if  the  event  prove  him  wrong, 
and,  further,  much  depends  on  his  decision.  The  question  of  heritage  of  property, 
of  prosecution  at  law  of  women  accused  of  crime,  of  an  illegitimate  conception, 
whereby  the  fair  name  of  a  woman  may  be  blasted,  of  legitimacy  of  offspring;  the 
proper  treatment  of  disease,  as  tuberculosis,  cancer — all  these  depend  on  the  cor- 
rectness of  his  opinion,  and  mistakes  are  very  disastrous  to  both  mother  and  child, 

The  chfficulties  are  greater  in  the  first  four  months,  before  the  fetus  is  large 
enough  so  that  we  can  hear  it  or  feel  it,  but  sometimes  the  question  of  pregnancy  is 
unsettled  until  the  time  for  eventual  delivery. 

In  uncomplicated  cases,  where  only  the  question  of  pregnancy  arises,  the  pa- 
tient is  more  likely  to  be  pronounced  pregnant  when  really  not  so,  but  when  it  is  to 
be  determined  whether  pregnancy  complicates  some  other  pelvic  condition  or  simu- 
lates something  else,  the  pregnancy  is  more  apt  to  be  overlooked.  Thus  in  operat- 
ing for  fibroids  the  surgeon  is  occasionally  surprised  by  finding  a  pregnant  uterus. 

Sources  of  Error. — In  the  early  months  there  is  no  absolute  sign  of  pregnancy. 
The  character  of  a  gravid  uterus  can  be  perfectly  mimicked  by  several  other  condi- 
tions. In  the  later  months  the  positive  signs,  the  fetal  heart-tones  and  movements, 
may  be  absent,  the  child  being  dead  or  the  perception  of  the  movements  being 
interfered  with.  The  patient  herself  may  render  the  examination  nugatory;  she 
may  be  too  fat ;  have,  in  addition  to  pregnancy,  a  tumor,  ascites,  excessive  tympany, 
etc.,  or  she  may  hold  the  abdominal  walls  and  perineum  so  rigid  that  the  accoucheur 
can  feel  nothing  in  the  pelvis.  This  may  be  due  to  nervousness  or  tenderness  in 
the  belly,  or  it  may  be  practised  with  intention  to  deceive.  Another  source  of  error 
is  dehberate  falsifying  by  the  patient.  If  she  is  pregnant,  she  may  desire  to  conceal 
it,  in  order  to  get  the  accoucheur,  unwittingly,  to  produce  abortion,  either  with 
medicine  given  for  amenorrhea  or  by  passing  a  sound  into  the  uterus  for  diagnostic 
purposes.  When  not  gravid,  she  may  desire  a  positive  opinion  of  pregnancy  in 
order  to  perform  blackmail  or  institute  bastardy  proceedings,  or  to  acquire  an  estate, 
as  in  the  case  of  a  widow  being  left  property  on  the  birth  of  a  posthumous  child. 
Under  these  circumstances  she  Avill  declare  all  the  symptoms  of  pregnancy  to  exist, 
and  may  even  try  to  imitate  the  fetal  movements  by  contractions  of  the  abdominal 
walls.  On  the  other  hand,  the  accoucheur  cannot  always  accept  the  statements  of 
the  patient  as  true,  because  she  may  even  delude  herself  into  believing  she  is  preg- 

250 


THE   DIAGNOSIS    OF    PREGNANCY  251 

nant.  When  approachinp;  the  menopause,  especially  if  childless,  women  sometimes 
imagine  themselves  pregnant.  The  abdomen  enlarges,  the  menses  cease,  they  feel 
the  movements  of  the  ciiild,  and  even  go  into  labor,  having  i^ains.  Pseudocyesis, 
spurious  pregnancy,  "grossesse  nerveuse,"  as  the  disease  is  called,  has  even  baffled 
the  diagnostic  ability  of  the  ablest  surgeons  and  accoucheurs. 

For  materials  on  which  to  build  a  diagnosis  of  pregnancy  we  must  review  those 
changes  of  the  maternal  organism  wrought  by  conception  which  were  considered 
in  the  Physiology  of  Gestation,  for  a  minute  study  of  which  the  reader  is  referred 
to  that  chapter.  As  in  the  discussion  of  a  disease,  we  divide  the  findings  into  two 
groups — first,  those  which  the  patient  tells  of,  called  "symptoms,"  and  those  which 
the  examiner  himself  discovers,  called  "signs."  Symptoms  are  subjective  or 
rational.  Signs  are  objective  or  sensible.  In  general,  in  medicine,  it  is  wise  to  ad- 
here to  objectivity,  for  then  the  chances  of  error  are  reduced,  the  suggestion  element 
of  the  patient  being  removed.  Subjective  symptoms  have,  therefore,  little  value, 
and  an  opinion  based  on  them,  at  best,  is  presumptive.  Objective  signs  have 
greater  value  and  may  allow  a  probable  or  unecjuivocal  opinion  of  pregnancy.  ]Mont- 
gomery  suggested  such  a  division  of  the  proofs  of  pregnancy — presumptive,  probable, 
and  unequivocal.  It  is  wise  to  pursue  a  definite  scheme  in  ehciting  the  proofs  of 
pregnancy,  then  to  assign  to  each  one  its  proper  valuation,  and  to  compare  it  with 
the  supposed  time  of  conception.  The  order  of  appearance  of  the  various  phenom- 
ena of  gestation,  their  mutual  relations  in  time  and  severity,  and  the  length  of 
their  existence — all  these  give  valuable  information  for  the  determination  of  preg- 
nancy, since  irregularities  from  the  typical  course  should  lead  to  discovery  of  the 
causative  anomaly.  For  purpose  of  study  and  practice  the  pregnancy  is  divided 
into  three  periods  of  three  months  each,  that  is,  three  trimesters. 


FIRST  TRIMESTER— SUBJECTIVE  SYMPTOMS 

Cessation  of  Menstruation. — ^This  is  one  of  the  two  really  important  sjTiiptoms 
of  pregnancy,  but  to  have  value  it  must  occur  in  a  woman  previously  regular — it 
must  persist  until  the  time  of  examination.  There  may  be  no  pathogenic  cause 
for  the  amenorrhea  and  no  disease  may  result  from  it.  Three  fallacies  underlie 
this  sjTxiptom: 

A.  Pregnancy  may  occur  without  menstruation:  (a)  As  in  a  girl  before  puberty; 
(6)  during  the  amenorrhea  of  lactation,  or  (c)  amenorrhea  from  other  causes,  as 
heart  disease,  tuberculosis,  and  from  no  cause  at  all;  (d)  after  curetage;  (e) 
after  the  menopause.  Several  cases  are  onVecord  where  a  woman  conceived  before 
the  menses  appeared,  conceived  again  during  the  amenorrhea  of  lactation,  and  thus 
the  reproductive  cycle  repeated  itself  several  times  without  the  appearance  of  the 
menses  for  years.  Cases  of  conception  occurring  during  lactation  are  so  frequent 
that  the  popular  idea  of  the  preventive  effect  of  nursing  should  be  dropped.  Preg- 
nancies occurring  two,  even  four,  years  after  the  climacteric  have  been  reported. 

B.  Menstruation  may  continue  after  conception.  It  is  not  rare  to  learn  of  a 
woman  having  one  or  two  periods  after  she  is  surely  pregnant,  but  usually  the 
amount  of  blood  is  small  and  the  character  of  the  flow  otherwise  abnormal.  If  the 
conception  occurred  just  before  the  menses  were  due,  there  may  be  an  abortive  men- 
struation at  the  proper  time.  That  a  true  menstrual  flow  could  occur  is  possible,  be- 
cause the  two  deciduse  do  not  fuse  until  the  fifth  month.  Instances  where  a  normal 
menstruation  persisted  during  the  nine  months  have  been  reported  by  Caruso  and 
Pettey.  The  older  wTiters  cite  cases  where  the  periods  appeared  only  during  preg- 
nancy. That  the  ovary  continues  to  functionate  during  gestation  is  highly  prob- 
able, as  cases  of  superfetatiou  and  of  menstrual  molimina  and  autopsies  on  preg- 
nant women  prove.  It  is  wisest,  whenever  such  a  discharge  of  blood  occurs,  to 
consider  it  pathologic  and  to  investigate  carefully,  because  usually  one  of  the  follow- 


252  THE  HYGIENE  AND  CONDUCT  OF  PREGNANCY 

ing  conditions  is  causative :  abortion,  cervical  erosions,  disease  of  the  endometrium, 
uterine  polyp,  fibroids,  rupture  of  a  varix  at  any  point  in  the  cervical,  vaginal,  vul- 
var canal,  extra-uterine  pregnancy,  diseases  of  the  ovum,  as  placenta  prsevia,  myxo- 
matous degeneration  of  the  chorion,  etc. 

C.  Other  conditions  may  cause  the  amenorrhea:  (a)  Change  of  climate  or 
environment,  noticeable,  for  example,  in  girls  coming  from  Europe.  It  seldom  per- 
sists over  three  months,  (h)  Mental  influence.  Fear  of  conception,  as  occurs  after 
illegitimate  exposure,  may  cause  the  menses  to  cease.  A  strong  emotion  may  do  the 
same,  (c)  Pathologic  conditions,  tuberculosis,  syphilis,  anemia,  exposure  to  cold, 
and  local  chsease,  atresia  of  the  hymen  or  the  vagina,  (d)  Some  women  are  habitu- 
ally irregular,  being  amenorrheic  for  several  months  at  a  time,  without  apparent 
cause  or  any  ill  health.  Occasionally  a  long  interval  will  interrupt  the  regular 
periods,  and  the  flow  is  likely  to  be  uncertain  during  lactation  and  the  approach  of 
the  menopause. 

One  is  reasonably  safe  in  regarding  a  woman  who  menstruates  perfectly  nor- 
mally as  not  pregnant,  and  also  one  who  can  conceive  and  is  otherwise  well,  and 
who  suddenly  ceases  to  flow,  as  presumably  with  child. 

The  value  of  this  symptom  is,  therefore,  only  presumptive,  but  it  is  useful  in 
fixing  the  date  of  conception  and  to  determine  the  time  of  labor,  and  must  always  be 
noted  for  this  purpose. 

The  Morning  Sickness,  or  Nausea  and  Vomiting. — ^Among  the  so-called 
sympathetic  symptoms,  a  tendency  to  nausea,  often  with  vomiting,  occurring  in  the 
early  morning,  must  first  be  mentioned. 

This  usually  begins  after  the  fourth  week,  but  may  show  itself  earlier,  as  in  a 
case  quoted  by  Montgomery,  where,  at  the  end  of  the  week  after  marriage,  the 
patient  felt  squeamish.  If  the  nausea  is  limited  to  a  certain  period  of  the  day, 
mostly  the  morning,  is  not  attended  with  symptoms  of  disease,  comes  on  in  a  woman 
who  can  conceive  and  who  previously  was  well,  it  is  highly  presumptive  of  the  be- 
ginning of  pregnancy. 

About  one-third  of  gravidse  have  nausea  and  vomiting  as  a  marked  symptom; 
one-third  complain  of  it  occasionally  or  as  being  inconsiderable,  and  about  one-third 
are  free  from  them  entirely.  The  nausea  and  vomiting  occur  earlier,  more  constantly, 
and  more  severely  in  primiparse  than  in  multiparse.  They  recur  in  succeeding  preg- 
nancies, though  usually  in  lighter  form.  Women  of  nervous,  high-strung  tempera- 
ments suffer  more  than  those  of  the  lower  and  hard-working  classes.  This  symptom 
is  further  of  value  in  that  its  continuance  renders  probable  the  life  of  the  fetus,  it 
having  been  observed  that  when  the  child  dies  the  vomiting  ceases.  As  we  shall 
see  when  we  come  to  discuss  the  pathology  of  pregnancy,  the  nausea  and  vomiting 
are  probaVjly  of  a  toxemic  nature.  By  the  time  of  quickening  the  stomach  is  usually 
settled.  The  value  of  this  symptom  is  only  presumptive,  because  there  are  so  many 
other  causes  for  stomach  disturbances.  It  seems  that  many  irritations  in  the  pelvis, 
tumors,  pelvic  peritonitis,  salpingitis,  and  appendicitis,  may  cause  them. 

Salivation. — A  slight  increase  of  saliva  is  a  not  infrequent  accompaniment  of 
the  naus(!a,  and  has  the  same  cause,  probably  a  toxemia.  Dewees  called  it  "cotton 
spitting,"  and,  occurring  in  a  healthy  woman,  unattended  with  foetor  ex  ore  or  other 
sign  of  mercurialization,  it  has  some  slight  value  in  the  diagnosis  of  pregnancy, 
though  it  may  occur  in  other  uterine  conditions  and  hysteria.  There  is  a  gingivitis 
which  occurs  at  this  period,  with  salivation,  loosening  of  the  teeth,  bleeding  from 
the  gums,  etc.,  which  is  distinctlypathologic,  and  will  be  considered  in  the  Pathology 
of  Pregnancy,  as  also  will  the  profuse  salivation,  an  exaggeration  of  the  above 
symptom. 

Change  in  disposition,  the  feeling  of  being  pregnant,  various  neuralgias,  and 
other  subjective  symptoms  are  unreliable  in  a  serious  diagnosis,  because  they  can 
all  be  auto-suggested  Ijy  the  patient,  especially  if  she  is  yearning  for  a  child.     How- 


Fig.  2S1. — Virgin  Blonde,  Xixeteex  Years. 


Fig.    2S2. — Pregnant     Blonde,    Pkimipara,    Eight 
AND  One-half  Months. 


Fig.     283. — \'irgin     Red-haired     Girl,     Seventeen  Fig.    2S4. — Pregnant     Red-haired    Woman,    Primi- 

Years.  para.  Eight  Months. 


Fig.     J-...         XlK'l-,      i'.  i:  IM.]'I  1   ,      XlNl/I  l,l-._\      'i'EAIi^: 


Fig.    2S(i. —  PiiK<i\ANT    I'.hi'nktti: 
Ft;LL  Term. 


FmMirAUA,   An<n  T 


THE    DIAGNOSIS    OF    PREGNANCY  253 

ever,  when  an  intelligent  multipara,  having  missed  a  period,  believes  she  is  preg- 
nant, one  must  tittacli  at  least  presum|)tiv('  value  to  the  sym[)tom. 

Irritability  of  the  Bladder  and  Symptoms  of  Pelvic  Congestion. — The  pregnant 
uterus  (Iocs  not  wci);li  heavily  on  the  bladder  because  its  specific  gravit}'  is  a))Out 
the  same  as  that  of  the  intestines,  but  the  anteversion  of  the  fundus  throws  the  cervix 
toward  the  hollow  of  the  sacrum  and  stretches  the  base  of  the  bladder,  causing  the 
frequency  of  urination  so  often  mentioned  by  gravida)  in  the  first  trimester.  Later, 
when  the  fundus  conies  to  be  supported  by  the  alxlominal  wall,  the  cause  and  the 
symptom  disappear.  The  softening  of  the  parts  and  tlie  congestion  of  the  pelvis 
lead  to  a  leukorrhea  of  which  the  i)ati(nit  complains  only  if  there  was  ])reviously  some 
catarrh  of  the  organs,  which  catarrh  is  usually  much  aggravated  by  the  pregnancy. 
The  value  of  these  two  symptoms  is  obviously  only  presumptive. 

The  tingling  and  even  shooting  pains  in  the  breasts,  with  their  enlargement, 
also  serve  to  draw  the  physician's  attention  to  the  possil)ility  of  pregnancy. 


OBJECTIVE  SIGNS— FIRST  TRIMESTER 

The  Breasts. — As  early  as  the  fourth  week  there. may  be  some  enlargement  of 
the  breasts,  and  often  the  patient  notices  a  tingling  or  burning  sensation  in  them. 
The  enlargement  progresses  from  periphery  to  center,  and  continues  throughout 
prc^gnancy,  though  not  evenly.  Lineie  albicantes  or  strife  gravidarum  appear  on 
them,  and  blue  veins  may  be  seen  coursing  under  the  thin  skin,  especially  near  the 
nipple.  The  nipple  darkens  and  becomes  more  sensitive  and  erectile;  the  primary 
areola  darkens  and  becomes  puffy,  as  if  there  were  air  under  the  skin.  One  may 
sometimes  feel  the  sinuses  lactiferi  in  the  areola.  The  tubercles  of  Montgomery 
enlarge,  and  occasionally,  even  in  the  first  trimester,  on  pressure,  a  fine  stream  of 
colostrum  may  be  expressed  from  them.  They  may  connect  with  the  sinuses  lac- 
tiferi. These  tubercles  not  seldom  become  infected  during  pregnancy  or  the  puer- 
perium.  Aroimd  the  areola,  especially  in  brunets,  there  often  develops  another 
pigmented  area — the  secondary  areola.  It  is  lighter  in  shade  than  the  pigmenta- 
tion of  the  primary  areola,  and  resembles  dusty  paper  on  which  water  has  been 
sprinkled,  an  effect  due  to  the  absence  of  coloring  around  the  sweat-glands.  The 
nipple  and  primary  areola  are  often  covered  with  branny  scales,  made  up  of  dried 
sebaceous  matter  and  epithelium.  The  epithelium  of  the  areola  sometimes  ex- 
foliates, carrying  the  pigment  with  it,  showing  that  the  latter  is  deposited  in  the 
deeper  epidermal  layers.  Much  of  the  coloring  disappears  after  weaning  of  the 
baby,  but,  especially  in  brunets,  more  or  less  remains  permanently. 

Colostrum  may  be  expressed  from  the  nipple  as  early  as  the  twelfth  week,  but 
it  may  not  be  present  until  after  delivery.  Of  these  findings,  the  most  significant  is 
the  change  in  the  areola,  the  deepened  color,  and  the  puffiness.  All  the  signs  are 
more  marked  in  primiparse,  as  in  multiparse  traces  often  hold  over  from  previous 
pregnancies.  The  breast  signs  have  no  value  in  an  old  multipara  as  the  breasts 
are  enlarged  and  often  contain  milk  for  years.  Aside  from  these  fallacies — (1) 
neurotic  women  may  have  tingling  in  the  breasts,  enlargement  of  the  areola,  and 
even  colostrum  during  the  menstrual  periods.  (2)  Cases  of  pseudocyesis  maj'  show 
all  the  signs.  (3)  Prostitutes  and  masturbators  not  seldom  show  the  signs,  es- 
pecially if  they  have  pelvic  disease.  (4)  The  breast  changes  have  been  observed  in 
cases  of  ovarian  cyst,  fibroids,  hematometra.  It  must  be  admitted  that  under  these 
circumstances  the  findings  are  not  so  typical,  but  their  occurrence  in  other  con- 
ditions than  of  pregnancy  lowers  the  value  of  the  sign.  Especially  is  the  presence  of 
colostrum  deceptive.  It  occurs  in  neurotic  women,  even  if  unmarried,  and  in  men, 
and  the  lower  animals  not  pregnant.  Cases  are  on  record  where  girls  have  suckled 
infants,  the  breast  being  stimulated  b}'  irritating  poultices  and  suction,  and  men 
have  nursed  children  (Tanner).     The  value  of  this  sign,  therefore,  is  presumptive. 


254 


THE  HYGIENE  AND  CONDUCT  OF  PREGNANCY 


and,  if  the  changes  are  all  marked  and  typical,  which  usually  occurs  about  the  fifth 
month,  the  pregnancy  might  be  said  to  be  probable,  but  at  this  time  there  are  other 
certain  signs. 

It  serves  to  call  attention  to  the  necessity  of  a  pelvic  examination.  During 
lactation  a  sudden  diminution  of  the  quantity  and  alteration  of  the  quality  of  the 
milk,  which  usually  produce  effects  on  the  nursling,  are  suggestive  of  the  existence 
of  a  new  ]3regnancy. 

Bluish  Discoloration  of  the  Vulva,  Vestibule,  and  Vagina. — Jacquemin,  in  1836, 
discovered  this  bluish,  dusky  hue  of  the  vestibule  and  anterior  wall  of  the  vagina, 
but  Chadwick,  in  1886,  emphasized  its  importance.  The  sign  is  named  after  both 
these  men.  It  is  usually  most  marked  around  the  meatus  and  in  the  vestibule, 
extending  up  the  anterior  vaginal  wall,  and  is  likened  to  the  color  of  the  lees  of  wine 


Fig.  287. — Hegar's  Sign.     Usual  Method. 


— that  is,  an  opaque,  bluish  tint  with  a  tendency  to  violet.  It  appears  about  the 
eighth  to  the  twelfth  week,  and  becomes  more  marked  as  pregnancy  advanceSo  It 
is  more  marked  in  multiparas  than  in  primiparaj,  in  women  with  catarrhal  or  other 
disease  of  the  genitalia,  and  in  those  with  contracted  pelvis,  especially  if  they  have 
had  previous  hard  deliveries.  It  is  almostalways  present,  but  may  not  appear  until 
very  late,  and  in  rare  cases  not  at  all.  It  often  disappears  if  abortion,  with  hemor- 
rhage, begins  and  if  the  ovum  is  blighted.  Since  the  discoloration  is  essentially  a 
local  venous  congestion,  it  may  be  simulatcnl  by  other  conditions  which  may  cause 
the  latter — for  example,  menstruation,  rapidly  growing  pelvic  tumors  of  all  kinds, 
displacements  of  the  uterus,  residua  of  previous  pelvic  inflammation  which  disturb 
the  pelvic  circulatory  conditions  (parametritis,  scars,  phlebitis,  thrombosis),  and  in 
heart  disease  and  obesity.     All  these  circumstances  detract  from  the  value  of  the 


THE    DIAGNOSIS    OF   PREGNANCY 


255 


sign,  leavinjj;  it  only  picsiimpl  i\c.  At  t('iii])ts  liave  been  made  to  diagnose  pregnancy 
with  tlic  cystoscopc,  aiulwlicn  all  the  other  pelvic;  organs  show  the  non-inflammatory 
congestion  of  pregnancy,  the  bladder  sIkjws  it  also. 

Softening  of  the  Cervix  and  Vagina. — The  congestive  hyperemia  of  the  pelvis 
is  early  nianil'ested  by  a  softening  of  the  vagina  and  the  cervix.  These  may  be 
noted  in  primi[)ara)  in  the  sixth  week,  and  even  earlier,  by  an  acute  observer,  in 
nniltipara?.  The  ui)per  and  lower  ])ortions  of  th(>  cervix  soften  first,  and  at  the  same 
time  one  notes  the  succulence  of  the  vagina,  with  an  increase  of  the  leukorrheal  dis- 
charge. Goodell  ascribed  much  diagnostic  value  to  this  sign,  saying:  "If  the  cervix 
feels  as  hard  as  the  cartilage  of  the  nose,  no  pregnancy  exists;  if  it  feels  like  the 
nuicous  membrane  of  the  lip,  pregnancy  is  possil:)le."  The  same  fallacies  underlie 
this  sign  as  the  last,  and  its  value,  therefore,  is  only  presumptive.  Further,  in  cases 
of  chronic  cervicitis  the  cervix  may  soften  ])ut  little  until  the  last  months  of 
])regnancy. 

Hegar's  sign,  or  softening  and  compressibility  of  the  isthmus  uteri  and  lower 


Fig.  2SS. — Hegar's  Sign,  Taken  by  Thumb  in  Vagina  and  Finger  in  RECxrM.     Useful  in  Fat  Women. 


uterine  segment  (Fig.  287).  On  bimanual  examination  the  isthmus  uteri  is  com- 
])ressed  between  the  two  fingers  in  the  posterior  fornix  and  the  abdominal  hand.  In 
typical  cases  one  can  bring  the  fingers  together  so  that  the  uterine  tissue  between 
seems  reduced  to  the  thinness  of  paper.  In  fat  women,  or  those  in  whom  the  ab- 
dominal muscles  are  held  rigid,  one  may  elicit  the  sign  with  one  finger  in  the  rectum 
and  the  thumb  in  the  vagina  (Fig.  288).  It  may  be  necessary  to  give  ether  and  to 
draw  the  uterus  down  with  a  vulsellum  to  get  the  information,  but  cases  are  rare 
where  such  a  procedure  is  indispensable.  This  sign  is  only  another  evidence  of  the 
softening  of  the  uterine  muscle.  The  succulence  of  the  tissues  is  most  marked  in 
the  lower  uterine  segment  and  upper  cervix  (the  isthmus),  and  permits  the  pressure, 
exerted  by  the  fingers,  to  displace  the  ovum  toward  the  fundus  uteri  and  to  slide 
the  various  muscular  lamellae  away.  In  some  favorable  cases  the  muscle  is  so  soft 
that  it  can  be  raised  in  a  fold  or  ridge.  Hegar's  sign  appears  in  multiparse  at  the 
sixth  week,  and  in  primiparae  at  the  eighth  week,  but  is  seldom  fully  developed 
until  the  tenth  week,  disappearing  when  the  uterus  attains  a  size  and  height  which 
make  the  part  inaccessible. 


256  THE  HYGIENE  AND  CONDUCT  OF  PREGNANCY 

"\Mien  well  marked  and  tj^pical,  the  sign  is  highly  presumptive  and  one  of  the 
most  reliable  of  the  first  trimester,  but  that  is  all.  The  author  has  found  the  isthmus 
uteri  soft  and  compressible  in  many  cases  months  after  an  abortion  or  labor,  in 
congested  uteri,  chronic  pelvic  peritonitis,  and  occasionally  just  before  and  during 
menstruation.  The  findings  may  be  imitated  by  a  retroflexed  uterus,  the  angle  of 
flexion  being  soft,  and  by  a  filDroid  in  the  uterine  wall.  Indeed,  the  isthmus  may  be 
so  softened  and  elongated  that  the  cervix  has  been  held  for  the  whole  non-pregnant 
uterus  and  the  pregnant  fundus  has  been  diagnosed  as  a  tumor  of  the  uterus  or 
adnexa.  On  the  other  hand,  even  in  pregnancy,  the  sign  may  be  absent  or  very 
slightly  marked,  or,  owing  to  fat  or  rigidity  of  the  parts,  it  cannot  be  elicited. 

Changes  in  Form,  Size,  Consistence,  and  Position  of  the  Uterus. — These  have 
been  descril^ed  in  the  Physiology  of  Pregnancy  and  Local  Changes  (p.  77). 

(a)  Form. — The  change  from  the  thin  pear  shape  of  the  virgin  uterus  to  the 
rounded,  plump,  bulbous  form,  is  very  noticeable.  If  the  ovum  nests  very  near  to 
the  entrance  of  one  tube,  that  half  of  the  uterus  will  develop  first  and  give  the  fundus 
great  asymmetry,  and  it  might  lead  to  a  false  diagnosis  of  extra-uterine  or  cornual 
pregiiancy  (Fig.  347) .  (See  Ectopic  Pregnancy.)  It  is  called  "  grossesse  angulaire  " 
by  the  French.  In  the  later  development  of  the  ovum  the  symmetry  is  reestab- 
lished. Early  in  pregnancy  one  lateral  half  is  thicker  than  the  other,  or  either  the 
anterior  or  the  posterior  wall  of  the  uterus  is  bulged  outward  more,  these  variations 
being  due  to  the  location  of  the  ovum.  Toward  the  end  of  this  trimester  the  bulg- 
ing of  the  fundus  at  the  sides,  above  the  relatively  small  cervix,  may  be  appreciated 
by  the  finger  placed  in  the  lateral  fornices. 

(h)  Size. — Every  enlargement  of  the  uterus  gives  rise  to  the  suspicion  of  preg- 
nane}^, and  steady  increase  in  size  is  one  of  the  most  valuable  signs  we  have,  but  at 
least  two  examinations  are  required,  and  the  examiner  must  be  capable  and  careful. 
The  same  rate  of  gro\Ni:h  is  found  with  no  other  uterine  tumor.  A  phenomenon 
that  has  not  been  explained  is  a  sudden  softening  and  enlargement  of  the  uterus, 
sometimes  asymmetric,  followed,  after  a  short  period,  by  a  return  to  the  original 
conditions.  It  easily  leads  to  errors  in  diagnosis.  If  a  uterus  that  has  shown  the 
usual  gradual  enlargement  of  pregnancy  suddenly  begins  to  grow  too  fast,  one  will 
suspect  a  polyhydramnion  or  hydatid  mole;  if  the  growth  is  interrupted  and  reces- 
sion begins,  a  blighted  ovum.  The  accoucheur  carefully  notes  the  size  of  the  uterus 
at  his  first  examination.  Four  weeks  later  he  examines  again,  and  if  the  uterine 
tumor  corresponds  in  size  to  that  expected  for  pregnancy,  such  a  diagnosis  is  always 
certain.     Hematometra  and  fibroids  do  not  grow  like  this. 

(c)  Consistence. — An  experienced  hand  can  very  often  make  a  diagnosis  of 
early  pregnancy  from  this  one  sign,  A  pregnant  uterus  is  elastic,  spongy,  and  soft, 
resembling  dough.  At  the  site  of  the  ovum  the  corpus  is  a  little  softer  than  the 
empty  part  of  the  uterus,  while  between  lies  a  groove  which  is  quite  soft.  This  last 
phenomenon  is  not  constant  and  hard  to  elicit,  and  the  conditions  must  be  un- 
usually favorable  (Fig.  95).  Braxton  Hicks  called  attention  to  the  intermittent 
uterine  contractions  of  later  pregnancy.  The  author  has  felt  the  uterus  contract 
as  early  as  the  eighth  week,  and  it  may  even  contract  in  spots.  This  sign  may  be 
used  for  diagnosis  (Dickinson). 

(d)  Position. — The  strong  anteversio-flexio  of  the  uterus,  lying  like  a  lump  of 
dough  upon  the  bladder,  serves  to  draw  the  attention  to  a  possible  pregnancy  im- 
mediately on  the  introduction  of  the  finger  into  the  vagina. 

These  four  signs,  taken  together,  and  by  an  experienced  examiner,  are  suffi- 
cient to  make  a  higlily  pr(jbable  diagnosis  of  pregnancy. 

General  Considerations. — The  examination  should  be  conducted  systemati- 
cally, all  the  points  being  elicited,  not  being  satisfied  with  one  or  two.  The  bowels 
and  })ladder  should  be  emptied,  all  constriction  of  the  abdomen  removed,  with  the 
patient  lying,  appropriately  draped  and  at  ease,  on  a  table.     If  a  definite  order  is 


TIIK    DIAGNOSIS    OF    PREGNANCY  257 

followed,  none  of  the  signs  will  be  overlooked,  and  the  accoucheur  will  be  spared  the 
mortifying  necessity  of  rociuosting  the  patient  to  go  back  on  the  table  for  reexamina- 
tion. It  need  not  be  said  that  tli(!  usual  antiseptic  precautions  an;  to  be  followed. 
Since  a  positive  diagnosis  in  the  first  trimester  may  be  made  only  under  most  favor- 
able circumstances,  the  accoucheur  should  leave  the  answer  doul)tful,  rather  than 
to  announce  a  probable  condition  as  certain,  and  request  the  patient  to  return  in 
four  weeks.  In  cases  where  tlu;  reputation  of  the  woman  is  concerned  it  is  best  to 
wait  until  the  positive  signs  of  the  second  trimester  are  present.  If  the  examiner 
suspects  that  the  woman  desires  a  diagnosis  with  a  view  of  going  to  an  abortioni.st 
for  criminal  purposes,  he  should  withhold  it  entirely  for  several  months,  as  the  public 
believes  abortion  is  safe  only  in  the  earliest  weeks.  Under  no  circumstances  may  a 
physician  prescribe  a  placebo  to  satisfy  the  woman's  desire  for  an  abortifacient. 

The  biologic  diagnosis  of  pregnancy  has  been  made  possible  by  Alxlerhalden,^ 
and  promises  to  be  of  permanent  value.  It  depends  on  the  determination  of  a 
ferment  in  the  blood  of  pregnant  women,  which  will  reduce  placenta-albumen. 

^  See  Abderhaldon,  Die  Serodiagnostic  der  Schwangerschaft,  Deutsche  Medizin.  Wochen- 
schr.,  Nov.,  1912,  Xo.  46. 


17 


CHAPTER  XIX 
SYMPTOMS  AND  SIGNS  OF  THE  SECOND  AND  THIRD  TRIMESTERS 

During  the  second  three  months  of  pregnancy  there  is  usually  a  subsidence  of 
the  SATnptoms  called  sjanpathetic, — the  nausea  and  vomiting,  salivation,  neuralgias, 
and  the  irritability  of  the  bladder, — with  an  increase  of  the  mechanical  symptoms. 
^Menstruation  is  still  absent,  and  a  new  subjective  symptom  develops — the  patient 
feels  the  motion  of  the  child. 

Quickening. — About  the  sixteenth  to- the  eighteenth  week  the  woman  begins 
to  feel  something  in  the  abdomen,  entirely  unlike  any  previous  sensation.  It  is 
said  to  resemble  the  fluttering  of  a  tiny  bird  in  the  hand.  It  usually  takes  her  a 
week  to  determine  what  it  is,  and  finally  she  concludes  it  is  the  movement  of  the 
child  within  her.  She  is  usually  beset  with  various  emotions,  especially  if  this  be 
her  nature,  and  immediately  feels  the  full  glory  of  maternity.  "Quickening"  is 
the  term  applied  to  the  first  perception  of  the  active  fetal  movements,  and  is  a  relic 
of  the  barbarous  time  when  the  ovum  was  considered  inanimate  until  it  was  felt. 
The  law  reflected  this  belief  and,  until  recently,  a  woman  could  be  hanged  for  murder 
if  she  had  not  "felt  life,"  or  "quickened,"  and  the  innocent  babe  thus  executed  too. 

Fetal  movements  are  felt  earlier  by  women  who  have  felt  them  before,  and  thus 
have  learned  to  recognize  the  faint  impulses,  and  cases  are  recorded  of  "  feelinghfe" 
at  ten  weeks  after  conception.  The  motions  may  not  be  sensible  until  the  sixth  or 
seventh  month,  and  in  rare  instances  not  at  all  throughout  pregnancy.  The  author 
had  one  such  case  where,  in  two  pregnancies,  the  child  was  never  felt  and  was  born 
well  at  term.  The  movements,  which  are  weak  at  first  and  later  stronger,  may  be 
so  vigorous  that  the  patient's  rest  is  disturbed,  or  they  may  be  very  sluggish  through- 
out pregnancy.  Rest,  warmth,  and  narcotics  diminish  the  motion;  their  opposites 
increase  them.  A  shock,  physical  or  mental,  may  abolish  the  movements  for  a  time, 
even  if  the  child  is  well.  The  motion  may  also  cease,  without  cause,  for  periods  of 
days  or  weeks.  Hunger  and  fever  at  first  stimulate  the  fetus;  later,  paralyze  it. 
As  a  symptom  of  pregnancy,  the  quickening  is  of  but  presumptive  value,  because  the 
mother,  if  she  desires  offspring,  only  too  easily  imagines  the  sensation.  Fetal  move- 
ments are  declared  in  nearly  every  case  of  pseudocyesis.  Montgomery  refers  to  the 
famous  case  of  Queen  Mary,  whose  disappointment  on  learning  that  her  fancied 
fetal  movements  were  only  the  signs  of  a  beginning  dropsy,  caused  her  to  instigate 
terrible  persecutions  of  the  Protestants.  Active  intestinal  peristalsis  gives  the 
patient  the  impression  of  the  movements  of  a  child,  as  also  may  contraction  of  the 
recti  muscles,  a  tumor  in  the  belly  falling  from  side  to  side,  and  contractions  of 
portions  or  all  of  the  uterine  wall  when  there  is  a  fetus,  but  it  is  dead. 

One  may  use  the  symptom  for  diagnosis  in  intelligent  women  who  are  without 
motive  for  deception.  It  may  serve  as  a  sort  of  check  on  the  date  of  the  last  menses, 
in  determining  the  length  of  pregnancy.  In  primiparae,  count  twenty-two  weeks 
ahead  to  find  the  probable  date  of  confinement;  in  a  multipara,  twenty-four  weeks. 

OBJECTIVE  SIGNS— SECOND  TRIMESTER 
Owing  to  the  presence  of  positive  signs,  the  diagnosis  of  pregnancy  may  be 
affirmed  during  this  trimester.     Although  some  authors  assert  that  conditions  exist 
where  one  must  wait  until  the  physiologic  end  of  gestation  arrives  for  a  sure  diagnosis, 
the  writer  has  never  met  such  a  case. 

258 


SYMPTOMS   AND    SIGNS    OF   THE    SECOND   AND   THIRD    TRIMESTERS  259 

The  Intermittent  Uterine  Contractions. — Braxton  Hicks  first  described  them, 
and  they  are  soinelinu's  nuiuetl  alter  liiiu.  As  early  as  the  tenth  week  the  wliole 
uterus  can  ])e  felt  to  contract,  assuming  more  of  a  pear  shape  and  then  relaxing, 
without  any  jxTceijlion  hy  the  mother.  ^Die  contractions  recur  at  very  irregular 
intervals — minutes  or  hours  and  perhaps  days.  Parts  of  the  uterine  nmscle  may 
also  contract  and  confuse  the  diagnosis.  A  cold  hand,  brusk  manipulation,  the 
active  movements  of  the  child  (B.  Hicks),  bring  on  the  contractions,  and  toward  the 
end  of  pregnancy,  or  when  premature  labor  is  threatening,  the  irritability  of  the 
uterus  is  such  that  even  ordinary  palpation  causes  the  uterus  to  harden.  Nor- 
mally not  felt  by  the  mother,  they  may  be  present  in  the  latter  weeks  and  disturb 
her  rest  seriously  as  "false  pains."  These  produce  no  dilatation  of  the  cervix,  and 
thus  are  distinguished  from  true  lal)or  pains.  A  neurotic  temperament  usually 
explains  the  i)henomenon.  It  is  claimed  that  the  virgin  uterus  contracts,  and  we 
know  that  a  non-pregnant  uterus  can  expel  Ijlood-clots,  membranes,  and  fibroid 
tumors.  The  contractions  of  pregnancy,  therefore,  are  only  the  evidence  of  an 
exaggerated  normal  function  of  the  uterine  unstriped  muscular  fibers.  The  inter- 
mittent uterine  contractions  have  the  action  of  a  local  heart,  squeezing  the 
blood  out  of  the  sinuses  and  allowing  the  influx  of  new  blood  in  diastole;  second,  the 
pelvic  tissues  and  cervix  are  softened  by  the  local  hyperemia  produced,  and  the  so- 
called  "vital  dilatation"  is  favored;  third,  the  regular  assumption  of  the  uterus 
of  its  proper  pear  form  causes  the  fetus  to  take,  and  keep,  a  position  favorable 
to  la])or. 

Soft  fibroids  and  hematometra  may  cause  the  uterus  to  contract,  but  not  in 
typical  fashion,  and  the  recti  muscles  sometimes  imitate  the  sign ;  but  with  these 
eliminated,  the  intermittent  uterine  contractions  become  positive  evidence  of 
pregnancy,  and  are  found  irrespective  of  the  life  or  death  of  the  fetus. 

Active  fetal  movements  felt,  seen,  or  heard  by  the  obstetrician  are  a  certain 
sign  of  pregnancy,  and,  in  favorable  cases,  the  observer  being  skilled,  may  be  de- 
termined as  early  as  the  twelfth  week  (Pinard).  One  may  see  the  slight  shock  of 
the  abdominal  wall,  or  the  passage  of  a  limb  under  it,  and  sometimes  the  motions 
are  so  vigorous  that  they  are  visible  through  the  clothes,  much  to  the  embarrassment 
of  the  mother.  With  the  stethoscope,  one  hears  a  light  tap,  like  that  of  the  finger 
against  the  back  of  the  hand,  held  with  its  palm  against  the  ear.  With  the  hand 
laid  on  the  belly,  one  perceives  a  weak  knock,  or  stroke,  but  sometimes  quite  tumul- 
tuous actions  of  the  extremities  and  back.  Fetal  hiccup  has  already  been  referred 
to.  Active  intestinal  peristalsis  bears  some  resemblance  to  this  motion,  as  do  also 
partial  uterine  contractions,  and,  remarkable  as  it  may  seem,  these  movements  have 
been  imitated  by  the  abdominal  muscles,  so  that  even  painstaking  examiners  have 
been  misled.  The  famous  case  of  Joanna  Southcott,  the  false  prophetess,  who 
thus  carried  on  an  imposture  for  years,  is  one  in  point.  Eliminating  these  sources 
of  error, — and  this  is  very  easy, — the  sign  is  a  positive  one  of  pregnancy  and  of  the 
life  of  the  child. 

Passive  Fetal  Movements. — Owing  to  the  flaccidity  of  the  uterine  wall  and  the 
amount  of  liciuor  amnii,  we  can  give  certain  movements  to  the  fetus  which  have  l^een 
called  " ballottement "  or  "repercussion."  The  sign  is  best  elicited  with  the  patient 
in  position  for  the  usual  g^aiecologic  examination.  Two  fingers  in  the  vagina  give 
the  body, felt  just  above  the  cervix, a  gentle  push;  the  abdominal  hand  feels  it  strike 
the  fundus  of  the  uterus,  and  the  fingers  feel  it  come  to  rest  again  on  the  cervix. 
This  is  t\ioical  l^allottement  and  is  very  rarely  thus  obtained,  one  usually  feeling  the 
body  leave  and  return  to  the  fingers  in  the  vagina.  Repercussion  is  found  from  the 
sixteenth  to  the  thirty-second  week.  Before  this  time  the  fetus  is  too  small  and 
after  it  too  large,  with  too  little  liquor  amnii,  but  one  may  obtain  partial  ballotte- 
ment  of  the  head  by  means  of  the  abdominal  examination,  especially  in  breech  cases. 
Another  method  of  obtaining  the  sign  is  to  place  the  woman  at  the  edge  of  the  bed 


260  THE  HYGIENE  AND  CONDUCT  OF  PREGNANCY 

on  her  side,  allowing  the  uterine  tumor  to  hang  over.  A  stroke  on  the  uterus  from 
below  is  now  given — a  very  uncertain  procedure. 

Ballottement  may  be  simulated  by  an  anteverted  uterus  floating  in  ascitic  fluid, 
a  fibroid  or  ovarian  tumor  with  long  pedicle  in  the  same,  and  a  stone  in  the  bladder. 
It,  therefore,  becomes  a  positive  sign  of  pregnancy  only  when  these  three  are  ex- 
cluded. 

Direct  Palpation  of  the  Fetal  Body. — This  sign  depends  entirely  on  the  skill  of 
the  observer.  On  palpating  an  enlarged  uterus  one  will  feel  a  hard  body  with  parts 
which  resemble  the  head  or  extremities  of  a  fetus,  but  one  must  avoid  hasty  con- 
clusions. 

Fetal  parts  may  be  discovered  as  early  as  the  fourth  month,  and  as  the  child 
grows  more  and  more,  can  be  differentiated,  so  that  later  we  can  distinguish  "large 
parts  "—head  and  breech — and  ''small  parts  " — the  extremities.  Lumps  of  feces  in 
the  sigmoid,  carcinoma  of  the  peritoneum,  sarcoma  of  the  ovaries,  tumors  of  the 
omentmn,  fibroids  of  the  uterus,  can  all  assume  shapes  and  positions  which  would 
mislead  a  careless  observer.  The  absence  of  fetal  parts,  in  a  case  of  pregnancy  where 
they  should  be  felt,  will  lead  to  the  suspicion  of  a  blighted  ovum  or  polyhydramnion. 

Auscultatory  Signs. — The  Fetal  Heart-tones. — Mayor,  of  Geneva,  in  1818, 
described  the  fetal  heart-tones,  but  it  is  believed  (Fasbender)  that  they  were  first 
heard  by  Philip  le  Goust,  in  1650.  Lejumeau  de  Kergaradec,  in  1822,  published  a 
monograph  on  the  subject  which  is  classic,  and  but  little  has  been  added  to  our 
knowledge  since.  Both  observers  were  listening  to  discover  the  sounds  made  by  the 
fetus  splashing  in  the  liquor  amnii.  Depaul  heard  the  heart-tones  as  early  as  the 
eleventh  week,  but  usually  one  finds  them  first  in  the  fifth  month  of  gestation, 
though  it  often  requires  close  application,  and  favorable  external  conditions,  even 
at  this  tune.  At  first  faint,  the  beat  becomes  stronger  as  the  child  grows  larger. 
When  nearer  to  the  abdominal  wall,  the  sound  is  heard  better,  also  through  a  thin 
wall,  and  when  the  baby's  back  is  directed  anteriorly.  A  large  amount  of  liquor 
amnii,  the  placenta  lying  in  front,  the  uterine  bruit,  rumbling  gas  in  the  bowels,  and 
external  noise  all  easily  extinguish  the  sound. 

The  fetal  heart-tones  resemble  the  tick-tack  of  a  watch  heard  by  the  ear 
through  a  pillow;  tick — short  pause,  tack — long  pause.  The  first  sound  is 
isochronous  with  the  systole  of  the  heart  and  with  the  pulse  in  the  umbilical 
arteries;   the  second  sound  is  due  to  the  closure  of  the  semilunar  valves. 

The  rapidity  of  the  beat  normally  varies  from  120  to  160  per  minute,  the  usual 
range  l^eing  132  to  144.  Mention  has  been  made  of  the  supposed  influence  of  sex, 
and  experience  does  seem  to  show  that  girls'  hearts  beat  faster  than  boys',  but  the 
knowledge  is  of  httle  value  in  practice.  Marked  variations  in  rapidity  of  the  heart- 
beat occur  without  cause,  the  count  running  up  to  180  even,  and  then  subsiding. 
Fetal  movements  accelerate  the  beat;  palpation  of  the  fetal  body  does  the  same. 
Fever,  fasting,  asphyxia,  and  hemorrhage  increase  the  rapichty  of  the  heart. 
Uterine  contraction,  pressure  on  the  fetal  brain,  slow  it. 

Pestalozza  obtained  a  cardigram  of  the  fetal  heart,  and  the  writer  has  felt 
it  beat  through  the  abdominal  wall  in  a  case  of  face  presentation,  an  experience 
reported  by  others  also. 

Methods  of  Examination. — The  naked  ear,  the  monaural  stethoscope,  and  the  binaural 
stethoscope  all  give  good  results.  One  will  use  the  ear  when  without  an  instrument,  and  in  places 
where  rumVjling  exterior  noises  interfere,  but  it  is  disagreeable  to  patient  and  examiner.  A  con- 
straincfl  j)osition  should  })e  avoided,  because  this  produces  circulatory  noises  in  the  middle  ear, 
and  a  srnrjoth  towel  must  always  be  laid  between  the  ear  and  the  skin. 

The  monaural  stethoscope  (Fig.  289)  made  of  metal  is  very  useful,  because  it  can  be 
easily  sterilized  (as  with  the  instruments  before  an  operation),  and  pressure  toward  the  fetua 
may  be  made  with  it  by  the  head,  thus  diminishing  the  thickness  of  the  intervening  structures. 
Best  of  all  is  the  binaural  stethoscope  with  a  large  bell.  This  should  be  made  all  of  metal  and 
rubber,  so  that  it  may  be  boiled  with  the  instruments  for  obstetric  operations.  During  ausculta- 
tion, nothing  may  touch  the  instrument  save  the  skin  of  the  patient  and  the  ear  of  the  examiner. 
Pressure  with  the  fingers  causes  a  faint  hum,  which  often  completely  covers  the  sounds.     To 


SYMPTOMS    AND    SIGNS    OF    THE    SECOND    AND    TMIfU)    TRIMESTERS 


261 


prevent  this  imiscul;ir  hum  and  the  sUeUnK  of  llii'  hell  ;iii  cxiKiliciil  (I'iy;.  liOOj  may  ho  adopted — 
the  bell  is  lield  firmly  by  mc'aiis  of  a  rubber  band. 

The  patient  is  comfortably  ananned  at  tlu?  side  of  the  bed  or  on  a  table,  and  appropriately 
draped,  exijosiiifi;  the  abdomen.  In  doubtful  eaises  the  niKht-time  should  be  selected,  and  all 
exterior  noises  rigidly  excluded.  Up  to  the  ftflh  month,  the  stethoscope  should  be  placed  in 
the  median  lin(>  at  the  edf>;e  of  the  pubic  hair.  When  the  child  is  palpable,  one  will  be  able  to 
determine  where  the  heart  is  located  and  listen  there.  It  may  be  neces.sary  to  push  the  child 
against  the  abdominal  wall  with  the  hand,  .so  as  to  bring  its  heart  nearer  the  stethoscope. 

The  fetal  hcart-tonos  arc  the  mcst  reliable  sign  we  have  for  the  diagnosis  of 
pregnancy.  Unless  the  mother's  heart-beat  is  transmitted  to  the  lower  abdomen 
and  has  the  same  rapitlity  (lever,  Basedow's  disease),  there  is  no  question  about  the 


Fig.  2S9. — Monaural  Stethoscope 

OF  ALUMIXnM. 

Can  be  boiled  for  use  during  labor. 


Fig.  290. — Steadying  the  Stethoscope  with  a  Rubber  Baxd. 
The  latter  absorbs  the  muscular  vibrations  and  prevents  the  humming. 


existence  of  a  cliild  in  the  belly.  By  feeling  the  mother's  pulse  while  listening 
over  the  uterus,  and  noting  the  difference,  72  and  140,  and  bj-  following  the  line  of 
increasing  intensity  of  the  sounds,  the  sign  is  easily  proved. 

The  Fetal  Souffle. — This  is  sometimes  called  the  funic  souffle,  a  name  given  to  it 
by  its  discoverer,  Evory  Kennedy,  in  1833.  It  is  due  to  the  rush  of  blood  tlirough 
the  umbilical  arteries,  and  is  heard  when  they  are  subject  to  pressure  or  torsion 
or  tension,  for  example,  coiling  of  the  cord  around  the  neck,  cord  too  short,  between 
the  back  of  child  and  abdominal  wall,  and  under  compression  by  the  stethoscope. 
In  thin  women  the  writer  has  felt  the  cord  coursing  over  the  fetal  back.  In  fetal 
heart  disease  one  hears  cardiac  murmurs  with  the  usual  fetal  heart-tones.  These 
murmurs  may  disappear  after  delivery,  or,  if  the  disease  is  organic,  be  permanent. 

The  fetal  souffle  is  a  soft,  blowing  murmur  heard  -^dth  the  first  sound,  but  it 


262  THE  HYGIENE  AND  CONDUCT  OF  PREGNANCY 

may  be  with  both,  or  even  diastolic.  It  occurs  in  about  15  per  cent,  of  pregnant 
women,  being  more  common  during  labor.  When  present,  this  sign  is  diagnostic 
of  pregnancy. 

The  Uterine  Souffle. — Kergaradec,  in  his  paper  (1822),  described  a  sound  which 
he  heard  while  listening  at  the  sides  of  the  uterus,  and  he  ascribed  it  to  the  rushing  of 
blood  through  the  placenta,  calling  it  the  ''placental  souffle."  It  is  a  soft,  blowing 
sound,  synchronous  with  the  maternal  heart,  having  a  rushing  character,  similar 
to  the  bruit  heard  in  an  aneurysm  or  in  the  veins  of  the  neck,  or  like  the  French 
''vous,"  pronounced  in  a  low,  blowing  tone — "voo."  During  uterine  contraction 
it  is  diminished  or  altered  in  quality;   sometimes  both. 

It  is  heard  best  at  the  left  side  of  the  uterus,  low  down,  but  may  be  heard  on 
the  right  side  or  anteriorly — occasionally  all  over  the  uterus,  or  on  both  sides. 

It  may  be  loud,  drowning  the  fetal  heart-tones,  or  soft,  hardly  audible^even 
absent  in  some  (10  per  cent.)  cases.  It  may  be  heard  at  one  time  and  be  absent 
in  the  same  place  later.     It  may  disappear  during  the  examination. 

In  character  it  is  humming,  blowing,  rushing,  sibilant,  or  even  musical.  It 
may  be  continuous  or  intermittent  or  wavy.  It  is  without  shock,  and  is  usually 
single,  but  may  be  both  systolic  and  diastolic.  Sometimes  pressure  with  the  stetho- 
scope intensifies  the  sound  and  alters  its  character,  and  one  may  feel  the  rush  of 
the  blood  at  the  side  of  the  uterus  with  the  fingers  as  a  systolic,  fine  vibrant  thrill. 
The  origin  of  the  sound  is  in  the  large  vessels, — arteries  and  veins  in  the  sides  of 
the  uterus, — and  its  similarity  to  the  sound  of  a  varicose  aneurysm  is  striking. 
It  is  not  in  the  placenta  because  it  has  been  heard  after  the  placenta  is  removed, 
and  at  locations  far  from  the  placental  site.  It  seems  loudest  near  the  placental 
site.  There  is  no  sound  by  which  we  can  locate  the  placenta,  though  in  extra- 
uterine pregnancy  a  marked  uterine  souffle  will  serve  to  indicate  the  location  of 
the  ovum  in  the  belly.  The  sound  does  not  come  from  compression  of  the  iliac 
arteries  by  the  uterus,  because  it  is  heard  with  the  patient  in  the  knee-chest  posi- 
tion and  before  the  uterus  has  a  chance  to  compress  them. 

Depaul  has  discovered  the  uterine  souffle  as  early  as  the  twelfth  week,  but  most 
observers  have  not  heard  it  until  the  sixteenth  week.  It  is  found  whether  the  fetus 
is  alive  or  dead,  but  usually  diminished  in  the  latter  case. 

As  a  diagnostic  sign  of  pregnancy  its  value  is  only  probable,  because  it  is 
heard  over  all  rapidly  growing  tumors — fibroids,  ovarian  cysts,  even  in  enlarged 
spleen  and  liver,  and  in  cases  of  anemia  and  maternal  heart  disease,  the  cardiac 
murmurs  being  transmitted. 

Changes  in  Form,  Size,  Consistence,  and  Position  of  the  Uterus. — These  have 
already  been  considered  under  the  Physiology  of  Pregnancy.  In  the  diagnosis  of 
pregnancy  the  shape  of  the  uterine  tumor,  its  size  for  the  supposed  length  of 
gestation,  the  consistence  and  location — ^all  these  are  hardly  imitated  by  any  other 
condition:  the  practised  hand,  with  one  grasp,  can  usually  get  enough  information 
for  a  decision.  Any  doubt  will  be  set  at  rest  by  determining  the  rate  of  growth  of 
the  uterus,  when  examined  at  intervals  of  two  to  four  weeks.  No  other  tumor 
grows  so  rapidly  nor  so  typically.  A  peculiar  phenomenon  that  is  as  yet  unex- 
plained, and  which  may  confuse  the  diagnosis,  is  a  sudden  enlargement  of  the  uterus 
to  the  size  of  one  several  months  longer  pregnant,  and  then,  as  sudden,  a  subsidence 
to  the  natural  size.  It  is  referred  to  by  Buettner  and  Dickinson.  In  the  author's 
case  it  very  materially  complicated  the  diagnosis.  Should  the  uterus  cease  grow- 
ing uniformly,  or  even  get  smaller,  the  ovum  is  probably  bhghted. 

These  signs,  together,  give  us  positive  information  of  pregnancy. 

Changes  in  the  Skin, — Pigmentation;  the  mask  of  pregnancy;  the  strise 
gravidarum;  the  changes  in  the  navel — at  first  retracted,  then  pouting,  then  drawn 
up;  the  varicose  veins — all  these  are  significant,  but  have  little  real  diagnostic 
value. 


SYMPTOMS    AND    SIGNS    OK   THE    SECOND    AND    TllUU)   TRIMESTERS  2G3 

O'Donncll,  of  Chicago,  ii>  l''ll,  (Icinonstratcd  an  .r-ray  picture  of  a  woman 
six  months  j)r('<^nant .  It  is  rcpi-oduccd  hci'cvvith.  Mention  must  be  marie  of 
the  serocUagnosi.s  of  pregnancy  by  means  of  tlie  epii)hanin  and  other  reactions. 


Fig.  291. — X-Ray  of  Pregnancy  About  Six  Months.      Slightly  Retouched  (taken  by  O'Donuell,  Chicago). 

SYMPTOMS  AND  SIGNS  OF  THE  THIRD  TRIMESTER 
The  menses  continue  absent.  Any  bloody  show  now  is  either  pathologic  or 
means  that  labor  is  beginning.  The  morning  sickness  is  usually  absent.  Its 
persistence  or  reappearance  indicates  the  necessity  for  a  careful  examination  of 
stomach,  liver,  and  kidneys.  Rarely,  the  vomiting  is  the  result  of  cramping  of  the 
stomach  by  the  high  uterus.  Active  fetal  movements  are  a  more  pronounced 
symptom,  and  may  harass  the  mother,  but  the  child  usually  quiets  down  as  labor 
becomes  imminent. 

1.  The  painless  uterine  contractions  become  more  and  more  noticeable  as  the 
months  go  bv,  until,  toward  the  end  of  this  trimester,  the  uterus  often  responds  to 


264  THE   HYGIENE   AND    CONDUCT   OF   PREGNANCY 

very  slight  irritants.     In  this  way  the  cervix  and  pelvic  structures  are  prepared 
for  the  great  dilatation  they  are  about  to  undergo. 

2.  The  examiner  now  has  no  trouble  to  find  the  movements  of  the  child. 

3.  Ballottement,  or  repercussion,  is  not  obtainable,  unless  there  is  a  great 
deal  of  liquor  amnii  (polyhydramnion),  but  partial  repercussion  is  easily  elicited, 
especially  in  breech  presentations. 

4.  Direct  palpation  of  the  fetal  body  is  plain,  and  toward  the  end  of  the  tri- 
mester is  the  same  as  during  labor.  One  may  now  chagnose  the  presentation  and 
position. 

5.  The  fetal  heart-tones  are  louder  and  more  constant,  and  one  is  more  likely 
to  hear  the  funic  souffie  and  active  fetal  movements. 

6.  The  uterine  bruit  is  more  intense  and  more  distributed. 

7.  The  changes  in  form,  size,  consistence,  and  position  of  the  uterus  are  very 
marked.     These  have  already  been  discussed.     (See  p.  83.) 

8.  The  .T-ray  will  always  disclose  the  fetal  skeleton. 

Only  gross  carelessness  will  explain  a  mistake  in  the  diagnosis  of  pregnancy 
during  this  trimester.  Excessive  fat  in  the  abdominal  wall,  the  presence  of  tumors, 
anasarca,  and  general  peritonitis,  in  the  author's  experience,  have  caused  much 
difficulty,  but  have  not  rendered  a  working  decision  impossible. 


SUMMARY  OF  THE  DIAGNOSIS  OF  PREGNANCY 

First  Trimester 

Cessation  of  menses Presumptive 

Morning  sickness,  salivation,  etc Presumptive 

Changes  in  the  breasts Presumptive 

Jacquemin's  sign Presumptive 

Softening  of  cervix  and  vagina Presumptive 

Hegar's  sign Probable 

Changes  in  form,  size,  consistence,  and  position  of  uterus  .  .  .  Probable 

Taken  all  together,  with  careful  exclusion  of  conflicting  conditions,  a  higlily 
probable  diagnosis  may  be  made  toward  the  end  of  the  first  three  months. 

Second  Trimester 

Absence  of  menses Presumptive 

Quickening Presumptive 

Intermittent  uterine  contractions Probable 

Active  fetal  movements  discovered  by  the  accoucheur Certain 

Ballottement Certain 

Direct  palpation  of  fetal  body Certain 

Fetal  heart-tones  and  souffle Certain 

Uterine  souffle Probable 

Changes  in  form,  size,  consistence,  and  position  of  uterus  .  .  .  Certain 
Skiagraph  of  fetal  skeleton Certain 

Rarely  it  is  impossible  to  make  a  positive  diagnosis  at  the  end  of  the  sixth 
month  of  gestation.  In  the  third  trimester  all  the  signs  become  more  apparent 
and  more  convincing. 

The  Diagnosis  of  Lightening. — When  the  woman  notes,  toward  the  end  of 
pregnancy,  a  subsidence  of  tlio  symptoms  referable  to  the  upper  alxlomen  and  an 
increase  of  pelvic  symptoms,  and  at  the  same  time  a  change  in  the  configuration 
of  the  belly,  as  is  described  on  p.  86,  it  is  fair  to  assume  that  lightening  has 
occurred. 

If,  on  examination,  one  finds  the  antevcrsion  of  the  uterus  increased, — the 
plateau-like  fundus,  the  head  deep  in  the  inlet,^and  on  internal  exploration  the 
changes  described  and  illustrated  on  p.  88,  the  diagnosis  is  positive.  A  real 
prognostic  value  attaches  to  this  phenomenon.     It  means  that  the  particular  head 


SYMPTOMS    AND    SIGNS    OF   THE   SECOND    AND    TIIIKIJ    'JIUMESTERS  265 

can  pass  tlic  pailiciilar  pclx'ic  inlet,  and  since  the  niajorit}'  of  serious  pelvic  de- 
fonnities  are  at  the  inlet,  it  predicts  a  successful  delivery.  Li{i,liteninfi;  may  be 
al)setit  in  the  following  conditions:  Contracted  pelvis  and  its  complement-  a  large 
fetus;  twin  i>ref>;nancy ;  polyhydramnion;  nuiltiparity ;  occipitoposterior  posi- 
tions; i)resence  of  the  placenta  in  the  lower  uterine  segment  (placenta  praivia); 
tumors  blocking  the  inlet.  In  primiparae  the  absence  of  lightening  is  very  .signifi- 
cant. 

Diagnosis  of  the  Life  and  Death  of  the  Fetus. — Without  positive  evidence  to 
the  contrary,  a  fetus  is  considered  alive.  While  we  can  easily  assert  that  the  child 
lives,  we  can  less  readily  be  sure  that  it  is  dead.  The  heart-tones,  the  fetal  souffle, 
and  active  fetal  movements  determined  by  the  accoucheur  are  convincing  that 
the  fetus  liv(^s.  In  a  woman  who  is  healthy  and  feels  perfectly  well  it  is  usually 
safe  to  assume  that  the  child  is  living. 

Symptoms  and  Signs  of  Fetal  Death. — 1.  Cessation  of  fetal  movements  after 
they  have  been  felt.     Presum]^tive. 

2.  Languor,  malaise,  light  chilliness,  foul  taste  in  the  mouth,  symptoms  Avhich 
are  due  to  the  absorption  of  toxins  from  the  dead  fetus  and  arc  analogous  to  those 
arising  from  degenerating  fibroids,  are  presumptive  symptoms  only.  The  same  is 
to  be  said  of  the  feeling  of  weight,  or  of  a  ])ody  lying  heavily  in  the  abdomen. 
Sudden  cessation  of  the  nausea  and  vomiting,  in  the  early  months,  is  suggestive  of 
fetal  death. 

3.  If  a  woman  gives  a  history  of  losing  several  children  at  a  certain  month  in 
pregnancy  and  now  has  identical  symptoms,  the  information  is  suggestive.  When  a 
cause  exists  for  anticipating  fetal  death,  the  diagnosis  is  rendered  easier.  Such 
conditions  are  syphilis,  eclampsia,  nephritis,  high  fever,  cholera,  etc. 

4.  Absence  of  heart-tones.  This  sign  is  of  value  only  after  repeated,  pro- 
longed examinations,  under  most  favorable  conditions  (quiet  room,  proper  posi- 
tion, etc.),  have  failed  to  find  the  heart-tones. 

5.  Cessation  of  gro^vth  of  the  uterus  and  abdominal  tumor.  A  valuable  sign 
if  controlled  by  examinations  repeated  every  three  weeks.  The  uterus,  instead  of 
growing,  gets  smaller,  harder,  and  usually  more  evenly  resistant  all  over;  though, 
occasionally,  it  becomes  irregular,  and  then  making  the  distinction  from  a  fibroid 
is  very  difficult.  The  intermittent  uterine  contractions  are  more  marked  and  there 
may  be  an  occasional  discharge  of  bloody  or  bro^\^lish  mucus.  L'nless  carefully 
considered,  this  sign  may  be  fallacious,  because,  sometimes,  the  uterus  apparently 
ceases  to  grow  or  even  grows  smaller  for  a  time,  even  with  a  living  child  (one  of 
the  causes  of  placenta  circumvallata),  and,  again,  the  uterus  may  enlarge  after  the 
death  of  the  o\"um,  as  in  hydatidiform  mole. 

6.  The  only  positive  sign  of  fetal  death  is  the  palpation  of  the  softened  and 
macerated  fetal  head,  with  the  bones  freely  movable  on  each  other,  the  scalp 
hanging  like  a  loose  sac.  This  sign  may  be  elicited  through  the  vault  of  the  vagina, 
through  the  cervical  canal,  or,  rarely,  through  the  abdominal  wall.  ]\Iaceration  of 
the  fetus  is  usually  so  far  advanced  in  a  week  to  ten  days  that  the  softening  of 
the  skull  may  ha  discovered.  On  abdominal  examination  the  uterus  and  fetus  do 
not  have  the  characteristic  feeling  of  elasticity  and  firmness,  but  this  sign  is  hard 
to  elicit  and  is  valuable  only  to  an  experienced  accoucheur. 

7.  The  discharge  of  bloody  liquor  amnii  or  milky  fluid  is  suggestive,  l)ut  one 
must  eliminate  hydrorrha^a  gra\'idarum  and  early  rupture  of  the  anmion  ^^•ith  sub- 
chorionic  development  of  the  ovum. 

8.  The  breasts  cease  to  grow,  becoming  flabby  and  pendent.     Presumptive. 

9.  The  patient  loses  weight,  which  is  significant,  because  she  ought  to  gain  in 
the  last  four  months. 

10.  The  finding  of  acetone  and  peptone  in  the  urine  has  no  significance. 
IL  Absence  of  the  usual  blood-pressure  variations  in  pregnancy  (Schatz). 


266  THE  HYGIENE  AND  CONDUCT  OF  PREGNANCY 

It  is  not  absolutely  necessary  to  make  a  positive  diagnosis,  since,  if  the  fetus  is 
dead,  deli^•ery  ^nll  soon  occur.  (See  Missed  Abortion,  Chap.  XXXII.)  It  is  usu- 
ally not  necessary  to  induce  labor,  because  no  harm  results,  except  in  the  rarest 
instances.  The  woman  is  instructed  not  to  have  intercourse,  to  take  no  douches, 
etc.,  and  to  report  any  unusual  symptoms. 

Diagnosis  of  Multiparity. — It  sometimes  becomes  necessary,  especially  in 
medicolegal  cases,  to  determine  if  an  existing  pregnancy  is  the  first  one,  or  if  a 
woman  has  previously  borne  a  child.  Such  a  diagnosis  can  usually  be  made  if 
sufficient  care  be  used,  but  if  more  than  five  years  have  elapsed  since  the  birth  of  the 
last  child,  if  it  was  small  or  prematurely  born,  if  it  was  removed  by  a  crushing  opera- 
tion or  by  a  cesarean  section,  or  if  the  genitalia  be  very  large,  it  may  be  impossible 
to  come  to  a  positive  decision,  because  the  only  signs  we  have  are  the  relics  of  the 
traumatisms  of  labor. 

1.  The  deep  rupture  of  the  hymen  and  perineum.  If  the  perineum  is  torn 
and  the  patient  avers  that  no  operation  on  it  had  been  performed  and  that  she  never 
suffered  local  injury  or  had  an  ulcerous  disease,  the  sign  is  positive.  If  the  patient 
•vsdshes  to  hide  the  previous  pregnancy,  she  may  claim  to  have  suffered  injury  in 
some  way.  Rupture  of  the  hymen  alone  is  not  so  certain  a  sign,  since  it  almost 
always  tears  during  coitus.  Deep  tears,  forming  later  the  carunculse  myrtiformes, 
occur  only  during  labor  or  the  delivery  of  a  large  body,  as  a  fibroid.  The  hymen 
may  be  congenitally  absent,  or  it  may  be  so  distensible  that  it  does  not  rupture 
during  delivery.  The  author  saw  only  one  such  case,  with  a  syphilitic  fetus  weighing 
three  pounds. 

2.  Deep  tears  and  scars  in  the  cervix.  In  primiparse  the  cervix  is  conic, 
with  a  round  os.  In  multiparse,  owing  to  inevitable  greater  or  less  laceration,  the 
portio  vaginalis  is  more  cylindric  or  knob-shaped,  and  the  os  is  a  transverse  slit. 
Even  if  the  laceration  of  the  cervix  is  only  moderate,  one  can  distinguish  two  lips — 
an  anterior  and  a  posterior.  Scars  in  the  cervix  may  result  from  operation,  ulcera- 
tion, and  disease,  congenital  or  acquired.  Prolapsus  uteri  and  eversio  cervicis 
have  been  found  in  infants;  and  chronic  cervicitis,  in  virgins,  may  cause  changes 
which  imitate  a  parous  cervix. 

3.  Vaginal  scars  are  often  the  result  of  labor,  but  they  may  be  due  to  opera- 
tion, injury,  or  ulcerative  process,  which  not  infrequently  complicates  the  acute 
infectious  diseases,  e.  g.,  measles  and  scarlatina.  The  vagina  of  a  nullipara  is 
rugous,  rough,  and  tight,  the  levator  ani  holding  it  well  up  against  the  pubic  arch. 
In  a  multipara  the  reverse  is  true,  but  if  many  years  have  elapsed  since  child- 
birth, a  great  deal  of  the  original  condition  is  reestablished.  The  laceration  of  the 
urogenital  septum  and  of  the  anterior  strands  of  the  levator  ani  is  one  of  the  most 
constant  of  puerperal  injuries. 

4.  The  breasts  are  more  pendulous,  flabby,  with  deeply  pigmented  areolae, 
and  sometimes  colostrum  may  be  expressed  from  the  nipioles.  The  fallacies  under- 
lying this  sign  have  already  been  mentioned. 

5.  Striae  gravidarum  may  be  found  on  the  breasts,  abdomen,  and  thighs — 
old,  white,  crinkled,  and  silvery,  mixed  with  the  pinldsh  or  purplish  lines  of  a  new 
pregnancy.  Striae  are  found  in  fat  people,  in  girls  as  they  round  out  at  puberty,  in 
some  cases  of  abdominal  tumors,  after  typhoid  fever;  and,  further,  they  are  absent 
in  5  per  cent,  to  10  per  cent,  of  pregnancy  cases. 

6.  The  recti  and  abdominal  muscles  are  usually  relaxed  and  stretched  after 
the  woman  has  had  a  full-term  child,  but  the  author  has  seen  several  women  in 
whom  the  abdominal  figure  was  perfect  after  two  or  three  full-term  deliveries. 

In  mcflicolegal  cases,  therefore,  one  can  seldom  assert  positively  that  preg- 
nancy has,  or  has  not,  taken  place.  Abortions  and  premature  labor  leave  still 
fewer  traces  behind  them,  and  in  such  instances  the  medical  witness  must  exer- 
cise still  greater  caution. 


SYMPTOMS   AND    SIGNS    OF   THE   SECOND    AND    TlllltD    TRIMESTERS 


267 


The  Diagnosis  of  the  Time  of  Pregnancy  and  the  Prediction  of  the  Day  of 
Confinement. — Botli  physiciim  and  piitient  (Icsirc  t(j  know  when  labor  will  occur. 
One  may  wish  t(i  induce  labor  for  contracted  pelvis  or  to  prevent  overgrowth  of 
the  child;  tiie  other  wishes  to  know  so  that  she  may  arrange  her  household  affairs, 
engage;  the  nurse,  and  so  forth,  hence  it  is  a  matter  of  some  moment  t(j  Ije  able  to 
discover  the  exact  day,  or  come  near  it.  Since  tlie  real  duraticjii  of  pregnancy  is 
unknown,  w(;  can  never  be  sure  of  the  day  when  labor  is  to  begin.  The  moment  of 
(•(juception  varies,  lal)or  is  more  or  less  accidental,  antl,  finally,  the  length  of  preg- 
nancy varies  in  different  women  and  in  the  same  woman  in  her  succeeding  preg- 
nancies.     (See  p.  2(),  The  Duration  of  Pregnancy.) 

Determination  Jrom  Data  Given  by  the  Patient. — 1.  The  date  of  the  fruitful 
coition.  No  reliance  is  to  be  placed  on  the  statement  of  the  patient  that  the 
fruitful  coition  is  distinguished  l)y  a  peculiar  sensation,  and,  therefore,  may  be  used 
in  tiie  reckoning.  The  date  of  a  single  coitus  is  more  reliable,  and  this  may  be 
known,  us  in  cases  of  sudden  death  or  absence  of  husband,  rape,  etc.    If  the  monthly 


Fig.  292. — Ascertaining  Intra-Uterine  Length  of  Fetus. 
Photograph  at  Chicago  Lying-in  Hospital. 


period,  due  within  a  few  days  of  this  date,  remains  absent,  the  jDrolDability  that 
conception  occurred  about  this  time  is  very  strong.  One  should  count  273  days  from 
the  date  of  the  single  coitus  to  determine  the  date  of  confinement.  In  about  one- 
half  of  the  cases  this  date  will  be  right  wdthin  seven  days. 

2.  The  last  menstruation.  Naegele's  rule  is  to  count  back  three  months  from, 
and  add  seven  days  to,  the  date  of  the  first  day  of  the  last  menstruation;  for  ex- 
ample, if  the  patient  menstruated  last  beginning  jNIarch  1st,  December  8th  will  be 
the  day  of  labor.  In  about  60  per  cent,  of  cases  this  method  is  correct  ^nthin  eight 
days. 

3.  Quickening.  It  is  customary  to  count  ahead  twenty-four  weeks  in  multi- 
parse  and  twenty-two  weeks  in  primiparne;  but  in  view  of  what  was  said  regarding 
this  symptom,  it  is  plain  that  no  reliance  at  all  is  to  l^e  placed  on  the  data  obtained. 

Objective  Signs. — 1.  Size  of  the  uterine  tumor,  circumference  of  the  abdomen, 
height  of  the  fundus  from  the  pul)is  or  the  navel— all  these  are  valueless  measure- 
ments, since  so  many  concUtions  may  cUsturbthem;  for  example,  the  amount  of  fat 


268 


THE  HYGIENE  AND  CONDUCT  OP  PREGNANCY 


in  the  abdominal  wall,  tumors  and  gas  in  the  belly,-  the  full  bladder  or  rectum, 
polyhydramnion,  t^vins,  pendulous  abdomen,  contracted  pelvis. 

2,  The  determination  of  the  size  of  the  fetus  gives  more  certain  information, 
as  from  this  we  may  guess,  with  a  fair  amount  of  accuracy,  its  age.  Direct  mea- 
surement of  the  length  of  the  fetus  in  the  uterus,  as  practised  by  Ahlfeld  (Fig.  292), 
is  possible,  and,  since  the  length  of  the  child  is  our  best  (but  poor  at  that)  guide  to  its 
age,  we  frequentl}'^  make  use  of  this  method.  In  primiparse  one  branch  of  the 
pelvimeter  (sterilized)  is  placed  against  the  head  from  the  vagina,  the  other  branch 
resting  on  the  breech.  In  multiparse,  since  the  head  usually  does  not  enter  the  pel- 
vis until  labor  has  begun,  one  puts  the  first  branch  of  the  pelvimeter  over  the  upper 
border  of  the  pubic  symphysis.     By  doubling  the  figure  obtained  and  subtracting 


Fig.  293. — Using  Ferret's  Cephalometer. 
Any  pelvimeter  may  be  used  as  well.     Fhotograph  at  Chicago  Lying-in  Hospital. 


2  cm.  for  the  thickness  of  the  soft  parts,  one  arrives  at  the  length  of  the  fetus  and 
from  this  may  deduce  the  period  of  the  pregnancy. 

Direct  measurement  of  the  fetal  head  has  been  practised,  and  Perret  has  in- 
vented a  cephalometer  for  the  purpose  (Fig.  293).  Such  an  instrument  is  entirely 
unnecessary,  the  ordinary  pelvimeter  giving  equally  good  results.  One  first  care- 
fully determines  the  position  of  the  head  with  reference  to  the  pelvis,  and  then 
places  the  branches  of  the  pelvimeter  as  nearly  as  possible  in  the  occipitofrontal 
diameter.  One  to  two  centimeters  must  be  deducted  from  an  oblique  measure- 
ment to  obtain  the  biparietal  diameter,  and  another  centimeter  for  the  thickness  of 
the  abdominal  wall.  Surprisingly  accurate  results  are  obtained,  and  the  value  of 
the  procedure  increases  with  experience.  In  breech  and  shoulder  presentation  the 
head  is  easily  measured,  unless  labor  has  begun,  but  when  the  head  has  engaged,  it' 
can  no  longer  be  properly  grasped;  then,  however,  the  measurement  is  not  needed. 


SYMPTOMS   AND    SIGNS    OF   THE    SECOND   AND    THIRD    TRIMESTERS  269 

A  biparietal  diameter  of  7>2  ^'"i-  mcHns  tliat  tlie  child  is  (jf  about  thirty  weeks' 
pregnancy,  S}/^  cm.,  about  thirty-four  weelcs,  and  93^  cm.  about  forty  weeks. 

The  measurement  of  the  fetal  head  is  especially  desirable  in  cases  of  contracted 
pelvis,  where  the  (juestion  of  the  induction  of  premature  labor  arises,  or  of  a  radical 
operation  at  the  time  of  full-term  lalxjr. 

8.  Direct  palpation  of  the  fetal,  body.  Long  experience  will  enable  the  prac- 
titioner to  guess  quite  accurately  the  size  and  weight  of  the  child  in  utero,  but  even 
if  his  guess  is  correct,  the  information  is  of  little  value,  because  children  may  vary 
so  much  in  size  even  at  identical  periods  of  pregnancy.  The  author  delivered,  on 
the  same  day,  a  child  at  the  eighth  month  of  pregnancy  which  weighed  eight  pounds, 
and  another,  where  the  mother  was  three  weeks  beyond  her  reckoning,  which 
weighed  three  and  one-half  pounds.  It  has  also  seemed  that  the  child  has  periods 
of  slower  and  quicker  growth,  similar  to  those  of  its  extra-uterine  existence.  Again, 
the  child  may  have  a  large  head  and  a  small  trunk,  or  vice  versa.  It  is  clear,  there- 
fore, that  all  estimations  of  the  period  of  pregnancy  and  of  the  probable  date  of 
confinement,  based  on  the  size  of  the  fetus,  are  unreliable. 

4.  Lightening  before  labor.  It  is  quite  safe  to  expect  the  delivery  to  occur 
within  three  weeks  from  the  time  the  head  settles  into  the  pelvis.  Often  this  oc- 
currence is  attended  by  regular  uterine  contractions  which  may  simulate  the  real 
pains  of  delivery.  Schatz  has  sought  to  determine  the  time  of  labor  by  a  study  of 
the  periodicity  of  the  false  pains  of  the  latter  months  of  pregnancy,  and  by  deduc- 
tions from  a  study  of  the  variations  in  the  maternal  blood-pressure.  It  has  been 
found  that,  during  pregnancy,  daily  examinations  of  the  blood-pressure  show  regular 
phases  which  seem  to  have  two  types, — a  twenty-one-day  and  a  twenty-eight-day 
type,  similar  to  the  usual  menstrual  periodicity.  The  false  pains  of  pregnancy 
seem  to  occur  at  the  period  of  the  curve  where  the  blood-pressure  is  highest,  and  it 
has  been  noted,  too,  that  labor  occurs  at  these  periods.  A  determination,  "v^ath  the 
sphygmomanometer,  of  the  blood-pressure  type,  in  the  latter  months  of  pregnancy, 
therefore,  might  give  some  hint  as  to  the  day  on  which  labor  might  be  expected. 

5.  The  changes  in  the  lower  uterine  segment  and  cervix,  as  described  in  the 
physiology  of  pregnancy,  give  only  relatively  valuable  information  of  the  proximity 
of  labor,  because  they  have  been  observed  three  to  six  weeks  before  delivery,  and 
may  remain  absent  until  actual  pains  have  been  in  operation  some  time.  The  ex- 
treme sensitiveness  of  the  uterus  to  external  irritation  may  give  a  hint  as  to  the 
nearness  of  labor. 

Literature 

Buettner:  Cent.  f.  Gyn.,  August,  1900. — Caruso:  Arch.  di.  Ost.  e.  Gin.,  1900. — Depaul:  Traite  d'Auscultation  Ob- 
stetricale,  Paris,  1S47. — Dickinson:  Amer.  Gyn.  and  Obst.  Jour.,  1892,  vol.  ii,  p.  545;  Trans.  Amer.  Gyn. 
Soc,  1901. — Fasbender:  Geschichte  der  Geburtshilfe,  p.  428. — Hegar:  Deutsclie  med.  Woch.,  1895,  No.  .35. — 
Montgomery:  Obstetrical  Essays  on  Pregnancy,  1857,  pp.  122,  128. — Pettey:  Brit.  Med.  Jour.,  190.3. — Schatz: 
Arch.  f.  Gyn.,  vol.  Ixxii,  p.  168;  vol.  Ixxx,  pp.  558  and  86,  p.  749,  et  seq. — Simpson:  Obstetrics  and  Gjiiecol- 
ogj-,  p.  101. — Tanner:    The  Signs  and  Diseases  of  Pregnancy;  1S6S. 


CHAPTER  XX 

THE  CONDUCT  OF  LABOR 

It  is  a  great  satisfaction  to  the  accoucheur  to  go  to  the  home  of  the  parturient 
knowing  that  everything  for  the  proper  conduct  of  labor  has  been  provided  and  is 
in  readiness.  This  sense  of  satisfaction  is  enhanced  if  he  has  with  him  a  case  or 
satchel  containing  all  the  instruments  and  apparatus,  dressings,  and  medicines 
necessary  for  the  usual  case  of  labor  and  for  the  most  common  complications. 
What  the  accoucheur  will  carry  in  his  obstetric  satchel  will  depend  on  the  condi- 
tions of  his  practice  and  individual  preference.  If  his  patients  are  on  distant  farms, 
he  should  take  with  him  a  complete  obstetric  armamentarium,  which,  though  heavy 


Fig.  29-1. — Author's  Obstetric  S.^tchel.     White  Suit  and  Stethoscope  Taken  Out. 


and  bulky,  is  necessary  if  he  would  give  them  all  the  benefits  of  his  art.  For  a 
town  or  city  practice,  the  instruments  for  the  rarer  operations— craniotomy,  hebos- 
teotomy,  etc. — need  not  always  be  carried.  It  is  absolutely  essential  that  the 
physician  be  prepared  for  the  operations  of  perineorrhaphy,  forceps,  and  version, 
and  for  the  complications,  postpartum  hemorrhage  and  asphyxia  neonatorum. 
The  author's  satchel,  for  ordinary  labor  cases,  contains  the  articles  on  the  list  sub- 
joined. For  complicated  cases  a  separate  bag,  containing  everything  for  operations 
from  perineorrhaphy  to  cesarean  section,  is  provided.  It  weighs  50  pounds  and 
is  very  bulky,  but  when  the  parturient  cannot  be  taken  to  the  hospital  operating- 
room,  the  operating-room  must  be  taken  to  the  parturient. 

270 


THE    CONDUCT   OF    LABOR 


271 


List  of  Articles  in  Obstetric  Satchel  (Fig.  294), 


FOR    ASEPSIS 

Two  storilo  hand-brushes. 

One  surgeon's  gown  tind  eup. 

One  white  duck  suit. 

Four  pairs  sterile  rubber  gloves. 

Four  ounces  lysol. 

Thr(>e    jars    sterile    gauze    and    cotton 

sponges. 
Four  ounces  95  per  cent,  alcohol. 
One     bottle     bichlorid     or      suljlamin 

tablets. 

MEDICINES 

One  quart  of  ether. 
One  ounce  of  fluidextract  of  ergot. 
Six  bulbs  of  "Ergot  Aseptic." 
Three  of  adrenahn  1:10,000. 
Three  of  pituitrin. 
Three  of  sterile  camphorated  oil. 
One  ounce  1  per  cent.  AgNOa. 
A    working    hypodermic    syringe    with 
tablets  of  morphin  and  strychnin. 

sundries 

Linen  bobbin  (sterile)  for  cord. 

Six  tubes  twenty-day  catgut  No.  2. 

One  wide-mouth  jar  with  sterile  silk  gut. 

C.  P.  sodium  bicarbonate  for  boiling  in- 
struments. 

One  nickeled  copper  pan  for  same. 

History  sheets  and  cards  for  physician 
and  nurse. 


Birth-certificates. 
Two  sterih;  version  slings. 
Test-tube  and  reagents  for  albumin  and 
sugar. 

INSTRUMENTS 

One  pair  Simpson  forceps. 

Two  scissors,  long  and  short. 

Four  artery  forceps,  long  and  short. 

Two  tissue  forceps. 

Two  vulsellum  forceps. 

Two  special  cervix  holders. 

One  long  uterine  packing  forceps. 

Three  broad  retractors. 

One  box  needles. 

Two  needle-holders. 

One  stethoscope. 

One  silver  catheter. 

One  rubber  catheter. 

Two  tracheal  catheters. 

One  baby  scale  and  tape-measure. 

One  anesthetic  mask. 

One  pelvimeter. 


FOR  POSTPARTUM  HEMORRHAGE 

One  douche-can  and  tube. 

One  12-yard  jar  lysolized  gauze. 

One  8-yard  jar  of  same. 

One  salt  solution  needle. 

Three  2-dram  bottles  sterilized  salt. 

One  tube  Merck's  sterile  gelatin. 


Fig.  29.5. — Contexts  of  Obstetric  Satcheu 


272  THE    HYGIENE   AND    CONDUCT   OF    LABOR 

Basins  and  towels  are  to  be  found  at  the  patient's  house.  If  they  are  not, 
three  one-quart  cream  pans  and  a  package  of  six  sterile  towels  must  be  added  to 
the  above  outfit.  All  these  things  can  be  comfortably  packed  into  a  17-inch 
"cabin"  satchel.  The  instruments,  all  but  the  scissors  and  stethoscope,  are 
packed  in  the  pan,  and  are  boiled  in  the  same  just  before  they  are  used.  The  medi- 
cine bottles  are  held  in  two  bags  made  of  ordinary  white  cotton  duck,  washable. 
Objection  has  been  made  to  the  leather  satchel  on  the  score  of  its  becoming  infected. 
This  is  possible  if  the  physician  is  careless  and  allows  it  to  become  soiled  with  blood, 
etc.  No  contrivance  can  be  invented  to  take  the  place  of  an  aseptic  conscience. 
By  exercising  care  that  the  satchel  is  not  soiled,  by  frequently  cleaning  it  with  a 
cloth  dampened  in  alcohol,  it  may  be  kept  in  a  safe  condition.  The  instruments  are 
boiled  before  using,  and  the  aseptic  articles  are  all  in  hermetically  sealed  bottles. 
When  the  satchel  has  been  exposed  to  a  known  infected  case,  a  half-ounce  of  forma- 
lin poured  on  a  towel  laid  among  the  bottles,  with  the  lids  closed  for  a  few  hours, 
will  sterilize  it.     A  separate  satchel  should  be  used  for  infected  cases. 

The  methods  for  the  sterilization  and  preparation  of  gloves,  gauze,  etc.,  will 
be  found  in  the  Appendix. 

The  Question  of  Assistance. — A  distinction  between  hospital  and  home 
practice  in  obstetrics  is  gradually  creeping  into  our  scientific  discussions.  Careful 
study  of  existing  conditions  will  convince  any  one  that  the  safest  place  for  the 
parturient  woman  is  the  special,  well-equipped  lying-in  hospital.  Here  are  all 
the  facilities  for  the  aseptic  conduct  of  labor  and  the  puerperium,  here  is  the  danger 
of  child-bed  infection  properly  evaluated,  here  only  are  the  refinements  of  an 
operative  technic  possible,  because  the  operator  has  the  help  of  trained  assistants. 
The  newer  procedures — vaginal  cesarean  section,  hebosteotomy,  cesarean  sec- 
tion and  its  modifications,  the  treatment  of  eclampsia,  ruptured  uterus,  asphyxia 
neonatorum,  the  repair  of  lacerations,  etc.,  all  procedures  which  save  life  and  reduce 
invalidism — can  be  carried  out  immeasurably  so  much  better  in  the  maternity 
than  at  home,  that  one  could  wish  every  woman  would  go  to  such  a  hospital  for  her 
confinement.  That  the  obviously  pathologic  case  belongs  in  the  hospital  cannot 
even  be  discussed.  Another  benefit  which  is  not  so  generally  recognized  is  the 
effect  on  the  physician.  The  maternity  relieves  him  of  a  great  deal  of  actual  labor, 
it  saves  him  many  hours  of  tedious  waiting,  it  lightens  the  burden  of  responsibility, 
and  the  knowledge  that  he  is  prepared  for  all  emergencies  gives  him  a  feeling  of 
security  which  reflects  itself  in  his  work.  The  drudgery  inherent  in  obstetric 
practice  is  thus  largely  eliminated,  and  the  field  becomes  more  inviting  to  the  best 
men  of  the  profession.  That  such  a  movement  will  have  a  marked  effect  on  our 
obstetric  mortality  and  morbidity  tables  is  self-evident. 

But  the  vast  majority  of  births  occur  in  the  patients'  homes  and  will  continue 
so  in  our  day,  and  it,  therefore,  becomes  our  duty  to  better  the  conditions  we  are 
forced  to  meet.  The  people  must  not  expect  such  good  results  as  are  obtained  by 
the  accoucheur  in  his  specially  equipped  maternity,  but  it  is  surprising  how  much 
may  be  accomplished,  and  with  simple  means.  The  preparations  and  the  obstetric 
satchel  have  been  described.  It  is  essential  that  the  accoucheur  have  sufficient 
assistants.  Every  labor  case  should  have  two  physicians.  The  duties  of  the  assis- 
tant are,  first,  to  watch  the  fetal  heart-tones  so  that  if  the  child  should  show  signs 
of  exhaustion  or  asphyxia,  it  be  recognized  in  time,  and  the  frequency  of  still-births 
be  thus  diminished;  second,  to  keep  an  accurate  history  of  the  labor;  third,  to 
care  for  the  patient  during  the  first  stage  while  the  accoucheur  is  attending  to  other 
work,  or  obtaining  the  rest  he  will  need  for  the  proper  conduct  of  the  second  and 
third  stages.  In  this  way  an  impending  convulsion,  or  rupture  of  the  uterus,  or 
internal  hemorrhage  or  any  other  complications  will  be  discovered  early  enough 
for  successful  treatment;  fourth,  to  give  the  anesthetic,  and  assist  at  eventual 
operation;  fifth,  to  care  for  the  baby  or  for  the  third  stage,  if  the  accoucheur  is  busy 


THE    CONDUCT   OF   LABOR  273 

with  the  baby;  sixth,  to  stay  in  tlir  house  an  lioiir  oi-  more  after  delivery  to  handle 
a  possible  pc^stpartuiu  lieniorrhui;c. 

If  obstetrics  is  ever  to  attain  the  dij^nity  of  surgery, — and  it  should,—  if  the 
parturient  woman  is  ever  to  enjoy  the  same  benefits  as  the  surgical  patient, — and 
she  deserves  them, — the  accoucheur  must  be  given  sufficient  help  and  the  make- 
shift policies  of  ol)stetric  prat^tice  must  be  abolished. 

Response  to  the  Call. — The  pregnant  woman  is  to  be  instructed  to  summon 
the  physician  immediately  when  she  feels  that  labor  has  Ijegun,  or  when  she  thinks 
that  something — anything  unusual — has  taken  place,  and  the  physician  should 
respond  at  once.  If  the  call  comes  at  a  time  when  he  cannot  answer,  the  ac- 
coucheur sends  his  associate  or  assistant  to  care  for  the  woman  until  his  arrival. 
In  this  way  a  malpresentation  of  the  child  or  other  complication  may  }je  recog- 
nized early,  at  a  time  favorable  for  its  correction,  the  preparations  for  labor  may  be 
made  (if  the  patient  has  no  trained  nurse),  the  bowels  and  bladder  properly  cared 
for,  and  the  nervousness  of  the  parturient  allayed. 

Arriv(^d  at  the  case,  the  accoucheur  immediately  begins  to  throw  around  the 
patient  all  the  barriers  against  infection,  and  to  study  all  the  conditions,  with  a 
view  to  prevention  and  cure  of  all  possible  complications.  Part  of  this  study  is  a 
test  of  the  urine  for  albumin,  which  may  very  suddenly  appear,  and  a  general 
physical  examination, — heart,  lungs,  etc., — unless  the  same  has  already  been  made. 

Asepsis  and  Antisepsis, — These  have  reference  to,  first,  the  physician; 
second,  the  patient;  third,  the  environment,  and  the  same  minute  attention  to 
detail  is  required  as  for  an  abdominal  section.  It  is  a  question  if  the  uterus  can 
care  for  more  infection  than  the  peritoneum. 

Semmelweis,  in  1847,  called  the  attention  of  the  world  to  the  physician  as  a 
carrier  of  infection,  and  the  latter's  importance  in  this  role  has  been  recognized 
ever  since— in  fact  it  is  exaggerated,  for  the  public  has  held  him  responsible  in 
cases  of  sepsis  wdien  he  was  not  to  blame.  Cases  of  infection  will  occur  under 
ideal  conditions,  and  we  must  look  for  the  cause  elsewhere  than  in  the  accoucheur 
— pro])al:)ly  in  the  woman  herself,  or  even  in  the  husband.  The  precautions  the 
accoucheur  is  to  take,  as  far  as  his  work  is  concerned,  are  well  recognized  and  ought 
to  be  the  common  property  of  the  profession. 

The  accoucheur  should  be  of  clean  personal  habits,  should  not  soil  his  clothes 
by  contact  with  postmortem  tables,  pus-basins,  contagious  disease  cases,  etc.,  etc. 
The  accoucheur  should  not  attend  contagious  diseases,  individual  favorable  ex- 
perience to  the  contrary  notwithstanding,  and  He  Must  Scrupulously  Avoid 
Getting  Infective  Material  on  His  Hands. 

This  is  the  key-note  of  subjective  asepsis  and  cannot  be  sufficiently  emphasized. 
All  infected  things — pus,  dressings,  etc. — should  be  handled  with  forceps  and  per- 
fect rubl^er  gloves.  If  the  skin  of  the  hands  is  once  infected,  it  requires  two  daj^s  of 
frequent  scrubbings  to  obtain  relative  cleanliness  again.  No  method  of  hand  dis- 
infection will  do  it  at  one  operation. 

Hand  Sterilization. — F I'lrbringcr' s  Method. — Pare  the  finger-nails  and  remove  subungual 
dirt  with  a  (hdl  instrument.  Scrub  for  five  to  ten  minutes  in  very  hot  water  with  green  soap. 
Soak  hands  in  9.5  per  cent,  alcohol  one  minute.  Soak  in  biclilorid  1 :  1000  three  minutes.  Sub- 
lamin  is  a  newer  mercury  preparation  said  to  injure  the  hands  less  than  bichlorid  and  to  be  as 
strongly  germicidal. 

Atilfeld's  Hot-Water- Alcohol  Method. — Pare  finger-nails  and  remove  subungual  dirt.  Scrub 
with  soap  and  hot  water  for  three  to  five  minutes;  scrub  in  9.5  per  cent,  alcohol  three  to  five 
minutes,  using  a  square  of  flamicl  inwhich  the  hands  are  wrapped  until  ready  to  examine  or 
operate. 

Halstcd's  Permanganate-of -potash  Method. — Pare  finger-nails,  wash  hands  thoroughly,  and 
remove  subungual  dirt.  Scrub  with  soap  and  hot  water  five  to  ten  minutes,  immerse  hands 
and  forearms  in  hot  saturated  solution  of  pota.ssium  permanganate  until  stained  deep  bro^\Ti. 
Immerse  in  saturated  solution  of  oxalic  acid  until  the  skin  is  decolorized.  Rinse  in  sterile  water  or 
sterile  hme-water.     Some  surgeons  use  bichlorid  in  adchtion. 

While,  scientificallv,  it  is  impossible  absolutely  to  sterilize  the  human  skin,  for 
18  ' 


274  THE   HYGIENE   AND    CONDUCT   OF   LABOR 

practical  purposes  anj^  one  of  the  above  methods,  if  conscientiously  carried  out,  and, 
providing  the  hands  have  not  recently  been  soiled  with  virulent  septic  matter, 
will  prove  safe  to  the  patient. 

For  absolute  assurance  against  carrying  infection  the  accoucheur  should  always 
wear  rubber  gloves  in  his  practice,  and  these  have  the  further  real  advantage  that, 
to  a  great  extent,  they  spare  the  skin  of  the  hands  from  the  corrosive  action  of 
antiseptics.  The  preservation  of  a  smooth  hand  with  well-groomed  finger-nails  is 
an  essential  item  of  an  aseptic  surgical  technic.  The  author  has  not  observed  any 
difference  in  his  results  since  using  rubber  gloves,  but  he  invariably  uses  them  be- 
cause the  frequent  scrubbings  and  applications  of  corroding  antiseptic  solutions 
were  fast  ruining  the  skin  of  his  hands,  and  making  them  harder  and  harder  to 
sterilize.  Other  advantages  of  the  gloves  are:  they  prevent  the  finger-nails  from 
scratching  the  softened  and  dehcate  mucous  membrane;  they  render  the  examina- 
tion less  painful  and  distasteful  to  the  woman — the  gloves  appeal  to  her  sense  of  the 
esthetic ;  finally,  beside  preserving  the  hands,  the  gloves  reduce  the  dangers  of  in- 
fection of  the  accoucheur  by  syphihs,  pus,  etc. 

Objections  urged  against  the  use  of  rubber  gloves  are:  they  interfere  with  the 
sense  of  touch,  making  diagnosis  more  uncertain;  they  do  not  permit  the  use  of  the 
finger  in  puncturing  the  membranes,  in  tearing  through  the  placenta  where  it  is  pre- 
vial;  ancl  in  removing  fragments  of  placenta  from  the  uterine  wall  when  such  are 
adherent;  thej^  interfere  with  instrumentation,  rendering  operations  more  diffi- 
cult and  prolonged;  they  are  liable  to  tears  and  punctures  which  then  permit 
perspiration,  accumulated  in  the  hand,  to  escape  into  the  wound. 

It  is  admitted  that,  at  first,  the  gloves  dull  the  sense  of  touch,  but  practice  soon 
restores  it,  and  one  can  feel  as  well  as  before,  even  though  the  glove  be  moderately 
thick.  One  exception  must  be  made  to  this  statement.  It  may  be  impossible  to 
feel  the  untorn  peritoneum  over  a  ruptured  uterus.  The  removal  of  fragments  of 
placenta  from  the  uterine  wall  is  rendered  possible  by  wrapping  one  or  two  fingers 
of  the  operating  hand  with  gauze.  (See  Fig.  714.)  The  gloves  will  interfere 
very  little  wdth  instrumentation  if  they  fit  well.  The  makers  will,  for  an  insignifi- 
cant extra  charge,  make  a  glove  from  a  model  of  the  accoucheur's  hands.  This 
specially  fitted  glove  will  hardly  prolong  an  operation,  and,  further,  it  is  less  likely 
to  be  torn  or  punctured.  The  possibility  of  injury  to  the  gloves  is  the  only  real  ob- 
jection to  their  use,  but  this  is  reducible  to  a  negligible  minimum  by  proper  technic. 
In  the  first  place,  the  accoucheur  must  consider  every  puncture  of  the  glove  an  error 
in  technic,  and  throughout  the  operation  must  strive  to  avoid  it.  After  each  opera- 
tion all  concerned  in  it  should  publicly  test  the  gloves  and  make  note  of  the  number  of 
punctures.  Then,  too,  the  operator  should  dispense,  as  far  as  possible,  with  instru- 
ments that  are  sharp  or  have  teeth — for  example,  fork  retractors,  bullet  forceps, 
tenacula.  The  author,  with  this  point  in  mind,  has  had  dull  instruments  made  to 
replace  the  rat-tooth  tissue  forceps,  the  vulsellum  forceps,  and  the  rat-tooth  artery 
forceps.  The  ends  of  the  scissors  are  blunt,  and  points,  where  necessary,  are  pro- 
tected as  much  as  possible.  As  a  result  of  these  and  other  precautions  nearly  every 
labor,  and  many  operations — even  craniotomy — are  performed  without  injury  to 
the  gloves. 

An  important  factor  is  the  use  of  dry  sterile  gloves.  If  the  gloves  are  drawn  on 
over  the  wet  hand,  they  macerate  the  skin,  favor  perspiration,  and,  if  punctured, 
allow  the  accumulated  secretions  to  escape  readily.  The  dry  glove  has  not  these 
oV:)jections.  The  puncture  of  one  finger  does  not  communicate  with  the  others,  and 
the  amount  of  secretion  that  escapes  is  negligible.  Further,  it  is  always  understood 
that  the  hands  are  hahitually  kept  from  infection  and  are  carefully  sterilized  before 
putting  on  the  gloves.  Without  gloves,  perspiration  and  scraped-off  epithelium  get 
into  the  wound;  with  intact  gloves,  neither  escapes;  with  a  few  punctures,  only  a 
small  portion  escapes,  and  the  chances  of  infection  certainly  are  less  than  with  the 
bare  hand. 


THE    CONDUCT   OF   LAUOR  275 

The  advantasos,  tlicrcfon',  of  the  gloves  far  outwoigli  tlic  disadvantages,  and 
their  use  cannot  l)e  too  heartily  recommended.  (See  Appendix  for  methods  of  ster- 
ilizing and  caring  for  gloves.) 

White;  duck  trousers  and  a  sterile  gown  are  recommended  for  wear  during  nor- 
mal delivery  and  obstetric  operations.  For  the  hours  of  Avaiting,  the  accoucheur  is 
cleanly  attired  in  a  white  duck  coat.  Street  dirt  and  contagion  are  thus  kept  from 
the  confinement  IkhI.  Th(>  hea(l-i)iece  slunvn  in  Fig.  780  is  used  by  the  author  in 
all  oljstetric  operations  and  most  normal  deliveries.  If  the  accoucheur  is  going  to 
lecture  during  such  a  procedure,  the  head-piece  should  surely  be  worn  to  prevent 
infection  from  droplets  of  saliva  expelled  during  speaking. 

U'ithout  doubt  the  j)hysician  carries  the  greatest  danger  of  infection  to  the 
confinement  room.  The  germs  in  the  air,  in  the  bed-clothes,  in  the  patient's  gar- 
ments, even  those  of  the  vulva,  may  be  the  same  in  name  as  those  he  brings 
with  him,  but  the  former  are  not  virulent,  as  they  usually  have  been  living  a 
saprophytic  (\xistence.  The  physician  comes  in  daily  contact  with  infectious  dis- 
eases, pus,  and  erysipelas  cases,  and  his  person,  clothes,  and  especiall}'  liis  hands 
carry  highly  virulent  organisms. 

That  everything  introduced  into  the  vagina  should  be  absolutely  sterile  re- 
quires no  mention.  The  author  does  not  carry  already  sterilized  instruments  to 
the  case  Ijccause,  to  insure  permanent  sterility,  the  containers  must  be  hermetically 
sealed,  which  is  impractical.  Gauze  and  sponges  in  glass  jars  can  be  thus  carried. 
Instruments  are  boiled  in  2  per  cent,  soda,  borax,  or  lysol  solution,  in  a  tightly 
covered  vessel,  for  five  minutes  just  before  they  are  to  be  used. 

The  Asepsis  of  the  Patient. — Using  culture-media  very  favorable  to  its  groA\i:h, 
Kronig  and  Pankov  have  shown  that  the  streptococcus  pyogenes  exists  in  75 
per  cent,  of  the  vaginas  of  pregnant  women  and  in  nearly  all  puerperee.  Walthard 
found  pathogenic  bacteria  in  27  per  cent,  of  the  vaginas  of  pregnant  women,  and 
these  bacteria  could  be  made  virulent  by  proper  cultural  methods.  The  uterus  and 
upper  third  of  the  cervix  are  sterile,  but  the  vagina  is  often,  and  the  vulva  always, 
infected  with  non-pathogenic  and  pathogenic  bacteria.  Why  does  not  every  woman 
in  labor  become  infected?  Why  does  not  "autoinfection"  occur  more  often? 
Autoinfection  means  the  development  of  sepsis  during  the  puerperium  from  germs 
which  existed  somewhere  in  the  woman's  person  at  the  time  of  labor.  Its  existence 
was  recognized  by  Semmelweis,  later  denied  by  many  authorities,  but  recently  ad- 
mitted as  possible,  but  of  great  rarity,  by  the  majority  of  students  of  the  subject. 
The  reasons  for  the  rare  appearance  of  infection  are:  the  parturient  has  developed 
immunities  against  the  germs  which  have  made  the  vagina  their  habitat;  the  proc- 
ess of  labor  is  a  continual  scouring  out  from  above,  the  flow  of  the  liquor  amnii,  the 
progress  of  the  child  and  the  placenta,  the  running  of  blood,  all  from  above  down- 
Avard,  all  oppose  the  upward  wandering  of  the  vaginal  bacteria;  the  vaginal  mucus 
has  slight  bactericidal  properties;  the  bacteria  have  a  low  -vnrulence  during  labor, 
acquiring  invasive  properties  only  after  the  third  day  postpartum,  but  by  this 
time  the  puerp(>ral  wounds  are  covered  by  granulations  which  oppose  their  attacks. 

Let  the  natural  immunities  be  broken  down, — as  by  severe  hemorrhage,  shock, 
eclampsia,  etc., — or  let  a  new  virulent  bacterium  be  introduced;  let  the  accoucheur 
in  his  manipulations  carry  too  many  of  the  vaginal  bacteria  up  into  the  uterus  (a 
procedure  not  entirely  avoidable),  or  let  him,  by  his  operations,  bruise  and  mutilate 
the  parts  too  much,  or  let  him  break  up  the  protective  granulations  above  referred 
to,  and  the  germs  will  rapidly  invade  the  system,  producing  a  disease  knoAAni  as 
"puerperal  infection,"  termed  by  the  older  Avriters  "child-bed  fever." 

The  asepsis  of  the  patient,  therefore,  consists  mainly  in  the  preservation  of  her 
immunities  by  sustaining  her  strength,  procuring  a  normal  course  of  labor,  avoiding 
the  necessity  for  operative  interference,  and  conducting  these  with  the  least  possible 
amount  of  damage.     By  restricting  the  internal  examinations  and  conducting  the 


276  THE    HYGIENE   AND    CONDUCT   OF   LABOR 

labor  by  external  examination  antl  observation  of  its  course,  we  avoid  carrying  the 
infective  material  present  in  the  vagina  into  the  tissues. 

In  brief,  the  two  main  principles  are :  Limit  the  number  of  the  puerperal 
wounds,  and,  second,  prevent  infection  of  the  necessary  puerperal  wounds. 

How  to  carry  out  these  principles  will  occupy  our  attention  throughout  all  the 
chapters  devoted  to  the  practical  application  of  the  science  of  obstetrics. 

The  Antepartum  Bath. — As  generally  practised,  the  preparatory  bath  given 
in  a  tub  is  dangerous,  because  the  wash-water,  with  the  diluted  soil  from  the  body, 
gets  into  the  vagina.  Bacteriologic  proof  is  not  necessary  to  convince  one  of  this 
fact.  Any  woman  who  has  had  children  will  know  that  the  water  of  her  bath  fre- 
quently gains  entrance  to  the  vagina.  Stroganoff  has  shown  that  the  morbidity  of 
the  maternity  in  St.  Petersburg  has  improved  since  the  shower  was  substituted  for 
the  tub-bath,  and  the  author  recommends  the  shower  in  the  antepartum  prepara- 
tion. First,  the  pubic  region  is  carefully  shaved,  as  for  a  gynecologic  operation. 
A  safety  razor  is  best  for  this  purpose.  Then  the  whole  body  is  scrubbed  with  soap 
and  water.  In  hospitals  a  shampoo  table  is  used.  The  person  is  then  showered 
^^nth.  lukewarm  water,  after  which  the  pudendal  region  is  again  scrubbed  with  soap 
and  hot  water,  using  a  wash-cloth  (no  stiff  brush),  and  paying  especial  attention  to 
the  folds  around  the  clitoris.  Accumulated  smegma  is  removed  with  olive  oil, 
albolene,  or  soft  soap.  After  the  soap  has  been  rinsed  off,  the  region  from  the  ensi- 
form  to  the  knees  is  liberally  sponged  with  1  :  1500  bichlorid  of  mercury,  again 
paying  especial  attention  to  the  pudenda. 

Before  the  bath  is  given,  a  colonic  flushing  of  soapy  water  is  administered,  and 
the  patient  empties  her  bladder.  After  the  bath,  the  patient  is  thoroughly  dried 
with  a  sterile  towel,  dressed  in  sterile  night-dress  and  stockings,  with  clean  slippers 
and  house  dress,  and  conducted  to  the  confinement  room. 

The  Antepartum  Douche. — Since  germs  with  virulent  possibilities  are  natur- 
ally present  in  the  vaginas  of  parturients,  it  would  seem  wise  to  disinfect  the  vagina 
as  we  do  before  gynecologic  operations.  Theoretic  consideration  and  practical 
experience,  however,  show  that  attempts  to  sterilize  the  vagina  before  labor  invite 
the  infections  we  seek  to  avoid.  The  scrubbing  of  the  vagina  and  cervix  robs  the 
mucous  membrane  of  its  protective  mucus  and  epithelium;  the  strong  chemical 
antiseptics  kill  the  delicate  cells  before  they  affect  the  bacteria.  All  that  the  treat- 
ment does  is  to  remove  some  of  the  germs  and  the  secretions,  and  within  a  few  hours 
afterward  the  germs  are  as  numerous  as  before.  The  tissues,  however,  have  sus- 
tained permanent  injury,  and  their  natural  immunities  have  been  reduced.  Ex- 
perience in  the  Leipzig  clinic  under  Menge,  in  parallel  cases,  treated  with  and  with- 
out vaginal  antisepsis,  has  shown  a  higher  morbidity  in  the  former  class.  If  vaginal 
antisepsis  were  necessary  for  good  results,  the  Chicago  Lying-in  Hospital  and  Dis- 
pensary, under  the  author's  management,  would  show  a  higher  mortality  from  sep- 
sis than  5  deaths  in  15,000  cases.  In  2  of  these  cases  sexual  intercourse  had  oc- 
curred within  a  few  hours  of  the  delivery  of  the  child. 

Further,  it  is  as  little  possible  to  sterilize  the  vagina  as  it  is  to  sterilize  the  skin. 
The  author  does  not  use  antiseptic  vaginal  douches  as  a  routine.  Before  operations, 
just  before  introducing  the  hand  into  the  uterus,  the  vagina  is  liberally  flushed  with 
1  per  cent,  lysol  solution  from  pledgets  of  cotton  held  in  the  hand,  the  idea  being  to 
reduce  the  amount  of  infectious  matter  unavoidably  carried  into  the  puerperal 
wounds  by  the  manipulations. 

Under  Asepsis  of  the  Patient  may  be  mentioned  abstinence  from  coitus  during 
the  last  month  of  pregnancy.  The  danger  of  such  a  bestial  practice  is  a  real  one,  as 
the  two  cases  just  referred  to  will  indicate.  In  one  of  these  two  cases  the  procedure 
ruptured  the  membranes,  the  infant  was  born  as  the  medical  attendant  entered  the 
room,  and  the  rest  of  the  labor  was  conducted  without  any  internal  examinations 
or  treatment  whatever. 


THE    CONDUCT   OF   LABOR 


277 


Asepsis  of  the  Environment.  The  loooi  selected  I'or  the  confinement  should  be 
lifi;ht,  airy,  vvitli  {i;u()(l  |)luiiil)iii<'-,  and  may  not  have  been  recently  used  for  a  septic 
case.  The  air  in  the  ordinary  home  does  not  contain  any  virulent  bacteria,  hut 
tliis  cannot  be  said  of  j2;eneral  hospitals  admitting  ])us  cases,  pneumonia  cases,  anrl 
tonsillitis  j^atients  into  the  same  wards  with  maternity  patients.  That  under  these 
circumstances  puerperal  infection  may  originate  has  been  amply  demonstrated  to 
the  author.  The  maternity  case  should  be  in  a  part  of  the  general  hospital  ab- 
solutely isolated  from  tlie  rest  of  the  wards;  better,  in  a  detached  pavilion  of  its 
own,  but  best  as  a  separate  institution  under  its  own  administration. 

The  confinement  room  should  be  cleared  of  all  unnecessary  and  of  upholstered 
I'urniture.     Heavy  hangings,  dust  accunmlators,  and  rugs  should  be  removed  before 


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Fig.   2'M'). — Diagram  of   Hdom  Prf.paked  for  Confinemknt. 


actual  labor  has  commenced.  Sufficient  provision  must  also  have  been  made  for 
light,  especially  for  operations  at  night.  The  room  should  be  conveniently  arranged, 
some  thought  having  been  given  to  it.     Fig.  296  is  an  example. 

The  bed,  preferably  a  narrow  one,  is  moved  away  from  the  wall.  Three  table 
boards  or  shelves  from  a  book-case  are  put  under  the  mattress,  on  top  of  the  spring, 
to  give  it  a  ta])le-like  character,  and  to  prevent  sagging  in  the  center.  The  mattress 
is  covered  with  a  long  ruljber  cloth ;  over  this  comes  a  sheet ;  at  the  middle  of  the 
bed  is  put  a  small  rubber  protector,  and  over  this  a  sterile  sheet,  folded  once,  and 
all  securely  pinned  with  safety-pins.  If  the  patient  has  no  rubber  sheeting,  the 
mattress  is  covered  \yith  five  layers  of  clean  newspapers,  and  these  also  substitute 
the  small  rubber  sheet  under  the  buttocks.  Sterile  newspapers  are  easily  procured, 
and  they  may  be  used  in  many  places  instead  of  sterile  towels.     A  large  bundle  may 


278 


THE    HYGIENE   AND    CONDUCT   OF    LABOR 


be  baked  in  the  oven  like  a  loaf  of  bread.  The  dresser,  side-tables,  and  chairs  on 
which  the  solution  basins  are  laid  are  to  be  covered  with  newspapers. 

To  carry  the  solution  basins,  instrument  tray,  and  pile  of  sterile  towels,  the 
ordinary  sewing-table  serves  admirably,  additional  table  room  being  obtained  by 
means  of  the  ever-present  euchre-table.  The  table  from  the  kitchen  or  a  strong 
library  table  is  used  for  all  operations.  With  a  degree  of  effort  and  forethought  the 
conditions  of  the  lying-in  hospital  delivery  room  may  be  successfully  imitated. 

The  First  Examination. — On  entering  the  lying-in  chamber  the  accoucheur 
takes  note  of  the  general  appearance  of  the  parturient,  the  frequency  and  strength 
of  the  pains,  takes  the  pulse,  and  later  the  temperature.     It  is  not  always  necessary 


Fig.  297. — Is  the  Ovoid  Longitudinal  or  Transverse? 


to  proceed  to  the  examination  at  once:  the  first  few  minutes  may  be  devoted  to 
general  observations  unless  the  indications  point  to  a  quick  delivery.  The  accou- 
cheur then  takes  off  coat  and  cuffs,  rolls  sleeves  above  the  elbow,  puts  on  an  apron, 
washes  the  street-dirt  off  his  hands,  cleans  his  finger-nails  carefully,  and  scrubs  his 
hands  and  forearms  vigorously  with  soap  and  hot  running  or  frequent  changes  of 
water  for  five  minutes  by  the  clock.  The  nurse  in  the  mean  time  prepares  the  pa- 
tient for  the  external  examination,  bringing  her  near  the  side  of  the  bed,  uncovering 
the  abdomen,  but  covering  the  limbs  and  chest  with  a  sheet  and  a  towel.  The 
physician  driers  and  warms  his  hands  and  proceeds  with  the  abdominal  exploration. 
Five  questions  must  be  answered:    (1)  Is  the  woman  pregnant?     (2)  How  many 


THE    CONDUCT   OF   LABOR 


279 


children  has  she  had?  (3)  Is  she  at  term?  (4)  Is  she  in  lahor?  (5)  Complete 
diagnosis  of  tiie  case.  The  first  three  (juestions  will  iiave  Ijeen  answered  l)y  the 
pre<i;naney  examinations  unless  the  physician  is  first  called  during  labor,  hut  let  a 
warning  l)e  sounded  not  to  take  too  much  for  granted,  but  to  proceed  on  the  safe 
grounds  of  a  careful  physical  objective  examination.  Is  the  woman  in  labor?  The 
regular  character  of  the  i)ains,  the  hardening  of  the  uterus,  the  show,  the  proved 
rupture  of  the  membranes,  antl  the  findings  on  internal  examination  will  determine 
this  point;  Init  lal)or  may  cease,  even  after  partial  or  complete  dilatation  of  the 
cervix,  and  pregnancy  continue  for  daj'^s  or  weeks.  The  pains  cease,  the  os  closes, 
and  the  incident  is  called  a  "false  alarm."  False  pains  are  painful  uterine  contrac- 
tions occurring  during  the  latter  part  of  pregnancy,  not  followed  Ijy  dilatation  of 
the  cervix  or  the  appearance  of  a  show.     They  often  attend  lightening,  may  occur 


Fia.  298. — What  is  Over  the  Inlet? 


at  night,  not  seldom  repeat,  and  may  summon  the  physician  and  nurse  on  a  fruitless 
errand.     A  warm  bath  and  an  enema  or  a  dose  of  bromid  will  dispel  them. 

The  diagnosis  of  position  and  presentation  by  abdominal  examination  was  first 
developed  by  Pinard,  and  has  since  been  amplified  by  many  authors.  One  should 
have  a  certain  plan,  which,  if  followed,  will  lead  to  accurate  results  and  prevent 
omissions.  After  noting  the  size  and  shape  of  the  uterine  tumor,  the  follo^Aing  four 
questions  are  answered:  (1)  Is  the  uterine  ovoid  longitudinal  or  transverse?  (2) 
What  is  over  the  inlet?     (3)  What  is  in  the  fundus?     (4)  Where  is  the  back? 

1.  The  hands  are  laid  on  either  side  of  the  belly,  and  the  uterine  tumor  straight- 
ened between  them,  thus  easily  determining  if  the  fetal  and  uterine  ovoid  lies  paral- 
lel A^ith  the  long  axis  of  the  mother  or  not.  If  it  is  parallel,  the  presentation  is 
either  head  or  lireech;  if  not,  we  are  dealing  wath  an  oblique  or  a  transverse  presen- 
tation (Fig.  297). 


280 


THE   HYGIENE   AND    CONDUCT   OF   LABOR 


2.  The  two  hands  are  gently  pressed  into  the  inlet  of  the  pelvis  from  the  iliac 
fossae.  If  they  find  a  hard,  ball-shaped  body,  it  is  the  head.  If  they  come  almost 
together  above  the  inlet,  it  means,  first,  that  the  head  is  very  high,  not  having  begun 


Fig.  299. — What  is  in  the  Fundus? 


t 


Fig.  300. — Grasping  Hkad  with  One  Hand  in  O.D.P.      Thumb  Sinks  Deep  to  Occiput.      Fingers  Strike  Fore- 
head OVER  Left  Ramus  Pubis. 


THE    CONDUCT   OF   LABOR 


281 


to  engage;  or,  second,  that  the  breech  lies  over  the  inlet  and  is  likewise  pushed  up; 
or,  third,  that  there  is  no  })art  over  the  inlet,  the  shoulder  presenting  and  not  being 
engaged.  If  the  fingers  (-(jine  together  on  a  soft,  irregular  Ijody,  it  is  the  breech  in 
the  process  of  engagement  (Fig.  298). 

8.  The  two  hands  are  laid  on  the  fundus  uteri,  the  examiner  now  facing  the 
mother.  In  the  other  manoBuvers  his  back  was  toward  her  face.  Attempting  to 
grasp  the  ()])jcct  in  the  fuiulus  l)(»tween  his  two  hands,  he  determines  its  hardness  and 
sliai)e,  and  diU'crcutiatcs  between  the  hard,  round  liead  and  the  softer,  irregular 
breech.     It  is  often  easy  to  feel  the  genital  crease,  the  crests  of  the  ilia,  and  the 


•#■ 


Fig.  301. — Palpating  the  Anterior  Shoulder  in  O.L.T. 


small  extremities  of  the  child  (Fig.  299).  If  he  finds  the  fundus  pushed  to  one  side 
or  full  of  small  parts,  he  suspects  transverse  presentation  or  uterus  unicornis. 

4.  The  location  of  the  back  is  determined  by  laying  the  hands  on  the  belly,  as 
for  the  first  manceuver,  and  pressing  alternately  inward  toward  the  navel  with  them. 
The  back  offers  more  resistance,  allows  the  hand  to  be  pressed  in  less,  and  can  usually 
be  felt  as  such. 

Having  thus  mapped  out  the  child,  one  proceeds  to  the  finer  diagnosis  of  the 
position  and  attitude.  The  head  is  studied  first.  Two  hands  press  downward 
toward  the  linea  innominata.  The  occiput  lies  deeper  in  the  pelvis;  it  is  flatter 
than  the  forehead,  nearer  the  middle  line,  and  harder  to  outline.     The  forehead  is 


282 


THE   HYGIENE   AND    CONDUCT   OF    LABOR 


reached  sooner  by  the  advancing  hand,  is  angular,  further  from  the  middle  line,  and 
easier  outlined.  Having  thus  located  these  two  points,  the  position  of  the  head 
becomes  clear.  The  forehead  camiot  be  distinguished  from  the  occiput  when  the 
head  is  deflexed  in  face  presentation;  but  here  we  have  corrective  means  of  diag- 
nosis. Another  method,  by  a  single  grasp  to  palpate  the  head,  is  illustrated  in 
Fig.  300.  An  expert  diagnostician  may  often,  with  this  one  grasp,  diagnose  the 
presentation,  position,  and  degree  of  engagement  of  the  head.  One  determines  the 
position  of  the  head  in  the  pelvis  by  the  relation  of  the  occiput  and  the  forehead  to 
the  inlet.     If  the  forehead  is  felt  to  the  right  side  behind,  and  the  hand,  to  reach  the 


Fig.  302. — Fetai>  Triangle. 
Four  fingers  of  the  right  hand  are  laid  in  the  broad  base  of  the  triangle  and  feel  the  side  of  the  fetus. 

the  thigh  is  felt,  and  downward,  the  arm. 


Pushing  upward 


occiput,  sinks  deeply  behind  the  left  ramus  of  the  pubis,  the  position  is  O.L.A.  If 
the  forehead  is  over  the  left  pubic  ramus,  it  is  O.D.P.  Another  method  of  determin- 
ing position  is  by  locating  the  shoulder  (Fig.  301).  One  hand  passes  upward  from 
the  rounding  of  the  head  and  comes  to  rest  on  a  soft  prominence — the  shoulder.  If 
this  is  in  the  median  line  or  to  the  right  of  it,  when  the  back  is  on  the  left  side,  the 
position  is  O.L.A. ;  if  to  the  left  of  the  median  line,  the  position  is  O.L.T.  or  O.L.P., 
and  correspondingly  when  the  back  is  on  the  right  side.  Passing  upward  the  hand 
feels  a  triangular  space  (Fig.  302)  made  by  the  side  of  the  baby's  trunk — the  thigh 
above  and  the  arm  below.     Still  another  method  of  determining  the  position  of  the 


THE    CONDUCT   OF    LABOR 


283 


head  in  t  he  pelvis  is  the  si  uil>'  (if  t  lie  I'clation  of  the  feet  to  1  he  hrcccli  and  th(;  ])rcoch 
to  the  quadrants  of  tlic  fundus  (Fiji;.  'MY.i).  Careful  study  of  the  subject  has  con- 
vinced tlie  author  that  the  breecli  and  trunk  verj^  closely  follow  tlie  movements  of 
the  head,  so  that,  for  example,  if  one  finds  the  breech  in  a  position  which  it  would 
occujw  in  O.L.P.,  the  head  will  lie  in  this  position,  anrl,  ])y  definitely  outlining  the 
breech,  one  may  deduce  the  jxjsition  of  the  head.  The  fundus  is  marked  out  with  a 
circle  and  divided  into  four  quadrants.  If  the  l)reech,  with  the  small  parts,  is 
found  in  the  left  anterior  ciuadrant,  the  position  is  occipitolseva  anterior,  O.L.A.; 
if  in  the  right  posterior  quadrant,  the  head  lies  O.D.P. 


Fio.  303. — The  Four  Fdndal  Segments,  Showing  the  Position  of  the  Breech  in  the  Four  Positions  of  the 

Head. 


The  Engagement  of  the  Presenting  Part. — What  is  the  degree  of  engagement? 
Where  does  the  head  stand? — a  most  important  question,  which  must  be  answered 
several  times  in  every  labor.  (1)  Place  the  two  hands  on  the  head,  as  in  Fig.  299, 
and  try  to  move  the  head — or  breech — from  side  to  side.  If  movable,  the  part  is 
not  engaged.  (2)  Note  how  much  of  the  head  can  be  felt  above  the  inlet,  using  the 
pubis  as  a  landmark.  If  only  the  forehead  is  palpable,  and  that  on  deep  pressure, 
the  head  is  well  engaged.     Other  information  is  obtained  on  internal  examination. 

The  Location  of  the  Placenta. — In  a  few  instances  this  may  be  discovered  at  this 
time,  though,  except  in  cases  of  placenta  ])rtevia  and  cesarean  section,  the  infonna- 
tion  is  of  little  value.  The  i)lacental  site  has  a  boggy  feel,  the  parts  underneath  are 
less  sharp,  and  sometimes,  if  the  abdominal  wall  is  thin,  one  may  see  a  somewhat 
circular  groove  on  the  uterus.     When  the  placenta  is  on  the  anterior  wall,  the  round 


284  THE   HYGIENE   AND    CONDUCT   OF   LABOR  / 

ligaments  are  pushed  to  the  sides,  and  when  the  organ  occupies  the  posterior  wall, 
the  round  ligaments  converge  on  the  front  of  the  uterus  (Figs.  102  and  103,  p.  81) 
(Leopold  and  Bayer).  There  are  no  auscultatory  signs  which  may  be  used  in 
locating  the  placenta  in  the  uterus. 

The  round  ligaments,  their  course,  thickness,  tenseness,  and  tenderness,  should 
be  studied  and  noted. 

Now  the  pelvis  is  measured,  unless  this  has  been  done  before  labor  (see  p. 
233),  and  an  opinion  is  to  be  formed  of  the  amount  of  resistance  the  child  will 
meet.  This  comprehends  the  palpation  of  the  child  and  the  formation  of  a  mental 
picture  of  its  size,  also  fetal  mensuration.  It  is  a  good  plan  to  write  down  the 
probable  weight  of  the  child,  to  gain  experience  in  estimating. 

The  presence  of  tumors  in  the  uterus  or  abdomen,  ascites,  tympany,  excessive 
or  unusual  tenderness,  should  all  be  noted.  One  may  feel  the  umbilical  cord  cours- 
ing over  the  fetal  back  or  around  its  neck;  also  feel  unusual  fetal  movements,  as 
hiccups  and  gasps;  or  may  determine  a  fetal  anomaly,  as  hydrocephalus,  twins,  etc. 

Auscultation. — It  is  better  to  make  the  diagnosis  of  presentation  and  position 
by  abdominal  palpation,  and  confirm  it  by  locating  the  fetal  heart,  than  to  rely  on 
the  location  of  the  tones  to  give  the  former  information,  because  there  are  vagaries 
in  the  transmission  of  the  heart-sounds  which  may  mislead.  Fig.  221,  p.  194,  shows 
the  location  and  course,  during  labor  in  O.L.A.,  of  the  fetal  heart-tones,  and  Fig.  227 
the  same  in  O.D.P.  As  labor  progresses,  the  child  advancing  and  rotating,  the 
point  of  greatest  intensity  of  the  heart-sounds  comes  anteriorly  and  sinks,  until, 
when  the  head  is  distending  the  perineum,  the  sounds  will  be  best  heard  just  over 
the  pubis.  The  auscultation  of  the  fetal  heart  gives  invaluable  information  as  to 
the  life  and  condition  of  the  child.  Normally,  the  rate  is  120  to  150  a  minute,  and 
the  beat  is  regular  and  rhythmic.  Any  slowing  below  120,  or  increase  above  150, 
is  suspicious  of  danger  threatening  the  infant,  as  also  is  irregularity  of  the  beat  or 
lack  of  the  normal  rhythm.  This  subject  will  again  be  considered  under  the  subject 
of  Asphyxia  Neonatorum.  Suffice  to  say  here  that  the  fetal  heart-tones  must  be 
studied  every  hour  or  two  during  the  first  stage  of  labor,  and  every  fifteen  to  twenty 
minutes,  or  even  continuously,  in  the  second  stage,  for  the  purpose  of  early  dis- 
covering any  danger  which  may  beset  the  infant  in  utero.  One  may  hear  the  funic 
souffle,  especially  if  the  cord  lies  over  the  fetal  back  or  is  coiled  around  the  neck, 
and,  if  it  is  found,  still  greater  caution  is  required. 

Finally,  the  observer  studies  the  uterine  contractions,  noting  their  character, 
frequency,  and  strength.  The  uterus  is  the  engine  of  delivery,  and  the  physician, 
as  does  the  engineer,  must  know  the  power  of  the  machine  that  does  the  work.  Too 
little  power,  too  much  power,  great  power  against  great  resistances— all  such  prob- 
lems must  be  solved  by  the  obstetrician  during  his  observations.  The  main  points 
in  the  aVjdominal  examinations  are: 

1.  Accurate  diagnosis  of  presentation  and  position. 

2.  Determination  of  the  degree  of  engagement. 

3.  Condition  of  the  child  in  utero. 

4.  Character  of  the  uterine  action. 

5.  Consideration  of  the  pelvic  measurements  and  determination  of  the  size  of 
the  child,  and  the  kind  and  amount  of  resistance  the  latter  will  meet  in  its  passage 
through  the  former. 

The  value  of  the  external  examination  is  that  we  can  get  the  information  quicker, 
earlier,  less  painfully,  and  with  no  detriment  to  the  patient.  A  large  number  of 
labors  can  be  conducted  successfully  without  any  internal  examinations,  and  as  one's 
experience  grows  one  will  be  able  to  do  this  more  and  more.  Still,  expediency  for- 
bids its  exclusive  practice.  For  the  sake  of  asepsis  one  limits  the  internal  examina- 
tions to  an  irreducible  minimum, — a  grateful  change  from  the  meddlesomeness  of 
olden  practices, — and  if  the  accoucheur  has  the  time,  if  the  presentation  and  posi- 


THE    CONDUCT   OF   LABOR 


285 


tion  arc  s<^)0(l  uiid  the  fetal  heart-tones  lujniial,  it  is  not  necessary  to  make  any 
internals  during  this  stage,  a  practice!  that  cannot  bo  too  highly  commended.  A 
vaginal  examination  is  made,  when  necessary,  to  complete  the  pelvic  measurements; 
to  diagnose  the  position,  if  such  was  impossil)le  before;  but  mainly  to  determine  the 
degree  of  effacement  and  dilatation  of  the  cervix  and  the  progress  of  labor,  and 
as  to  whether  the  accoucheur  is,  or  is  not,  recjuired  to  remain  at  the  bedside  of 
the  parturient. 

Internal  Examination. — The  nurse  is  requested  to  drape  the  patient  for  the 
internal  examination  (Fig.  304).  This  is  always  conducted  by  sight.  The  pa- 
tient lies  on  her  back,  near  the  edge  of  the  bed,  })ut  with  fat  women,  and  where  the 
diagnosis  i)romises  to  be  difficult,  she  is  l^est  placed  across  the  Ijed,  or  even  on  a  table, 
in  the  lithotomy  position.  A  sheet  covers  her  person,  the  ends  being  twisted  around 
the  legs,  leaving  the  genitalia  exposed.  Antiseptic  solutions  are  prepared  on  a 
table  near  the  bed — 1  :  1000  bichlorid  of  mercury  and  1  per  cent,  lysol,  each  basin 
containing  a  good  supply  of  cotton  pledgets  or  gauze  sponges.  The  hands  are  again 
scrubbed  for  five  minutes  in  running  water  or  frequent  changes,  soaked  for  a  minute 
in  70  per  cent,  alcohol,  and  then  for  one  minute  in  1  :  1000  bichlorid.     Since  the 


» 


y 


Fig.  304. — Patient  Draped  for  Internal  Examination. 


genitalia  have  already  been  disinfected,  in  the  primary  preparation  of  the  patient 
the  physician  needs  only  to  liberally  sponge  the  labia  and  introitus  with  lysol  solu- 
tion, then  with  the  bichlorid,  and  again  with  the  lysol  solution,  leaving  a  piece  of 
cotton  soaked  in  the  latter  lying  in  the  vulvar  canal.  He  now  washes  his  hands 
again  in  the  bichlorid  solution,  dries  and  powders  them,  and  draws  on  his  sterile 
rubber  gloves.  The  talcum  powder,  which  coats  the  gloves  during  sterilization,  is 
washed  off  in  the  two  antiseptic  solutions,  and  then  two  fingers  of  the  left  hand — 
taking  care  to  touch  nothing  on  the  way — are  carried  to  the  vulva,  removing  the 
bit  of  cotton  left  there.  Then,  separating  the  lal^ia  widely  withthe  index-  and  middle 
finger  of  the  other  hand,  the  two  fingers  enter  the  vagina,  passing  at  once  deeply 
into  the  canal,  after  which  the  labia  are  allowed  to  come  together  on  the  examining 
fingers  (Fig.  305) .  Great  care  is  to  be  employed  to  avoid  the  anal  region,  the  fingers 
coming  in  contact  only  ^^'ith  the  mucous  membrane  of  the  introitus  vaginae,  and  the 
mside  of  the  two  sterile  fingers  spreading  the  lal^ia.  These  fine  details  are  given 
because  of  the  importance,  from  an  antiseptic  point  of  \'iew,  of  the  internal  examina- 
tion, and  it  being  so  difficult  to  avoid  carrying  infection  from  the  surface  into  the 
vagina  and  uterus. 


286 


THE    HYGIENE   AND    CONDUCT    OF   LABOR 


Each  and  every  examination  is  to  be  conducted  with  the  same  care.  Six  points 
are  to  be  determined  during  vaginal  exploration,  and  the  laws  of  asepsis  demand 
that  they  be  made  in  a  certain  order : 

1.  The  Degree  of  Effacement  and  Dilatation  of  the  Cervix. — The  fingers  pass 
quickly  to  the  cervix,  noting  its  consistence  and  size,  whether  the  external  os  is  open, 
or  the  cervical  canal  shortened  or  effaced.  The  varying  degrees  of  effacement  and 
dilatation  have  been  described  and  illustrated  on  pp.  119-123.  One  will  speak 
of  the  cervix  being  effaced  and  the  os  admitting  three  or  four  fingers,  or  as  being  the 


Fig.  305. — Fingers  Entering  Vagina  from  Above,  to  Avoid  Contamination  from  Perineum  and  Anus. 


size  of  a  quarter,  etc.  The  author  prefers  to  use  metric  terms,  saying  the  os  is  two, 
three,  or  more  centimeters  across. 

Occasionally  one  will  find  the  cervix  partly  effaced,  much  softened,  or  even 
somewhat  dilated,  without  there  having  been  many  uterine  contractions.  This  is 
called  ''insensible  labor,"  and  is  very  welcome  in  operative  cases. 

2.  Has  the  Bag  of  Waters  Ruptured? — The  answer  is  usually  easy,  but  may 
present  great  difficulty.  If  the  membranes  are  of  watch-crystal  form,  one  feels  a 
tense  memVjrane,  a  short  distance  below  the  head,  during  a  pain.  In  the  interval 
this  membrane  is  relaxed.     If  the  membranes  are  pressed  tightly  against  the  head 


THE    CONDUCT   OF    LAUOR  287 

like  a  cap,  it  ma}'  Ix'  jiossihlc,  by  pushing  the  head  up  a  liltlo,  to  notice  lif|uor  arniiii 
fiowiiifi;  down  between  tlic  bajj;  and  the  head,  and  no  fhiid  will  escape  alongside  the 
fingers.  A  practised  touch  will  be  able  to  distinguish  between  the  smooth  chorion 
or  amnion,  and  the  rough,  hairy  scalp.  An  attenii)t  to  wrinkle  the  scalp  with  the 
fingei's.  or  catch  a  lock  of  hair  between  th(>m,  if  successful,  will  shoAV  that  the 
nicinbrancs  ;ii('  iiiplurcd,  and  the  head,  when  puslunl  up,  will  allow  li(jUor  aninii 
to  flow  into  the  hand.  'The  discharge  of  licjuor  aninii,  of  vernix  caseosa,  or  flakes 
of  meconium  will  clincli  the  diagnosis.  In  doubtful  cases  the  vagina  may  be 
opened  by  broad  specula  or  the  fingers,  and  the  presence  of  the  membranes  over 
th(>  head  determined  by  sight.  The  l)ag  of  waters  may  rupture  in  two  places — 
the  first  time  high  up,  the  second  over  the  os;  and  there  may  be  two  bags,  as  in 
twins,  or  there  may  be  an  accumulation  of  licjuid  between  the  amnion  and  chorion. 
3.  The  Diagnosis  of  Presentation  and  Position. — If  the  external  examination 
has  been  thorough,  little  more  is  to  be  learned  from  the  internal,  except  to  confirm 


Fig.  306. — Fingers  Inserted,  Elbow  Sunk,  to  Allow  Finger-tips  to  Point  Toward  Umbilicus. 

or  correct.  (The  findings  on  internal  examination  have  been  described  on  p.  193, 
to  which  the  reader  is  referred.)  It  is  usually  impossible  to  outline  the  sutures  and 
fontanels  through  the  cervical  wall,  but  the  membranes  do  not  hinder  it  except  dur- 
mg  the  pains.  After  deciding  that  the  hard,  roundish  bod}^  is  the  head,  and  the 
occipital  part, — not  the  face  or  brow, — the  finger  seeks  the  sagittal  suture.  If  it  is 
near  the  promontory,  the  head  is  in  Naegele's  obliquity,  or  anterior  asynclji;ism; 
if  near  the  pubis,  in  posterior  asj^nclytism ;  if  median,  it  is  sjiiclytic.  Follo'uing 
the  suture,  the  fontanels  are  felt — the  lozenge-shaped  one  is  the  largest,  and  has 
fom-  sutures  running  to  it;  the  Y-shaped  one  is  the  smallest,  ha\'ing  only  three 
sutures  running  to  it.  The  angle  of  the  Y  points  to  the  face;  the  obtuse  angle  of 
the  lozenge  points  back  toward  the  occiput.     (See  Figs.  191  and  192.) 

The  lateral  fontanels  may  impose  as  the  large  or  small,  but  one  always  finds  the 
ear  close  by,  and  the  zygomatic  process  ^^'ith  the  edge  of  the  orbit.  A  false  fontanel 
■\^^ll  confuse  the  diagnosis,  and  its  presence  should  always  be  suspected  when  the 
findings  are  not  t}T)ical.     To  distinguish  the  sagittal  suture  from  the  lambdoid  or 


288  THE    HYGIENE   AND    CONDUCT   OF    LABOR 

coronary,  it  is  to  be  noted  that  the  latter  two  he  in  strongly  curved  planes,  the 
sagittal  lying  in  a  less  arched  surface.  Certainty  in  defining  the  position  of  the 
head  can  almost  always  be  obtained  by  these  means,  but  in  cases  of  doubt  it  is  well 
to  search  for  the  ear.  The  position  of  the  ear  will  disclose  the  position  of  the  head. 
In  the  second  stage,  after  hard  labor  pains  have  molded  the  head  and  developed  on 
it  a  caput  succedaneum,  the  landmarks  are  obscured,  but  still  discoverable;  and, 
again,  recourse  may  be  had  to  the  ear. 

4.  The  Advancement  of  the  Head  Along  the  Birth-canal. — Again,  the  external 
examination  has  supphed  much  information;  but  in  many  cases  the  degree  of  en- 
gagement can  be  determined  only  by  internal  exploration. 

The  head  is  "floating"  when  it  is  freely  movable  above  the  inlet.  It  is  "fixed 
in  the  inlet"  when  moderate  pressure  will  not  dislodge  it,  but  its  parietal  bosses  have 
not  yet  passed  the  region  of  the  inlet. 

The  head  is  "engaged"  when  its  greatest  transverse  plane  has  passed  the  region 
of  the  inlet.  In  occipital  presentation  this  is  the  biparietal  plane,  and  "engage- 
ment" is  shown  clinically,  first,  by  the  lowest  part  of  the  head  having  reached  the 
interspinous  line  or  passed  it;  second,  by  the  covering  of  the  sacrum,  two-thirds; 
third,  by  the  covering  of  the  symphysis,  three-fourths,  by  the  advancing  head. 
The  head  is  in  the  "midplane"  when  the  lowest  part  of  the  vault  lies  between  the 
tuberosities,  and  "at  the  pelvic  outlet"  when  two  parietal  bosses  are  passing  the 
tuberosities.  After  this  the  head  comes  weh  down  "on  the  perineum"  and  hes  in 
the  distended  vagina  and  vulva.  By  first  touching  the  top  of  the  head  and  then 
carrying  the  fingers  to  the  bony  wall  of  the  pelvis,  it  is  easy  to  determine  the  rela- 
tion of  one  to  the  other,  especially  if  the  manoeuver  is  combined  with  external  palpa- 
tion. Too  great  emphasis  cannot  be  laid  on  the  importance  of  accurately  defining 
the  location  or  "station"  of  the  head  in  the  birth-canal.  Before  operating  this  in- 
formation is  absolutely  essential. 

.5.  Abnormalities. — The  finger  now  notes  any  abnormality,  the  presence  of  the 
cord  or  fetal  parts  in  the  vagina,  tumors,  excessive  rigidity  of  the  perineum,  etc. — 
points  which  will  be  touched  upon  later. 

6.  Internal  Pelvimetry. — Unless  the  pelvis  has  been  carefully  measured  before, 
it  is  done  now,  or  a  previous  examination  supplemented.  Running  the  fingers 
slowly  over  the  bony  walls,  the  general  size  of  the  cavity  is  appreciated,  the  size 
and  sharpness  of  the  ischiatic  spines  determined,  the  sacrum  and  posterior  wall  of 
the  pubis  and  as  much  as  possible  of  the  hnea  terminalis  are  palpated;  finally,  the 
fingers  take  the  conjugata  diagonalis.     (See  p.  241,  Fig.  271.) 

In  the  first  examination  all  these  six  points  are  to  be  elicited,  and  in  the  order 
named.  By  going  slowly  and  gently  the  patient  is  not  hurt,  and  all  the  required 
information  will  be  gained.  During  a  labor  pain  one  must  be  careful  not  to  rupture 
the  membranes,  but  it  is  justifiable  to  pass  the  finger-tip  lightly  around  the  os  to  see 
how  much  it  opens  during  a  contraction,  how  well  the  bag  of  waters  forms,  and  how 
tense  the  membrane  becomes,  thus  forming  some  idea  of  the  strength  of  the  pains. 
After  this  the  fingers  rest  at  the  side  of  the  pelvis  until  the  pain  has  passed  away. 

Rectal  Examination. — To  avoid  frequent  vaginal  exploration,  with  its  inherent 
dangers,  rectal  exploration  may  be  substituted.  Done  gently,  with  the  gloved 
index-finger,  the  rectum  will  not  be  injured  and  much  information  elicited.  With  a 
little  practice  it  is  possible  to  determine  the  degree  of  engagement  of  the  head,  the 
amount  of  dilatation  of  the  cervix,  and  whether  or  not  the  cord  has  prolapsed. 
Often  position  may  be  made  out.     It  is  to  be  recommended. 

The  accoucheur  now  fills  out  his  history  sheet  or  card. 

The  Prognosis  of  the  Mechanism  of  Labor. — After  all  the  above  information  is 
obtained  the  various  points  are  weighed  and  considered.  The  size  and  hardness  of 
the  fhild  are  balanced  against  the  size  of  the  pelvis,  and  both  compared  with  the 
labor-pains — i.  e.,  the  power  of  the  engine  is  compared  with  the  work  it  has  to  do. 


THE    CONDUCT   OF   LABOR 


289 


LABOR 

MRS.  ^^m^Cf-fiXJu  J^uj^t^t^^CCLn^ .  p././ AD. /t?/^  ^^2<^tit.<^   -^^ 

AGE       <74^       PAR/\.  AB'S,   M'TH   OF   P'CY    /i?^7''^LIGHTENING      Z  U/TCi      <:^^<7—  SHOW   ;5*1^<*'^^'^<?*H' 

OAT 


E     ^-y^^-OUJl,   /f  — /'^/Z        LABOR  BEGAN /^^k-tCfc^    9^/<*<^^rT-^-      OR.  ARftlVEO    W/// - /''^^ 
FIRST  STAGE.     EXAM.     O-r^-rif''.     Wbm^      y^^^^nA^-  ^^^f^-i^-^^JU^/  <rZ/iA/  ^,    <l^t^jL^^  \ / 

'0^.  At^SZi-^i-XA^r^-  ^^4<^ /-'^AO'^^  .       ^- — :^^     ^  V_y 

AUSCULTATION        /^l^~      —    /  &0   . 


SECOND  STAGE.     EXAfc 


AUSCULTATION      /</''/—    /cTS"    -    C*^.     '^V-A^. 

DELIVERY.     TIME      6~dll/,   ^U->^SL     //"-  /^//.     <^S^C^-^.  ^^^^^^iufc/T"  ^y^^-       t/lSuux^^ofU^ 

ANESTHETIC     h-^'^M,     "       ^-   ^■ 

THIRD  STAGE      lA^'ffrJ.^yt.AAj^.gUi     ~  <3^£t.-cix^\J^iJ'^  . 

TEMP.       /A  PULSE    /^O        f<, 

PLACENTA /^l^rtttj;*^    y%^7^  /ixM.  ■    ^<-et*4„<^<a,cc£^   ''U^e^     7^  ■/■■^tarv^^ 


ERINEUM /^^%^'^^5^P?^t<,<t<-i^«^-**^i^:  , 


Fig.   307. — Obverse  of  a  Filled  L.^bor  Card. 


CHILD 

DNDITION   '^^K'JZ^^iX.^Ct^ 

SEX  -^i^e^-e^^ 

Bis-f. 


ngth      I  Bi-P.         I  Bi-T.        I  S.  O.  8.     I  O.  F.         |  O.  M. 


Weight       I  Len 

Circ.  Head  I  |   Head  2      3^         |  Shoulders   *^6      |   Chest      5'>2.         |  Ossification 

MOULDING    ^■^C^OuUU^   <;3£V(<&S-<^^- '^^J'^^  ■ 

SUMMARY:    i«t  Stage     /^        and  Stage       C?  3rd  Stage    /OX      Present    ^U^-'rfrW, 

DIAGNOSIS   Or^fnif?     ^^r^'f^l^i^.  /2XT^?S^^  .      ^Zt'^   d^atsZU/ 

COMPLICATIONS,   ETC. 

^j[^uryUtSfv,     ^^-ux^  ((i.'K.a^/^   -/(CLut-t^  .2%'-&/^i^  -Cujpf  ^ 


-A.        I  Bis 


"^Ze^ft-ce^i^  a^Cu 


dl^.   S^^Pt-e,:^. 


^ 


i/e^t-ux. 


^^^^tx. 


^   ^1<Z/1. 


.' .  ^ac^Ae/ 7^9€uuuc>^    S^-J^i^  .       <^<*a^uju£:   <^£.aA£y  ur^Z^  ?^ 


19 


Fig.  308. — Reverse  of  a  F'illed  Labor  Card. 


290  THE    HYGIENE   AND    CONDUCT    OF    LABOR 

An  d^inion  is  hazarded  as  to  the  probable  mechanism,  and  possible  abnormalities 
of  the  same  studied  in  all  their  bearings. 

For  his  first  200  cases  the  young  practitioner  had  best  use  the  full  history 
sheet  reproduced  in  the  Appendix,  as  this  practice  will  best  develop  his  technic  and 
habits  of  carefulness  and  accuracy.  Later,  when  he  has  become  busy,  he  may  use 
the  cards  illustrated  here  (Figs.  307  and  308),  reserving  the  extensive  history  sheet 
for  special  or  pathologic  cases. 

The  anxious  patient  will  now  put  two  questions  to  the  accoucheur.  One,  "Is 
evervi:hing  right?"  should  always  be  answered  in  the  affirmative,  with  a  word  of 
encouragement.  In  the  presence  of  an  anomaly,  the  husband  or  near  relative  must 
be  informed,  for  the  doctor's  own  protection,  but  the  parturient  should  be  spared 
the  alarm  until  it  is  needful  to  interfere,  when  the  conditions  are  to  be  gently,  kindly, 
and  vaih  great  tact  explained  to  her. 

The  second  query,  "How  long  will  it  last?"  should  be  answered  with  consum- 
mate care.  If  a  certain  hour  for  the  delivery  of  the  child  is  stated,  the  clock  will 
very  often  contradict  the  statement,  and  the  parturient  will  lose  faith  and  courage. 
The  writer  usually  replies  that  the  length  of  the  labor  will  depend  on  the  strength 
and  frequency  of  the  pains,  but  that  everything  is  in  such  good  order  that  it  matters 
httle  whether  the  labor  lasts  a  little  longer  or  shorter  time. 

The  Attendance  of  the  Physician. — Ideally,  every  labor  case  should  be  con- 
tinuously attended  by  a  physician  from  beginning  to  end.  The  author  enjoys  this 
privilege,  having  the  interne  to  watch  his  hospital  cases  and  a  private  assistant  to 
stay  with  the  parturient,  in  his  home  practice.  How  great  the  advantages  of  such 
a  plan  are  and  how  comforting  the  practice  is  cannot  be  told.  It  undoubtedly 
saves  the  lives  of  many  mothers  and  children  and  it  certainly  prolongs  the  life  and 
usefulness  of  the  author.  If  the  accoucheur  must  leave  the  house,  he  does  so  only 
after  assuring  himself  that  the  presentation  and  position  of  the  fetus  are  good,  that 
the  pelvis  and  child  are  normal,  that  the  cervix  is  dilating  naturally,  that  the 
mother  is  not  threatened  with  eclampsia,  that  abruptio  placentae  and  placenta 
prsevia  do  not  exist,  and  that  the  infant  is  in  perfect  condition.  The  nurse  is  to 
be  instructed  to  listen  to  the  child's  heart-tones  every  hour,  and  to  report  at  once 
any  unusual  happening.  Only  accurate  observation  of  many  labors  will  give  the 
accoucheur  that  knowledge  which  will  enable  him  to  determine  if  it  is  safe  for  him 
to  leave  the  parturient, — and  when,  and  for  how  long, — and  even  with  such  knowl- 
edge he  ^vill  occasionally  return  to  find  the  child  delivered,  the  pains  having  sud- 
denly become  very  strong.  In  a  primipara  it  is  best  to  remain  in  the  house  after 
the  cervix  admits  three  fingers;  certainly  with  a  multipara;  and,  also,  if  the  pains 
are  very  strong  and  progress  rapid,  or  if  the  woman's  previous  labors  have  been 
quick. 

When  the  physician  does  leave  the  case,  he  must  not  visit  infectious  diseases 
or  touch  pus  while  absent.  It  is  the  physician's  duty,  in  the  absence  of  a  trained 
nurse,  to  provide  sufficient  sterile  water,  towels,  sheets,  etc.,  as  well  as  to  have  in 
readiness  the  materials  for  an  aseptic  reception  of  the  infant. 


riTAPTICR  XXI 
THE  TREATMENT  OF  THE  FIRST  AND  SECOND  STAGES 

The  treatment  of  the  first  stage  is  one  of  ivatchful  expectancy.  The  duty  of  the 
accoucheur  is  to  observe  the  efforts  of  nature,  not  to  aid,  until  she  has  proven  herself 
unequal  to  the  task.  Only  when  nature  fails,  is  art  to  enter.  Nothing  is  so  repre- 
hensible as  meddlesome  midwifery.  It  has  cost  thousands  of  valuable  lives. 
Attempts  to  hasten  the  dilatation  of  the  cervix,  either  manually,  by  bags,  or  by 
having  the  woman  bear  down,  may  not  be  made.  Premature  bearing-down  efforts 
of  the  mother  aid  very  little  in  the  first  stage,  and  tire  her  so  that  she  has  no  strength 
left  for  the  expulsive  work  of  the  second  stage;  further,  it  is  distinctly  harmful, 
since  the  child  is  forced  dowai  before  the  os  is  dilated,  overstretching  the  broad  liga- 
ments and  laying  tlie  foundation  for  a  future  prolapsus  uteri.  Let  the  parturient 
walk  around  the  room,  the  admission  of  dust  into  the  vagina  being  guarded  against 
by  a  large  sterile  pad  and  a  T-binder.  She  may  rest  at  intervals  on  a  couch,  lying 
on  her  back  or  on  the  side  to  which  the  occiput  is  directed, — for  example,  in  O.L.T. 
on  her  left  side.  This  is  to  favor  rotation.  Frequent  external  examinations  may 
be  made  to  discover  the  progress  of  labor,  and  the  fetal  heart  tones  should  be  listened 
to  at  least  every  hour.  If  this  were  more  generally  practiced,  intrauterine  asphyxia 
would  be  more  often  discovered  early  and  more  children  saved  by  rapid  delivery. 
Eclampsia,  abruptio  placentae,  rupture  of  the  uterus,  and  the  general  condition  of 
the  mother  must  also  be  in  the  mind  of  the  observant  accoucheur,  the  possibility'  of 
the  former,  and  the  changes  in  the  latter  being  constantly  subject  for  thoughtful 
consideration.  Temperature,  pulse,  and  respiration  should  be  taken  and  recorded 
every  four  hours.  If  labor  is  protracted,  the  accoucheur  should  try  to  procure 
some  sleep  for  the  parturient.  Early  in  the  first  stage  morphin  may  be  given, 
but  not  near  or  during  the  second  stage. 

Diet. — During  the  labor  the  woman  will  refuse  nourishment,  but  she  should  be 
pressed  to  take  liquids  in  order  to  preserve  her  strength  for  the  final  ordeal  of  de- 
livery and  the  third  stage.  This  is  imperative  where  the  labor  promises  to  be  pro- 
tracted. Postpartum  hemorrhage  is  more  formidable  in  a  weakened  patient. 
Nausea  and  vomiting  are  occasionally  troublesome  and  medicines  have  little  effect 
on  them. 

The  Bowels. — Every  twelve  hours  the  lower  bowel  should  be  evacuated  by  a 
salt  solution  enema,  but  no  enema  should  be  given  if  the  delivery  seems  very  near, 
because  of  the  danger  of  a  flood  of  liquid  feces  accompanying  the  birth  of  the  infant. 
If  feces  accumulate  in  the  rectum,  obstructing  delivery,  an  enema  of  one  ounce 
of  Epsom  salts,  two  of  glycerin,  and  three  of  water  may  be  given.  During  labor 
i)oth  physician  and  nurse  take  precautions  against  contaminating  the  vulva  with 
fecal  discharges. 

The  bladder  should  be  emptied  regularly  every  four  hours,  aided,  if  need  be, 
by  the  catheter.  If  filled,  it  forms  an  obstacle  to  delivery,  delays  rotation  and  pre- 
disposes to  incarceration  of  the  placenta  and  postpartum  hemorrhage  (Fig.  309). 

The  Rupture  of  the  Bag  of  Waters. — When  the  accoucheur  judges  this  is 
imminent,  the  patient  is  put  to  bed,  lying  on  her  back.  After  it  has  occurred,  the 
second  internal  examination  may  be  made.  The  author  does  not  alwaj's  examine 
if  the  head  is  engaged,  if  the  heart-tones  are  good,  ancl'labor  progressing  satisfac- 
torilv.     The  only  knowledge  to  be  gained  is  the  degree  of  dilatation  and  the  possible 

291 


292  THE   HYGIENE   AND    CONDUCT    OF    LABOR 

prolapse  of  the  cord.  If  required,  a  rectal  examination  may  be  made.  If  the  ex- 
ternal diagnosis  shows  a  posterior  position,  one  may,  during  the  internal  examina- 
tion, make  a  tentative  effort  to  correct  it  by  combined  manipulation.  If  labor  is 
delayed  long  after  the  presumable  dilatation  of  the  cervix,  an  internal  examination 
is  made  to  discover  the  cause,  or  perhaps  to  rupture  the  obstructing  membranes. 
JNIultiparse  often  have  very  rapid  deliveries  after  the  membranes  break,  wherefore 
it  is  ad\asable  to  begin  the  sterilization  of  the  hands  and  the  general  preparations 
for  the  delivery  earher  than  in  primiparous  labors. 


Fig.  309. — The  Full  Bladder  During  Labor. 
From  a  photograph  by  Bar. 

CONDUCT  OF  THE  SECOND  STAGE 

Bearing-down  pains  do  not  always  indicate  that  the  second  stage  is  begun,  nor 
does  the  rupture  of  the  bag  of  waters.  The  latter  may  occur  before  the  pains  start 
and,  again,  not  even  until  after  the  head  is  visible.  An  experienced  attendant,  from 
the  actions  of  the  parturient,  may  usually  decide  that  the  cervix  is  fully  dilated.  A 
few  particularly  sharp  pains,  atten4ed  by  a  show  of  bright  blood,  usually  inchcate 
that  the  head  is  slipping  through  the  cervix.  The  bed  is  prepared  for  dehvery  by 
being  dressed  with  sterile  sheets,  the  patient  has  a  pair  of  sterile  leggings  or  hose 
and  a  sterile  night-gown  put  on;  the  table  carrying  the  solution  basins,  sterile  towels, 
sterile  tape,  and  scissors  for  cord  is  drawn  near  to  the  bed,  and  the  operator  prepares 
his  hands  and  puts  on  the  sterile  gown  and  gloves. 

The  patient  often  feels  as  if  the  bowels  are  to  move,  but  she  may  not  go  to  the 
closet;  the  movement,  if  any,  being  made  on  a  sterile  bed-pan.  More  often  the 
sensation  is  due  to  pressure  of  the  head  against  the  rectum.  Fecal  particles  that 
escape  during  the  pressing  efforts  must  be  carefully  gathered  in  sponges  wrung 
out  of  1  :  1.500  bichlorid,  and  the  anal  region  disinfected  with  the  same  solution. 
The  bladder  is  emptied  by  catheter  if  necessary. 

Four  main  points  are  to  be  considered  during  this  stage:  1.  Asepsis  and  anti- 
sepsis. 2.  Anesthesia.  3.  Protection  of  the  life  of  the  child.  4.  Preservation  of 
the  perineum.  Complications,  as  abruptio  placentae,  eclampsia,  ruptura  uteri, 
will  be  considered  under  their  respective  heacUngs. 


THE    TREATMENT   OF   THE    FIRST   AND    SECOND    STAGES  293 

Asepsis  and  antisepsis  have  Ix-cii  considcrod  already,  and  will  be  touched  upon 
in  nearly  cNciy  phase  of  the  treatment  as  here  laid  down. 

Anesthesia. — After  niueh  experiene<>,  the  author  has  come  to  dispense  with 
anesthetics  in  the  first  stajj;e  of  labor,  except  in  unusual  instances.  A  cheerful, 
hopeful  demeanor,  sympathy  and  encouragement  from  the  physician,  will  usually 
help  tiie  woman  to  Ixnir  the  i)an<i;s  of  lal)or  until  the  second  stage  is  about  to  begin. 
Suggestion,  to  a  certain  extent,  may  be  employed.  Wlien  the;  head  is  passing 
through  the  cervix  the  pain  is  intense,  and  here  a  few  whiffs  of  ether  are  very  helpful. 
During  the  second  stage  the  author  gives  ether  to  the  "obstetric  degree,"  and  as  the 
head  escapes  from  the  vulva,  the  period  of  greatest  anguish,  the  anesthetic  is  pushed 
to  the  "surgical  degree,"  l)ut  stoj^ped  as  soon  as  the  head  is  born,  the  patient  usually 
waking  up  a  few  moments  after  the  child  makes  its  first  cry. 

Women  vary  very  much  in  their  ability  to  stand  pain  and  in  their  demands  for 
anesthetics.  The  author  conducts  many  labors  without  any  narcotic,  many  Avith 
just  a  few  deep  inhalations  of  ether  as  the  head  is  born,  and  only  a  few  with  pro- 
longed anesthesia.  Operative  deliveries,  with  a  few  exceptions,  are  done  under 
surgical  anesthesia,  but  perineorrhaphy,  cleaning  out  of  the  uterus,  and  tamponade 
are  as  often  done  without,  as  with,  narcosis. 

Two  degrees  of  anesthesia  have  been  mentioned.  Obstetric  anesthesia  is  the 
use  of  the  narcotic  only  to  dull  or  relieve  the  pain,  without,  or  with  only  a  very 
brief,  loss  of  consciousness.  Surgical  anesthesia  is  the  abolition  of  consciousness 
and  of  body  rigidity. 

Objections  to  Anesthetics — Chloroform  and  Ether. — 1.  Without  doubt  the  par- 
turient enjoys  a  slight  immunity  from  the  risks  of  surgical  anesthesia,  and  obstetric 
anesthesia  is  Ijut  little  dangerous.  It  is  not  true  that  deaths  have  not  occurred 
during  the  latter  form  of  administration,  but  they  are  rare,  and  other  conditions 
have  usually  been  present,  as  goiter  and  status  Ijanphaticus.  Diseases  of  the  liver 
and  toxemia,  especially  of  the  hepatic  type,  contraindicate  all  anesthetics.  Chloro- 
form is  especially  harmful  in  such  cases,  not  seldom  leading  to  acute  yellow  atrophy 
of  the  liver,  a  condition  which  closely  resembles,  if  it  is  not  identical  vdih,  "second- 
ary chloroform  death." 

2.  Anesthetics  weaken  the  uterine  contractions.  The  clinician  does  not  need 
the  proof  brought  from  the  laboratory.  Even  under  the  o]:)stetric  degree  the  pains 
are  sometimes  weakened,  are  further  apart,  and,  in  the  writer's  experience,  hemor- 
rhage in  the  third  stage  is  more  profuse,  and  contraction  and  retraction  of  the  uterine 
muscle  often  delayed  or  insufficient.  Ether  acts  thus  to  a  much  less  degree.  On 
the  other  hand,  when  contractions  are  tumultuous  or  irregular  and  too  acutely 
painful,  or  when  the  woman  will  not  bear  down  in  the  second  stage  because  of  the 
pain  in  the  vulva,  an  anesthetic  will  often  calm  and  soothe,  thereby-  actually  hasten- 
ing delivery. 

3.  The  anesthetic  may  affect  the  child.  Administered  for  a  long  tune,  as  was 
formerly  the  custom,  the  fetus  could  ol)tain  sufficient  of  the  drug  to  be  seriously 
affected  by  it,  investigation  having  shown  that  there  is  an  acute  albuminoid  de- 
generation of  its  vital  organs  during  the  first  days;  but  given  as  here  recommended, 
the  danger  to  the  child  is  very  slight. 

4.  Objections  on  the  score  of  religious  scruples,  that  pain  in  labor  is  "physio- 
logic" and  that  the  mother  will  not  love  her  child  born  without  pain,  need  no 
comment. 

5.  Anesthesia,  unless  deep,  in  rare  instances  excites  the  parturient  almost  to 
frenzy,  and  thus  places  her  beyond  control  of  the  -Rnll  of  the  accoucheur.  If  her 
efforts  are  needed  for  the  completion  of  the  delivery,  as  in  l^reech  cases,  the  attend- 
ant finds  himself  in  a  dilemma.  Either  he  must  deliver  under  surgical  anesthesia 
or  wait  until  the  woman  gains  full  consciousness.  The  latter  course  is  recommended 
where  practicable. 


294  THE   HYGIENE   AND    CONDUCT   OF   LABOR 

Choice  of  Anesthetic. — For  many  years  I  used  chloroform  exclusively  in  my 
obstetric  work,  because  it  was  quicker  in  action,  easier  to  carry,  pleasanter  to  take, 
and  seldom  caused  nausea  and  vomiting.  Its  bad  effect  on  the  pains  was  tolerated 
because  this  could  be  cared  for  satisfactorily.  One  secondary  chloroform  death  in 
a  normal  case,  and  two  after  eclampsia,  caused  serious  question  in  my  mind,  and 
now  ether  is  used  except  in  rare  and  special  instances  (see  Sippel),  Littig,  after 
reporting  63  chloroform  deaths  (5  obstetric),  condemns  the  drug  unqualifiedly. 
Ether  is  slower  in  action,  more  is  required,  it  is  bulkier,  and  the  woman  often  vomits 
afterward;  but  it  has  proved  itself  safer  in  obstetrics,  as  it  has  in  surgery,  and, 
properly  administered,  one  can  obtain  ver}^  satisfactory  results.  Chloroform  has  a 
serious  defect,  that,  in  the  presence  of  an  open  flame,  it  is  decomposed  into  carbonyl 
chlorid  and  hydrochloric  acid,  both  of  which  irritate  the  air-passages  of  all  in  the 
room,  making  the  attendants  cough  and  even  fatally  poisoning  them.  The  patient, 
too,  suffers  from  this,  and  perhaps  some  of  the  unexplained  puerperal  deaths  may 
thus  be  cleared  up.  Ether  is  to  be  used  where  it  is  necessary  to  operate  in  the 
presence  of  sepsis,  nephritis,  eclampsia,  cardiac  disease,  goiter,  or  uterine  atony. 
Ether  may  not  be  used  too  close  to  an  open  flame  because  of  the  danger  of  explosion, 
but  I  find  the  fear  of  this  accident  much  exaggerated. 

Indications. — 1.  Great  pain  at  the  end  of  the  first  stage  or  in  the  second  stage. 
2.  Great  excitability  at  these  periods.  3.  Tumultuous  pains  at  any  period  of  labor, 
especially  if  the  cervix  is  not  dilated  or  if  the  head  is  on  the  perineum,  the  idea 
being  to  moderate  the  power  of  the  uterus  and  to  save  it,  the  cervix,  or  the  peri- 
neum from  rupture.  4.  To  preserve  the  perineum  when  the  bearing-down  efforts 
are  too  strong.     5.  To  eliminate  the  inhibition  of  bearing  down  due  to  pain. 

Conditions. — (1)  Labor  must  be  sufficiently  advanced;  ether  is  very  rarely 
given  in  the  first  stage,  best  in  the  second.  (2)  The  pains  must  be  strong  and 
regular,  so  as  to  offset  the  weakening  effect  of  the  drug.  (3)  When  given  simply 
for  the  relief  of  pain,  examination  of  the  patient  must  have  excluded  toxemia, 
hepatic  disease,  goiter,  hemophilia,  and  sepsis.  (4)  In  cases  of  severe  hemorrhage 
special  rules  apply. 

Method  of  Administration. — Obstetric  Degree. — Any  simple  inhaler,  or  even  a 
handkerchief  held  in  the  hand,  will  suffice.  The  open  method  is  preferred,  because 
in  obstetrics  the  carbonization  of  the  blood,  so  common  in  general  anesthesia,  must  be 
avoided  in  the  interests  of  the  child.  When  the  pains  begins,  15  drops  of  ether  are 
poured  on  the  mask,  and  the  patient  takes  deep  breaths  of  the  vapor;  as  the  pain 
increases  a  few  drops  more  are  given;  as  the  pain  subsides,  the  mask  is  removed. 
This  procedure  is  repeated  until  the  head  is  just  about  to  escape  from  the  vulva, 
when  the  ether  is  poured  on  frequently,  and  the  first  stage  of  surgical  anesthesia 
is  reached,  consciousness  is  abolished  for  a  few  minutes,  during  which  time  the 
infant  is  delivered. 

Deep  anesthesia  is  needed  in  obstetric  practice  under  the  same  conditions  as 
in  surgery,  to  produce  unconsciousness  to  pain  and  complete  relaxation.  It  is  to 
])(i  remembered  that  while  the  parturient  does  possess  some  immunity  from  its 
dangers,  this  safety  has  been  exaggerated,  and  confidence  in  it  has  led  to  the  care- 
less use  of  the  drug,  with  many  resulting  deaths.  If  the  reports  of  deaths  and 
collapse  during  anesthesia  in  midwifery  practice  continue  to  come  in  at  the  same  rate 
as  for  the  last  three  years,  it  will  soon  be  necessary  to  deny  that  the  parturient 
enjoys  any  immunities  from  the  dangers  of  narcosis.  Ether  is  said  to  reduce  the 
phagocytic  power  of  the  blood  by  its  fat-solvent  properties,  and  the  introduction 
of  fat  could  perhaps  restore  this  power. 

History. — Narcotic  potions  were  administered  by  the  ancients  in  labor.  Theocritus 
mentions  them  as  given  to  Antigone.  Other  examples  are  cited  by  Simpson.  Sir  James  Y. 
Simp.son  was  the  first  to  use  ether  in  obstetric  practice  on  January  19,  1847.  He  did  a  version  and 
an  extraction.     In  November  of  the  same  year  he  discovered  the  anesthetic  properties  of  chloro- 


THE    TREATMENT   OF   THE    FIRST   AND    SECOND    STAGES  295 

form,  and  usod  it  m  labor  cases  to  tho  (exclusion  of  ether,  and  widely  advocated  the  practice.  A 
storm  of  adverse  criticism  against  both  anesthetics  broke  loose,  at  home  and  abroad,  and,  to  our 
minds,  a  curious  and  ridiculous  polemic  was  waged  between  Simpson  and  his  opponents.  (See 
Obstetric  Memoirs,  Simpson,  vol.  ii,  Anesthetics.)  N.  C  Keep,  of  Boston,  was  the  first,  according 
to  Chauniug,  to  use  etlier  in  labor  in  .\merica — .Vpril  7,  1S47.  The  use  of  an  anesthetic  in  labor 
spread  (|uickly,  particularly  after  X'ictoiia,  (^ueen  of  iMit^land,  in  IS.")."!  and  1857,  had  enjoyed  its 
benelits.      it  was  called  the  (Queen's  chioi'ororni,  (jr  (ntcsllicsui  a  hi  rcine. 

Other  Ancstluiicfi. — Regional  anesthesia,  invented  by  Corning,  and  elaborated  by  Bier  and 
Tufher,  the  cocainization  of  the  spinal  cord,  came  and,  fortunately,  quickly  went.  It  was  too 
dangerous,  headache,  vomiting,  hyperpyrexia,  tachycardia,  muscular  spasms,  drug  into.xication, 
meningitis,  periplu^ral  necroses,  being  the  evil  effects;  and,  further,  it  was  not  uniformly  efficient 
nor  the  effects  sufficiently  lasting.  Some  few  surgeons  still  employ  it,  using  novocain,  stovain,  or 
pantopon,  etc.  Itecently  Stoeckel  advised  the  injection  of  the  cocain  into  the  sacral  canal,  and 
Sellheim,  cocainization  of  the  pudic  nerves,  reaching  them  through  vaginal  puncture.  Local 
anesthetics  have  been  cmployecl,  as  cocain  and  belladonna,  to  the  cervix,  the  perineum,  and  the 
rectum. 

Hypnotism  has  been  used  in  hysteric  subjects  with  reported  good  effects.  Apollo  was  born 
of  Latona  imder  such  influence.  The  writer  frequently  uses  suggestion  during  labor  to  aid  the 
partiu'ient  to  bear  the  pain,  and  after  labor  gentle  suggestion  will  aid  in  obtaining  the  quiet  and 
restful  sleep  so  conduci\'e  to  rapid  restoration  of  the  patient's  nerve  equililjrium. 

Scopolamin-MorpJiin  Anesthesia. — Schneiderlin,  a  neurologist,  in  1899  recommended  the 
employment  of  morpliin  combined  with  scopolamin  for  the  production  of  surgical  anesthesia. 
Steinbiichel,  in  1902,  first  recommended  its  use  in  labor,  and  now  c(uite  an  extensive  literature 
exists  on  the  subject  (tfatcher).  Greene,  Newell,  Halpenny  and  ^'rooman,  Ries  in  America, 
Kronig,  Gauss,  I^eoi)old,  Sir  J.  H.  Croom,  in  Evu-ope,  and  others  ha-\-c  employed  the  combination, 
with  conflicting  results.  My  own  experience  has  been  small  and  not  favorable.  By  administer- 
ing V ou  grain  of  scopolamin  and  3^6  grain  morphin  hypodermically,  the  parturient  is  put  into  a 
sort  of  "twilight  sleep"  ("Dammerschlaf "),  from  which  she  is  easily  aroused,  but  after  which  .she 
has  no  recollection  of  pain.  Occasionally  slightly  larger  doses  are  required, — as  j-lij  and  }4:  of  the 
respective  drugs,— but  it  is  better  to  repeat  the  smaller  dose,  if  necessary,  at  the  end  of  two  hours, 
and  then  less  morphin  is  given.  The  dangers  of  these  drugs  are:  (1)  Asph>oda  and  narcosis  of  the 
child — two  of  my  cases  gave  me  considerable  difficulty  in  resuscitating  apparently  poisoned 
children;  (2)  prolongation  of  the  labor  and  more  frequent  necessity  of  forceps.  Others  report  a 
greater  number  of  postpartum  hemorrhages,  occasional  restless  delirium,  even  A-iolence,  and  un- 
certain results.  The  latest  waiters,  Lequeu,  Avarffy,  Strassman,  excepting  Newell,  condemn  the 
drugs  for  general  use  outside  of  hospitals,  where  the  parturient  cannot  be  closely  watched.  Greene 
and  most  others  restrict  their  emplojTnent  to  nervous  and  unstable  primipara^,  and  all  in.sist  on 
closest  observation  of  both  patients — all  of  wliich  show's  that  the  remedy  is  not  applicable  to  the 
conditions  met  in  ordinary  obstetric  practice. 

MorpJiin  and  Chloral. — Morphin  is  frequently  used  during  the  first  stage  of  labor,  alone  or 
combined  with  a  minute  dose  of  atropin,  to  calm  excessive  uterine  action,  to  soothe  the  patient,  or 
to  procure  needed  rest.  For  the  latter  purpose  it  may  be  supplemented  with  bromid  of  soda  per 
rectum.  Morphin  should  not  be  given  toward  the  end  of  the  fii-st  stage  nor  in  the  second  stage, 
because  experience  has  shown  that  the  fetus  is  then  more  likely  to  be  narcotized  and  rendered 
incapable  of  establishing  respiration  after  deliver}^  Chloral  should  be  A'ery  sparingly  used,  its 
action  being  very  similar  to  that  of  chloroform,  and,  too,  it  irritates  the  kidneys. 

Nitrous  oxid  gas  mixed  with  oxygen  has  been  used  in  labor  at  interA'als  since  1878.  It  is 
frequently  administered  during  pregnancy,  and,  with  apparent  safety,  for  the  extraction  of  teeth. 
Its  exhibition  during  labor  has  not  become  generalized.  The  author  recommends  that  it  be  not 
used  to  introduce  ether  anesthesia  for  obstetric  operations,  since  the  intense  carbonization  of  the 
blood,  though  temporary,  might  injuriously  affect  the  cliild.  Several  cases  of  such  apparent 
action  have  occurred  in  the  author's  experience. 

Preservation  of  the  Life  of  the  Fetus. — An  effort  should  be  made  to  reduce  the 
infant  mortaUty  during  child-birtli.  Tlie  author  is  convinced  that  attention  to  the 
child  during  the  second  stage  of  ordinary  labor  will  result  in  a  greater  total  saving 
of  life  than  the  application  of  all  the  newer  methods  of  operative  delivery — vaginal 
cesarean  section,  hebosteotomy,  and  the  extension  of  the  incUcations  for  cesarean 
section  in  contracted  pelvis.  All  honor  to  these  efforts!  but  a  greater  and  richer 
field  lies  close  at  hand  in  the  practice  of  ever}^  obstetric  attendant.  A  continual 
watch  for  the  first  signs  of  asphyxia  of  the  unborn  child,  and  for  the  s\auptoms  of 
abruption  of  the  placenta  in  the  second  stage,  will  not  seldom  he  rewarded  by  their 
discovery,  and  an  immediate  delivery  will  save  the  life  of  the  fetus. 

For  the  purpose  of  frequently  auscultating  the  fetal  heart,  during  the  second 
stage,  the  patient  is  allowed  to  lie  on  her  back  until  the  perineum  is  well  distended, 
and  then  turned  on  her  side  only  for  the  delivery,  if  the  accoucheur  prefers  delivery 
in  this  position.  The  atithor  delivers  most  women  on  the  back,  in  order  to  be 
able  to  hear  the  fetal  heart  more  satisfactorily. 


296  THE    HYGIENE   AND    CONDUCT   OF   LABOR 

Preservation  of  the  Perineum. — Anatomic  study  of  the  pelvic  floor  after  de- 
Hver}'  ahva^'s  shows  evidences  of  injurj^  to  all  its  structures.  The  connective 
tissue  is  torn  in  many  places,  the  layers  of  fascia  are  loosened,  the  levator  ani 
muscle  lacerated  more  or  less;  the  urogenital  septum  is  always  ruptured,  the 
perineal  l^ody  frequently,  and  all  the  tissues  are  bruised,  sho^ving  larger  or  smaller 
hemorrhages  and  suggillations.  The  later  results  of  these  macroscopic  and  micro- 
scopic injuries  are  shrinking  and  atrophy  of  the  pelvic  diaphragm,  relaxation  of 
same,  prolapse  of  the  urethra,  vagina,  bladder,  uterus — all  depending  on  the  extent 
of  the  traumatism.  In  importance  these  lacerations  vary  very  much.  Worst 
in  their  effects  are  the  tears  of  the  levator  ani,  the  perineal  ones  being  less  harmful, 
and  yet  it  is  the  prevention  of  perineal  lacerations  that  occupies  so  much  of  the 
accoucheur's  attention.  Our  best  efforts  are  to  be  directed  to  preserve  the  levator 
ani,  but  some  attention  should  be  given  to  the  perineum  itself,  because  it  has 
physiologic  and  pathologic  dignity;  extensive  rupture  of  this  body  may  cause 
sterilit}^,  vaginitis,  cervicitis,  endometritis  from  infection  ascending  through  the 
patulous  introitus;  a  perineal  tear  once  started  may  go  through  the  anus  into  the 
rectum,  causing  that  great  affliction — fecal  incontinence;  fresh  tears  may  form  the 
atria  of  bacterial  invasion;  the  structures  once  torn  can  never  be  perfectly  restored; 
finally,  the  injury  may  often  be  prevented,  and,  if  not  entirel}^,  it  may  be  limited  to 
a  safe  degree.  The  author  has  found  the  hymen  tears  in  all  cases;  60  per  cent,  of 
primiparse  have  tears  of  the  fourchet — the  so-called  first-degree  laceration;  25 
per  cent,  of  primiparse  and  10  per  cent,  of  multiparse  have  lacerations  extenchng 
well  into  the  perineal  body,  and  in  10  per  cent,  the  injury  exposes  the  sphincter 
ani — the  so-called  second  degree.  Only  in  operative  cases  has  a  complete  lacera- 
tion— that  is,  through  the  sphincter  ani — occurred.  These  percentages  are  larger 
than  those  given  in  most  text-books,  the  reason  being  that  the  author,  after  the 
levator  ani  is  w^ll  stretched,  allows  the  head  to  issue  rapidly,  with  a  view  to  sparing 
the  child's  brain  the  traumatism  of  a  prolonged  perineal  "protection."  Without 
doubt  children  suffer  brain  injuries  because  of  the  accoucheur's  anxiety  to  avoid 
perineal  lacerations.  The  excessively  slow  delivery,  too,  has  been  responsible  for 
cases  of  still-birth  from  asphyxia. 

Causation. — Rupture  of  the  perineum  may  not  always  be  prevented,  even  in 
the  best  hands  and  under  the  most  favorable  conditions.  The  pelvic  outlet  may  be 
diseased,  as  by  edema,  excessive  deposition  of  fat,  a  white-cell  infiltration  from 
syphilis,  condylomata  lata  and  acuminata,  varicosities,  or  through  lack  of  elas- 
ticity from  scars,  from  previous  operation,  age,  or  constitution.  In  some  women 
othen\dse  well  the  perineum  tears  like  wet  blotting-paper.  A  narrow  pubic  arch, 
by  forcing  the  head  back  into  the  perineum  and  not  allowing  the  occiput  to  crowd 
up  close  to  the  ligamentum  arcuatum,  favors  rupture.  A  vulva  situated  high 
on  the  pubis  is  subject  to  injury.  Necessity  for  rapid  delivery  often  makes  us 
disregard  the  perineum,  as  in  breech  cases  and  when  the  child  is  threatened  with 
asphyxia.  Delivery  effected  early  in  labor  finds  the  perineum  unprepared  for  the 
rapid  dilatation.  Exit  of  the  head  in  unfavoral^le  attitudes — face,  brow,  forehead, 
and  in  posterior  rotation  of  the  occiput — frequently  causes  lacerations,  because  the 
most  favorable  circumferences  are  not  presented  to  the  canal.  A  large  child  acts 
in  the  same  way  by  overstretching  the  outlet. 

Treatment. — Prevention  of  perineal  lacerations  naturally  will  proceed  along 
lines  indicated  above.  Here  only  those  precautions  needful  in  spontaneous  labor 
\v\\\  be  described.  How  to  care  for  the  levator  ani  and  perineum  during  forceps 
and  other  operative  dcUveries  will  be  given  in  full  in  the  proper  chapters. 

The  levator  ani  and  the  fascia  above  and  below  it,  making  up  the  pelvic  dia- 
phragm, can  be  spared  serious  injury  only  by  slow  dilatation.  While  carefully  watching 
the  fetal  heart -tones,  the  patient  is  not  allowed  to  bear  down  overmuch  during  the  first 
part  of  the  second  stage.     The  author  does  not  hurry  this  period  of  labor  without 


THE    TREATMENT   OF   TlIK    FIRST    AND    SECOND    STAGES 


297 


indication.  If  tho  pains  and  llic  hcaiiiifiinlown  efforts  arc  tumultuous,  tlic  woman 
is  laid  on  her  side  and  otiicr  };iv('n  as  a  moderator.  Whik;  uiorc  fr('(|UC'iit  in  opera- 
tive deli\'eries,  the  tear  in  the  levator  sometimes  occurs  at  the  pj^int  of  its  attach- 
ment to  the  piil)ic  rami,  uiidei'  (he  arch  of  the  pubis.  This  accident  may  rarely 
be  recognized  before  it  lias  occurred,  but  if  it  is,  oiut  should  incise  the  muscle  in  the 
right  vaginal  sulcus,  because  the  high  hidden  tear  may  be  impossible  to  sew  up 
afterward,  but  the  lower  incision  is  accessible  to  the  needle. 

The  princii)les  of  the  protection  of  the  perineum  are  two:  (1)  Deliver  slowly, 
developing  to  the  ultimate  the  elasticity  of  the  pelvic  floor;  (2)  deliver  the  head  in 
forced  flexion,  to  present  to  the  parturient  passage  the  smallest  circumferences  of 
the  head.  The  first  principle  needs  no  elucidation.  A  hard  Ixxly  which  has  to 
overcome  the  resistance  offered  by  an  elastic  cylinder  will  be  less  likely  to  tear  the 
cylinder  if  forced  through  it  very  slowly.  A  brief  study  of  the  mechanism  of  labor 
will  show  the  advantages  of  keeping  the  head  well  flexed  until  the  larger  part  of  it 


Fig.  310. — Arrangement  for  Delivery  on  Side  in  a  Home. 
Hot  and  cold  sterile  water  in  pitchens.     One  basin  has  HgCL-,  1:1500;   one,  1 J2  per  cent   lysol  solution.     Scissors, 
cord  tape,  artery  clamp,  and  catheter  lie  in  a  saucer  in  1  per  cent,  lysol  solution.     A  pile  of  sterile  towels  and  the  nurse's 
hand  forceps  are  on  the  table.     At  the  extreme  left  is  the  warm  receiver  for  the  infant. 


has  escaped  from  the  vulva.  If  the  head  were  to  come  out  in  partial  extension, 
there  would  be  presented  to  the  girdle  of  resistance,  made  up  of  the  pubic  arch  and 
the  pelvic  floor,  the  occipitobregmatic,  occipitofrontal,  and  occipitomental  diam- 
eters and  circumferences.  If  the  chin  is  forced  doAvn  on  the  sternum  and  flexion 
thus  maintained  until  the  nape  of  the  neck  comes  to  fit  closely  into  the  pubic  arch, 
the  diameters  and  circumferences  which  have  to  pass  the  ring  of  the  outlet  are  the 
suboccipitobregmatic,  suboccipitofrontal,  and  sul^occipitomental,  which  are  less 
by  13^2  to  3  cm. 

Mode  of  Procedure. — The  patient  may  lie  either  on  the  side  or  on  the  l^ack. 
It  is  well  for  the  accoucheur  to  learn  Iwth  methods,  since  each  has  its  advantages, 
and  the  ])rinciples  of  the  operation,  ^\^th  a  little  practice,  may  be  practised  equally 
w^ell  in  either  position.  0^^^ng  to  the  possibility  of  l^etter  control  of  the  fetal  heart- 
tones  the  author  usually  dehvers  the  patient  on  the  back.  In  out-patient  dis- 
pensary service,  because  of  the  filthy  beds  which  sag  in  the  middle,  the  poor  light, 


298 


THE    HYGIENE   AND    CONDUCT    OF    LABOR 


and  the  general  difficulty  of  maintaining  asepsis,  the  lateral  posture  is  preferred. 
This  posture,  too,  in  inexiDerienced  hands,  shows  a  smaller  percentage  of  lacera- 


FiG.  311. — Determining  the  Rate  of  Advance  of  the  Head  by  Pressing  in  the  Perineum. 


Fio.  312. — ^Delivery  on  Sidi;.     Iii:sTUAiNi\r;    luo  Rapid  Desci;nt  dv  (i]..\ii,i:  Pkehsuui;. 
The  following  eight  illustrations  aro  from  photographs  taken  at  the   Chieago  Lying-in  Hospital. 

tions.     For  purposes  of  description  and  illustration  delivery  on  the  side  will   be 
considered  first.     jMost  patients  are  allowed  to  lie  on  the  back  until  the  perineum 


THE   TREATMENT    OF   THE    FIRST   AND    SECOND    STAGES 


299 


begins  to  bulK<'  dtcidcdly.  'Jdic  ictul  licart -tones  being  normal,  the  woman  is  then 
brought  to  tiic  edge  of  the  1)0(1,  with  the  l)uttocks  directed  toward  the  best  Hght. 
Slie  lies  on  her  left  side,  with  tlie  lower  limb  drawn  up,  the  upper  somewhat  less 
flexed,  the  knee  being  supported  by  a  pillow  folded  once  and  protected  by  a  sterile 
towel  (Fig.  .310),     The  accoucheur  sits  on  the  edge  of  the  bed,  with  his  buck  to- 


pic. 31.S. — DiKEcrrM;  the  (ki  iiht  Under  the  Pubis  by  Pressure  on  the  Head  at  Ijji.l;  f)F  Frenulum. 


Fig.  314. — Restraining  Advance,  Yet,  at  the  Same  Time,  Favoring  Flexion.     Sponge  Ready  to  C.\tcu  Feces. 


ward  the  woman's  face,  his  left  hand  between  her  thighs,  with  the  wrist  resting  on 
the  pubis.  At  his  right  hand  stands  the  table  with  the  solution  basins,  sterile 
towels,  with  tape  and  scissors  for  cord.  The  anesthetizer  is  on  the  other  side  of  the 
bed,  and  since  the  parturient  lies  somewhat  obliquely,  her  head  is  nearer  to  him. 
Unless  the  patient  is  bearing  down  too  much  and  the  head  advancing  too  rapidly, 


300 


THE    HYGIENE   AND    CONDUCT    OF    LABOR 


the  accoucheur  does  not  interfere  by  word  or  act  until  the  scalp  is  visible  to  the 
size  of  an  egg.  The  rapidity  of  the  descent  of  the  head  may  easily  and  safely  be 
determined  by  pressing  the  fingers  upward  and  inward  along  the  ramus  of  the  pubis 
(Fig.  311).  One  can  feel  the  hard  resistance  of  the  presenting  part  if  the  part  is 
low  in  the  pelvis.     The  location  of  the  anus  also  indicates  the  degree  of  dilatation 


Fig.  31.5. — Tucking  Labia  Minora  Behind  Occiput. 


Fic.  31C. — Cleansing  Mouth. 


and  downward  displacement  of  the  levator  ani.  When  the  accoucheur  decides 
that  the  head  is  coming  through  too  fast,  he  asks  the  woman  to  cease  bearing  down, 
to  open  her  mouth  and  breathe  through  it  until  the  force  of  the  effort  is  expended. 

With  each  pain  the  head  is  allowed  to  come  down  to  distend  the  perineum  a 
little  more.  If  the  pain  is  too  strong,  the  head  may  be  gently  held  back  by  evenly 
distributed  pressure  of  both  hands.     A  word  of  warning  against  overzeal  must  here 


THK    TREATMENT    OK   THE    FIRST   AND    SECOND    STAGES 


301 


be  given.     Many  an  infant  lias  lost  its  life  because  the  attendant  was  overanxious 
to  deliver  the  woman  "without  stitches."     The  i)r()tracted  second  stage  resulted 


Fig.  317. — Delivery  of  Posterior  Shoulder. 

Crowding  the  child  gently  upward  into  the  pubic  arch,  to  forestall  injury  by  the  broad  chest.     The  elbow  of  the  left  arm 
follows  down  the  receding  uterus.     The  author  prefers  to  turn  the  patient  on  her  back,  as  in  Fig.  319. 


Fig.  31S. — The  Left  Hand  Now  Gr.\sps  the  Uterus,  the  Right  Lays  the  Lnf.o;t  in  Position. 


in  its  loss  by  asphyxiation.     Again,  the  infant  may  be  injured  by  pressing  on  the 
head  too  forcibly,  causing  skull  fracture,  and,  finally,  if  the  uterine  and  abdominal 


302 


THE    HYGIENE   AND    CONDUCT   OF   LABOR 


efforts  are  violent  and  the  child  not  allowed  to  come  out,  the  uterus  may  rupture, 
as  it  does  under  other  circumstances  of  opposition  to  its  powerful  action.  The 
author  has  seen  all  these  injuries. 

Not  seldom  feces  and  mucus  are  forced  from  the  anal  opening  during  the 
woman's  bearing-down  efforts.  Since  there  is  real  danger  of  infection  from  this 
source,  the  accoucheur  must  collect  such  discharges  in  large  cotton  sponges  soaked 
in  1 :  1500  bichlorid,  using  care  not  to  soil  his  glove  nor  the  region  around  the  anus. 
This  region,  as  an  additional  precaution,  is  resterilized  with  both  antiseptic  solu- 


FiG.  319. — Patient  on  Back,  with  One  Foot  on  Bed  and  One  on  a  Stool,  for  the  Delivery  op  the  Shoulders, 

IF  Difficult. 
Some  accoucheura  prefer  to  deliver  the  trunk  in  tliis  pcsition  in  every  labor. 


lions.     The  author  has  never  seen  any  harm  from  the  very  liberal  use  of  these 
antiseptics  on  the  vulva  and  perineum. 

In  gentle  fashion  the  head  is  permitted  to  descend  until  its  greatest  periphery 
stands  in  the  di.stended  vulva.  It  is  now  delivered  in  the  interval  between  pains. 
The  head  is  restrained  at  the  height  of  the  bearing-down  effort,  the  woman  is  asked 
to  breathe  through  her  mouth  or  to  cry  out,  while  the  accoucheur  tucks  the  clitoris 
and  labia  minora  behind  the  occiput  under  the  pubis.  If  the  patient,  in  the  de- 
lirium of  pain,  bears  down  violently,  ether  is  administered.      After  the  pain  has 


THE  TREATMENT  OF  THE  FIRST  AND  SECOND  STAGES 


303 


ceased  the  woman  is  asked  t(;  bear  down,  and  during  tliis  effort  the  distended  per- 
ineum is  slipped  back  over  the  forehead  and  face  unck-r  tiie  chin.  A  sterik-  towel  is 
tucked  under  tiie  chin  and  covers  tlie  anus,  whicli  prevents  infection  of  the  ac- 
coucheur's hands  and  of  the  chikl's  mouth  by  feces. 

During  this  manoeuver  the  head  is  maintained  in  a  state  of  fiexion,  not  by 
pressure  on  the  forehead  through  the  perineum,  but  by  manipulation  of  the  part  that 
is  accessible  to  the  fingers.  A  gcmtle  attempt  to  lead  the  suboccipital  region  under 
the  pul)is  is  first  made  by  pressing  tii(>  head  back  onto  the  perineum  with  the  finger 
on  the  occipital  protuberance,  during  two  or  three  pains.  When  the  head  has 
descended  far  enough  to  give  hold  to  the  fingers,  these  applied  right  at  the  edge  of 
the  frenulum  are  used  to  press  it  up  under  the  arch  of  the  pubis,  and,  as  the  head 


Fig.  320. — Depressing  Head  for  Delivery  of  Anterior  Shoulder. 
Be  careful  not  to  overstretch  the  neck  and  cause  Erb's  palsy. 


finally  rolls  up  onto  the  pubis,  the  flexion  is  maintained,  as  far  as  possible,  by 
making  pressure  on  the  part  delivered  against  the  bone  (Figs.  313  and  316). 

As  soon  as  the  face  is  delivered  the  forehead  and  eyelids  are  wiped  with  a  gauze 
sponge  Avrung  dry  out  of  1:1500  bichlorid  solution,  the  mucus  is  squeezed  out  of 
the  nostrils  and  wiped  out  of  the  mouth  with  the  finger,  covered,  if  need  be,  "udth  a 
piece  of  soft  linen  or  lintine.  These  details  are  important.  Removal  of  the 
vaginal  secretions  from  the  neighborhood  of  the  eyes  is  to  prevent  ophthalmia 
neonatorum;  the  removal  of  mucus  from  the  nose  and  mouth,  to  prevent  aspiration 
of  the  foreign  matter,  ^^^th  subsequent  intestinal  sepsis,  atelectasis,  and  broncho- 
pneumonia. 

The  accoucheur  now  feels  for  the  cord  and  notes  if  it  is  around  the  neck,  and  if 


304 


THE   HYGIENE   AND    CONDUCT   OF    LABOR 


it  is  tight,  maldng  an  obstacle  to  delivery.  If  it  does  this,  it  should  be  clamped  and 
cut.  A  cord  that  is  too  short,  or  relatively  too  short,  may,  unless  cut,  pull  on  the 
placenta  and  cause  anomalies  in  the  third  stage,  or  even  inversion  of  the  uterus. 
If  the  patient  has  been  lying  on  her  side,  she  is  now  gently  turned  onto  the  back 
for  the  delivery  of  the  trunk.  This  procedure  brings  the  upper  limb  over  the  edge 
of  the  bed,  and  it  may  be  allowed  to  rest  on  a  chair,  which  leaves  the  patient  in  the 
oblique  position,  with  the  vulva  near  the  side  of  the  bed,  and  very  favorably  placed 
for  dehvery  of  the  shoulders  (Fig.  319).  If  preferred,  the  patient  may  be  moved 
over  to  the  middle,  with  both  legs  resting  in  the  bed,  or  put  across  the  bed. 

Delivery  of  the  Shoulders. — A  tendency  to  hurry  this  part  of  labor  should  be 
resisted.  If  the  child's  face  is  normally  blue  and  reacts  to  stimuli,  e.  g.,  rubbing, 
one  mav  wait  for  the  renewed  action  of  the  uterus.     After  a  minute  or  two  another 


Fig.  321. — Lifting  the  Head  for  Delivery  of  Posterior  Shoulder. 


pain  comes  on  and  the  patient  gently  bears  down  until  the  anterior  shoulder  be- 
comes visible  just  behind  the  pubis.  Now  the  accoucheur  lifts  the  child  up  and 
brings  the  posterior  shoulder  over  the  perineum.  If  the  child's  hand  is  accessible, 
the  arm  is  drawn  out  gently.  Then  the  child  is  depressed  as  the  anterior  shoulder 
comes  from  behind  the  pubis,  and  now  the  rest  of  the  body  follows  in  one  long  pain 
without  particular  mechanism.  The  child  must  not  be  dragged  out  of  the  uterus. 
It  is  best  if  the  natural  powers  force  it  out,  the  physician  aiding  the  process  only  by 
directing  the  mechanism,  as  above  indicated.  A  perineum  may  be  torn  by  the 
shoulders  or  a  slight  tear  plowed  deeply  by  them,  and  the  clavicles  may  be  broken, 
or  the  nerves  and  muscles  of  the  neck  overstretched  at  this  stage  of  the  delivery 
unless  proper  care  be  exercised. 

If  the  delivery  of  the  shoulders  is  delayed  too  long,  the  woman  is  asked  to  bear 
down,  failing  which  the  hand  on  the  belly  performs  Kristeller's  expression,  or  the 


THE    TUEATMENT    OF   THE    FIRST   AND    .SECOND    .STAGES 


305 


child  is  (lcli\'('i((l  ]>y  slow  liactioii  lollowiii^-  the  iiiechani.sni  here  indicated.  (See 
p.  988  for  pathologic  shoulder  deliveries.; 

Historic. — Hipfujcmtcs  n'(;of^iiiz('(l  the  uiiportanoo  of  tlic  provontion  of  pcrirwal  lafcration, 
and  .sought  to  soften  the  .structures  hy  oily  .salves  and  relaxing  douelies,  a  i)raetieo  which  \vu.s 
recommended  hy  Haudeloc(iue  and  others,  even  hy  .some  toilay,  in  the  form  of  hot  moist  applica- 
tions. \an  Horn  (seventeenth  century j  dilated  the  perineum,  pushing  hack  the;  coccyx  and 
stretching  the  levator ani  manually,  with  horing  or  circular  mo\'ements,  a  proce<lin-e  that  was  used 
for  many  years  hy  most  authorities  and  is  still  recommended  in  a  mociified  maimer  ])y  Edgar  for 
normal  cases.  The  author  ad\'ises  such  interference  only  in  patliologio  cases,  and  as  a  preparation 
for  a  rapid  hreech  or  forc(>i)s  extraction.  \'arious  instruments  were  designed  to  lift  tiio  head 
away  from  the  perineum,  one  of  the  most  curious  hoing  a  perineal  horn,  like  one  used  for  putting 
on  shoes. 

Soranus  of  Ephc.sus  (aliout  110  a.  n.)  first  attempted  to  ".support"  the  perineum  with  the 
hand,  a  notion  that  it  has  been  imixissihle  to  eradicate  from  the  medical  mind.  Goodell  tried  to 
"relax  the  perineum"  hy  pressure  from  the  two  sifles  toward  the  middle  line.  Various  attempts 
have  heen  made  hy  .some  accoucheurs  to  lift  the  perineum  forward  with  fingers  introducerlinto  the 
anus,  or  l)y  the  liand  placed  on  the  jierineum  from  the  outside.  Others  try  to  strip  the  vulva  hack 
over  the  head — all  maiKcuvers  which  fail  in  their  (jl)ject,  are  harmful  hecause  of  injury  to  the  levator 
ani  and  rectum,  and  dangerous  hecause  of  sepsis.  Finally,  may  be  mentioned  the  employment  of 
incisions  in  the  perineum  to  avoid  deeper  tears  of  the  structure. 

Episiotomy. — When  a  tear  of  the  perineum  appears  inevitable,  the  question 
arises,  shall  it  be  allowed  to  occur  spontaneously  and  go  in  whatever  direction  it 
may,  or  shall  we  seek  to  anticipate  it,  or  at  least 
divert  it  away  from  the  sphincter  into  unimportant 
structures?  Ould,  in  1742,  cut  the  vulvar  outlet 
when  it  offered  too  great  resistance  to  the  escape 
of  the  head.  G.  P.  jMichaeHs,  in  1810,  incised  the 
perineum  to  avoid  a  dangerous  tear.  Ritgen  and 
Schultze  made  numerous  small  incisions  in  the 
tense  vulvar  ring.  Scanzoni  recommended  two 
lateral  incisions,  Crecle,  one,  directed  from  the 
frenulum  toward  the  tuberosity.  Many  accou- 
cheurs perform  the  operation,  preferring  a  clean 
cut  to  the  jagged  tear,  and  claiming  that  the 
lateral  structures  are  less  important  than  the  cen- 
tral portion  of  the  perineum,  and  fearing  that  a 
tear  beginning  in  the  middle  line  only  too  easily 
goes  beyond  control  of  the  attendant  into  the 
sphincter  ani,  even  into  the  rectum.  Episiotomy 
is  the  name  applied  to  the  operation,  which  might 
more  correctly  be  considered  under  the  heading  of 
operative  obstetrics,  but,  owing  to  its  frequency, 
will  be  described  here.  The  incision  is  made  in 
three  ways — the  lateral  or  bilateral  (Fig.  322), 
where  the  cut  is  parallel  with  the  long  axis  of  the 
mother's  person;  the  median,  where  the  line  lies  in 
the  raphe  (a  method  recently  again  urged  by 
Kiistner)  and  the  mediolateral,  recommended  by 
Tarnier  and  practised  by  the  author.    One  must  be 

sure  that  he  understands  what  is  expected  of  episiotomy.  It  simply  cuts  the  skin,  the 
urogenital  septum,  with  the  constrictor  cumii  and  transversus  perinei,  and  a  few  of 
the  anterior  fibers  of  the  puborectal  portion  of  the  levator  ani.  Diilu-ssen,  in 
1888,  recommended  a  deeper  episiotomy  or  perineotomy  for  pathologic  cases,  in 
w^hich  the  incision  went  through  the  levator  ani  into  the  ischiorectal  fossa.  There 
are  special  indications  for  this  extensive  operation,  and  it  is  performed  onl}'  when 
delivery  must  be  effected  before  the  levator  has  had  time  to  stretch  even  a  little. 

The  indications  for  the  usual  episiotomy  are:   Resistant  perineum,  causing 
delay  in  the  exit  of  the  head  through  the  vulva;  some  pathologic  condition  of  the 
20 


Fig.  322. — Diagr.ym  of  Three  Kinds  of 
Episiotomv. 
1,  1,  The  bilateral;  2,  the  median;  3,  3, 
the  mediolateral,  recommended  by  author. 
A  radial  incision  may  be  made  anywhere  be- 
tween 1  and  2. 


306 


THE   HYGIENE   AND    CONDUCT   OF    LABOR 


vulva,  scars,  syphilis,  etc.;  abnormal  size  of  the  child  or  abnormal  mechanism, 
causing  mechanical  disproportion;  the  necessity  for  rapid  extraction  when  one 


Fig.  323. — The  Operation  of  Episiotomy. 
If  labor  is  not  so  far  advanced,  the  incision  should  be  less  vertical. 

may  not  give  the  perineum  time  to  dilate,  and  when  one  sees  that  the  perineum  will 
surely  tear,  to  divert  the  laceration  away  from  the  anus. 


Fig.  324. — Perineum  Scissors. 
Rounded  points  do  not  injure  ehild'.s  scalp,  and  are  safer  for  rubber  gloves. 

It  is  best  to  wait  until  the  head  has  stretched  the  levator  ani  well  (which  is 
determined  by  the  opfning  of  the  anus  and  the  dislocation  of  the  anus  downward 
and  forAvardj,  and  only  the  resistance  of  the  vulvar  outlet  remains  to  be  overcome. 


THE   TREATMENT   OF   TIFE    FIRST   AND    SECOND    STAGES  307 

If  at  this  point,  by  vaginal  inspection  or  palpation,  one  discovers  the  beginning  of 
a  tear,  it  is  anticipated  l)y  cpisiot(jniy.  One  blade  of  the  scissors  is  laid  on  the 
vaginal  mucous  luenibranc,  the  other  rests  on  the  skin  of  the  perineal  bcxly,  mid- 
way between  the  anus  and  the  tuberosity  of  the  ischium,  the  cutting  angle  of  the 
scissors  being  at  the  median  raphe  (Fig.  323).  With  the  finger  and  thumb  of  the 
other  hand  the  sphincter  is  pressed  out  of  the  bite  of  the  scissors.  The  patient  is 
given  a  few  extra-deep  inhalations  of  ether,  and  with  a  single  quick  motion  the  tissues 
are  severed.  Hemorrhage  is  stopped  by  i)ressure.  Usually  the  head  issues  quickly 
after  the  incision  is  made,  and  then  the  bleeding  ceases,  but  if  it  does  not,  a  firm 
tampon  will  check  it  until  the  sutures  are  applied.  The  incision  is  repaired  after 
delivery  of  the  placenta,  in  the  manner  usual  with  perineorrhaphies  (p.  736). 


THE  CARE  OF  THE  CHILD 

A  warm  sterile  receiver  is  ready  for  the  new-V)orn  individual,  who,  as  soon  as 
born,  is  placed  near  the  vulva,  so  that  the  cord  is  not  dragged  upon,  yet  far  enough 
away  so  that  he  is  not  soiled  ■with  the  blood,  feces,  etc.,  about  the  anus,  and  also 
safe  from  compression  by  the  mother's  person. 

The  first  attention  to  the  child  is  the  wiping  of  the  face  and  eyelids  with  a 
sponge  squeezed  dry  from  a  1:1500  bichlorid  solution,  and  removal  of  the  mucus 
from  the  air-passages  immediately  after  the  head  is  born — points  already  men- 
tioned. 

Tying  the  Cord. — After  waiting  until  the  pulsation  in  the  exposed  mnbihcal 
cord  has  perceptibly  weakened  or  disappeared,  the  child  is  severed  from  its  mother. 
Until  the  cord  is  severed  the  child  is  still  a  part  of  its  mother  and  has  no  legal  exist- 
ence. With  a  piece  of  linen  bobbin,  coarse  silk,  rubber  band,  or  any  strong  string 
the  cord  is  ligated  close  to  the  skin  margin  of  the  navel  (3^  inch),  first  being  sure 
that  there  is  no  umbilical  hernia  which  might  allow  a  loop  of  gut  to  be  caught  in  the 
grasp  of  the  ligature.  Another  Hgature  is  placed  a  few  inches  from  the  first,  and, 
protecting  the  child  from  injury,  the  cord  is  severed  with  sterile,  dull,  and  blunt 
scissors  close  to  the  first  ligature.  It  is  important  to  leave  as  little  as  possible  of  the 
cord  to  be  cast  off,  and,  further,  a  short  stump  is  less  likely  to  be  dragged  upon  and 
easier  to  dress.  The  short  stump  method  was  practised  by  Mauri ceau  and  only 
recently  revived.  The  first  tying  must  be  made  very  secure,  and  security  is  ob- 
tained by  tightening  the  knot  slowly  and  interruptedly,  giving  time  for  the  jelly  of 
Wharton  to  escape  from  under  the  thread,  which  thus  comes  to  constrict  only  the 
vessels. 

During  the  four  or  eight  minutes  while  waiting  to  tie  the  cord  the  child  obtains 
from  40  to  60  gm.  of  the  reserve  blood  of  the  placenta — a  fact  which  was  first  shown 
b}^  Budin.  The  blood  is  pressed  into  the  child  by  the  uterine  contractions,  and  part 
is  aspirated  by  the  expanding  chest.  This  extra  blood  the  child  needs  in  its  first 
days  of  life,  -and  observation  has  shown  that  such  children  lose  less  in  weight  and 
are  less  subject  to  disease.  It  is  an  error,  on  the  other  hand,  to  force  the  blood  of 
the  placenta  into  the  child  by  stripping  the  cord  toward  the  child.  This  overloads 
its  blood-vessels,  causes  icterus,  melena,  even  apoplexy.  The  child  never  had  the 
extra  blood  of  the  placenta.  The  practice  of  waiting  until  the  placenta  is  dehvered 
before  tying  the  cord  is  not  recommended. 

A  second  ligature  is  applied  to  the  cord  to  keep  the  blood  in  the  placenta  and 
give  the  uterus  a  firm  body  to  act  on,  to  prevent  the  soiling  of  the  bed  and  patient 
with  blood  which  would  flow  from  the  open  vessels,  and  to  preserve  a  possible  tvan, 
still  in  the  uterus,  from  hemorrhage,  since  the  two  circulations  of  twins  usually 
anastomose. 

The  stump  and  the  region  of  the  belly  around  it  are  now  wiped  with  1 :  1500 
bichlorid  or  pure  alcohol,  a  piece  of  dry  gauze  laid  over  the  wound,  and  the  infant, 


308  THE    HYGIENE    AND    CONDUCT    OF    LABOR 

TVTapped  in  a  sterile  receiver,  is  handed  to  the  nurse,  who  puts  it  in  a  safe,  warm 
place,  delegating  a  relative  to  watch  it  and  see  that  it  breathes  naturally. 

The  Care  of  the  Eyes. — Many  States  have  passed  legislation  making  the  anti- 
septic treatment  of  the  eyes  of  the  new-born  obligatory  on  the  part  of  the  accoucheur. 
Statistics  prove  that  about  33  per  cent,  of  the  cases  of  blindness  admitted  to  the 
institutions  supported  by  the  State  have  lost  the  light  of  clay  through  the  lack  of 
proper  precaution  at  the  time  of  birth.  The  blindness  is  caused  by  a  disease  known 
as  ophthalmia  neonatorum,  which  is  a  purulent  inflammation  of  the  conjunctiva 
and  cornea,  due,  nine  times  out  of  ten,  to  the  gonococcus  of  Neisser.  The  disease  is 
highly  preventable,  and,  even  in  eleemosynary  lying-in  hospitals,  receiving  large 
numbers  of  patients  with  gonorrheal  vaginitis,  it  has  been  almost  eradicated.  The 
germs  get  into  the  eyes  during  the  passage  of  the  head  through  the  vagina,  or  are 
washed  into  them  by  the  attendant,  or  wiped  into  them  by  the  mother.  While 
the  gonococcus  is  usually  causative,  the  pneumococcus,  the  bacillus  of  diphtheria, 
and  other  germs  may  cause  serious  conjunctivitis.  The  child  may  be  born  with  the 
disease  already  well  advanced. 

Mode  of  Prevention. — If  the  husband  or  wife  is  known  to  have  gonorrhea,  the 
vaginal  inflammation  is  to  be  treated  during  pregnancy  by  the  usual  methods. 
Douches  of  1  :  1500  potassium  permanganate,  given  under  low  pressure,  and  applica- 
tions of  25  per  cent,  argyrol  tampons  give  good  results.  During  labor  the  vagina- is 
douched  out  every  six  hours  with  1  per  cent,  lysol  solution — this  only  in  cases  of  gonor- 
rhea, not  for  the  routine  delivery.  The  bag  of  waters  must  not  be  ruptured,  but  is  to 
be  allowed  to  come  clown  and  line  the  vagina  for  the  passage  of  the  head.  It  is  best 
if  the  child  of  such  a  mother  is  delivered  with  a  caul.  During  all  vaginal  examina- 
tions the  eyes  of  the  fetus  (for  example,  in  face  presentation)  must  not  be  touched. 
When  there  is  a  purulent  greenish  vaginal  discharge,  or  if  there  are  condylomata  on 
the  vulva,  the  precautions  are  redoubled,  the  aim  being  to  prevent  all  possibility  of 
maternal  secretions  getting  into  the  conjunctival  sac.  The  same  principle  is  carried 
out  after  the  head  is  born,  the  vaginal  mucus  being  removed  at  once  from  the  neigh- 
borhood of  the  eyes  with  pledgets  wrung  dry  from  1  :1500  bichlorid,  and  great  care 
observed  to  allow  no  reinfection. 

The  nurse  is  instructed  always  to  observe  this  same  care  while  giving  baths, 
and  the  first  cleansing  is  best  made  by  an  albolene  or  lard  rub,  to  remove  the 
vernix  caseosa.  When  gonorrhea  is  present,  oil  rubs  are  substituted  for  the  baths 
entirely.  In  maternity  practice  the  child  and  its  mother  are  rigidly  isolated,  because 
the  disease  is  highly  infectious. 

Active  antisepsis  of  the  eyes  may  not  be  needed  if  the  above  method  is  prac- 
tised, but  it  is  best  to  disinfect  the  eyes  as  an  additional  precaution.  Where  gon- 
orrhea is  suspected  in  either  parent,  the  old  Crede  method  is  used — a  drop  of  2 
per  cent,  silver  nitrate  solution  in  each  eye,  neutralized  immediately  with  salt 
solution. 

As  a  routine,  in  hospital  practice,  the  author  uses  1  per  cent,  nitrate  of  silver 
solution  and  does  not  neutralize  it,  a  practice  also  in  vogue  in  the  New  York 
Lying-in  Hospital,  the  University  of  Pennsylvania  Maternity,  and  the  Manhattan 
Maternity.  The  Johns  Hopkins  Maternity  uses  the  2  per  cent,  solution.  In  his 
private  practice  the  author  invariably  employs  some  antiseptic,  and  at  present  uses 
25  per  cent,  argyrol  solution  with  satisfactory  results. 

Other  antiseptics  have  been  recommended,  as  bichlorid,  boric  acid  (useless), 
acetate  of  silver,  sophol,  etc.,  but  the  author  has  found  no  reason  to  alter  the  prac- 
tice outlined  above. 

Some  practitioners  use  the  drops  immediately  after  the  child  is  born,  but  the 
author  prefers  to  wait  until  after  the  third  stage  is  completed,  so  that  he  can  do  the 
little  operation  himself,  under  favorable  conditions.  Thus  is  assurance  obtained 
that  the  medicine  actually  reaches  the  conjunctival  sac. 


THE   TREATMENT   OF   THE    FIRST   AND    SECOND    STAGES  309 

No  objections  nuiy  Ix'  urged  against  this  pi'opliyiactic  antis('j)tic  trcatnicnt  <jf 
the  eyes.  Statistics  prove  conclusively  that  it  reduces  the  I'nKjuency  of  j)uiulent 
conjunctivitis  to  less  than  ^2  u'  1  P'^'  f^nt.  In  the  Chicago  Lying-in  Hospital  only 
one  child  in  the  last  1000  cases  developed  the  disease,  and  this  was  very  mild.  The 
frequency  of  "silver  catarrh"  under  the  old  Crede  method  has  been  reduced  by  the 
use  of  a  1  per  cent.,  instead  of  a  2  per  cent.,  solution,  and  with  the  25  per  cent, 
argyrol  solution  such  .slight  catarrhal  reactions  are  very  rare  and  are  easily  cured. 
The  silver  solution  must  l)e  made  fresh  nearly  every  day,  as  it  is  the  tlecomposition 
l^roducts  which  cause  the  conjunctival  irritation. 

The  writer  is  not  certain  that  a  child  would  not  be  able  to  recover  damages  at 
law  from  the  accoucheur  if  it  should  be  blinded  at  birth  and  it  were  proved  that  the 
attendant  ditl  not  use  the  recognized  precautions. 

Literature 

Bevan:  Jour.  Amer.  Med.  Assoc,  1905. — Burh'n:  Fasbender,  Gesohichte  der  Geb.,  p.  610. — Gauss:  Arch.  f.  Gyn.,  1906, 
vol.  Ixxviii,  p.  579;  Centralbl.  f.  Gyn.,  1907,  Nos.  21,  3.3,  35. — Hatcher:  Jour.  Amcr,  Med.  Assoc,  1910,  vol. 
liv,  No.  7,  p.  518. — Kronig  and  Pankov:  Centralbl.  f.  Gyn.,  1909,  p.  161. — Littig:  Jour.  Amer.  Med.  Assoc, 
1908,  vol.  1,  p.  394.— Se?/;tem:  Centralbl.  f.  Gyn.,  1910,  No.  27;  also  ibid.,  1911,  p.  1334.— Sippe?.  "Chloro- 
form Death,"  Arch.  f.  Gyn.,  vol.  Ixxxviii,  1,  p.  167. — Steinbilchel:  Centralbl.  f.  Gyn..  1902.  No.  48,  p.  1304. — 
Sticker:  Zeitschr.  f.  Geb.  u.  Gyn.,  vol.  xlv,  Heft  1. — Stroganoff:  Centralbl.  f.  Gyn.,  1901,  p.  146,  No.  6. 


CHAPTER,  XXII 
THE  THIRD  STAGE 

More  women  die  from  accidents  of  the  third  stage  of  labor  than  during  the 
other  two  combined.  On  a  proper  conduct  of  this  part  of  the  deUvery  depend  the 
woman's  freedom  from  postpartum  hemorrhage,  the  expulsion  of  the  secundines 
complete,  the  smooth  convalescence  during  the  puerperium,  and  even  her  health 
later  in  life.  Postpartum  hemorrhage  may  be  directly  fatal,  or  may  leave  the 
woman  permanently  invalided;  retention  of  pieces  of  placenta  may  be  the  cause  of 
puerperal  infections  and  lay  the  foundation  for  ineradicable  disease.  It  is  impor- 
tant, therefore,  that  the  accoucheur  be  familiar  with  the  physiology  of  the  third 
stage,  and  possess  a  good  technic  in  its  conduct.  Baudelocque  distinguished  the 
separation  from  the  expulsion  of  the  after-birth,  and  this  difference  must  always  be 
kept  in  mind.  The  same  general  principle  applies  to  the  treatment  of  this  stage  as 
to  the  others,  the  accoucheur  studies  the  mechanism  as  it  unrolls  under  hand  and 
eye,  watches  the  patient,  and  interferes  only  for  good  reason. 

Mode  of  Conduct. — As  the  child  leaves  the  vagina  the  nurse  or  the  assistant 
follows  clown  the  receding  uterus  with  the  hand  placed  lightly  upon  it.  After 
delivery  the  accoucheur  himself  guards  the  uterus  through  a  sterile  towel.  No 
massage  of  the  fundus  is  practised :  the  hand  simply  rests  on  it,  noting  its  firmness 
and  the  varying  consistence,  due  to  contraction  and  relaxation.  When  the  child  has 
been  severed  from  the  mother,  the  accoucheur  resumes  his  watch  over  the  uterus, 
a  warm,  clean,  folded  sheet  is  laid  under  the  patient,  a  sterile  basin  or  bed-pan  is 
pushed  against  the  nates  and  perineum,  taking  care  not  to  push  feces  upward  onto 
the  vulva,  and  the  cord  is  drawn  up  over  the  thigh,  leaving  a  loop  hanging  so  that 
it  just  touches  the  bottom  of  the  basin  (Fig.  325).  The  woman  lies  on  her  back, 
with  the  legs  drawn  up  or  outstretched,  according  to  her  comfort.  The  abdomen  is 
covered,  but  the  basin  must  be  visible,  for  the  accoucheur  wishes  to  see  if  blood 
accumulates  in  it.  If  the  woman  has  been  delivered  on  the  side,  she  is  gently  turned 
on  her  back  for  the  conduct  of  the  third  stage,  taking  care  to  be  certain  that  the 
legs  are  pressed  firmly  together,  and  that  the  uterus  is  very  hard  during  the  move- 
ment— these  precautions  to  avoid  air-embolism,  which  has  occurred  (Braun). 

The  accoucheur  now  sits  or  stands  at  the  side  of  the  patient  (Fig.  325),  and 
studies  the  phenomena  of  the  separation  of  the  placenta,  and,  in  the  absence  of 
hemorrhage  from  the  vulva  or  into  the  uterus,  has  nothing  else  to  do  for  fifteen  to 
thirty  minutes.  The  hand  on  the  uterus  notes  the  frequency  and  strength  of  the 
after-pains;  the  eye  notes  the  amount  of  blood  accumulating  in  the  basin.  If  the 
uterus  remains  firm  and  does  not  balloon  out  with  blood;  if  there  is  no  external 
bleeding — nothing  is  done,  but  if  the  uterus  softens  and  fills  up,  or  if  there  is  exter- 
nal hemorrhage,  a  gentle  massage  is  practised.  The  four  fingers  make  circles  on  the 
posterior  wall  of  the  fundus,  while  the  thumb  rests  in  front,  the  motion  resembling 
the  kneading  of  bread.  As  soon  as  the  uterus  becomes  firm  the  oozing  will  cease 
and  the  kneading  may  be  discontinued.  Inspection  of  the  vulva  will  show  whether 
the  hemorrhage  comes  from  some  tear  of  the  vulva  or  clitoris  or  from  a  point  higher 
up  in  the  parturient  canal.  In  pathologic  cases  abnormalities  of  the  separation  of 
the  placenta  cause  hemorrhage,  and  then  the  treatment  of  the  third  stage  has  to  be 
altered.  (See  p.  775.)  The  accoucheur  waits  for  the  signs  that  the  placenta  has 
been  separated  and  has  been  expelled  from  the  uterus  into  the  dilated  lower  uterine 

310 


THE   THIRD    STAGE 


311 


segment  and  upper  vagina.  Strong  uterine  contractions  themselves  would  indi- 
cate this  to  the  accoucheur,  but  there  are  other  signs:  (1)  The  cord  becomes  limp 
and  advances  3  or  4  inches  from  the  vulva  (diagnosed  by  observing  the  longer  loop 
in  the  basin) ;  (2)  the  uterus  rises  up  in  tiie  abdomen,  usually  to  the  right  side,  while 
below,  over  the  pubis,  a  soft,  boggy  mass  apjx-ars  (the  placenta);  (3)  the  globular 
uterus  has  flattened  out  from  before  backward,  presents  a  sharp  ridge  at  the  fundus, 
is  more  movable,  smaller,  and  harder;  (4)  a  flat  dimple  is  palpable  on  the  fundus. 

These  phenomena  are  apparent  in  ten  to  forty-five  minutes,  depending  on  the 
strength  of  the  uterine^  contractions.  When  the  placenta  is  surely  out  of  the  cavity 
of  the  uterus,  there  is  no  real  need  of  waiting  longer  for  its  delivery;  indeed,  the 
author  believes  that  it  is  better  practice  to  remove  it  at  this  time,  because  there  is 


Fig.  325. — Guarding  Uterus  Postpartum. 
To  show  exact  position  of  the  hand,  the  sterile  towel  was  removed. 


less  likelihood  of  blood-clots  forming  in  the  partially  emptied  parturient  canal. 
On  the  average,  twenty  to  twentj^-five  minutes  elapse  before  the  placenta  is  fully 
separated. 

Now  the  attendant  assures  himself  of  three  things — that  the  bladder  is  empty 
(catheterize,  if  necessary) ;  that  the  uterus  is  in  firm  contraction  (wait  for  an  after- 
pain);  that  the  uterus  is  in  the  median  line  (l)ring  it  there  by  pressure  from  the 
sides).  The  woman  is  asked  to  bear  down,  to  see  first  if  she  can  expel  the  placenta 
herself.  If  she  cannot,  the  uterus  is  grasped  in  the  whole  hand  with  the  thumb 
in  front  (Fig.  326)  and  gently  pushed  icithout  squeezing  down  onto  the  placenta,  in 
the  axis  of  the  inlet.  The  uterus  is  used  simply  as  a  piston,  as  a  body  through 
which  to  exert  pressure  on  the  placenta  lying  in  the  vagina,  and  this  manoeuver  is 
called  "early  expression" — "early,"  because  it  anticipates  nature's  expulsion.     As 


312 


THE   HYGIENE   AND    CONDUCT   OF   LABOR 


the  placenta  distends  the  vulva  the  woman  usually  bears  down  and  expels  it  into 
the  basin,  into  which  it  should  be  allowed  to  fall,  dragging  the  membranes  after  it. 
It  is  best  to  allow  the  membranes  to  come  out  of  their  own  weight,  but  if  they 
should  be  adherent  (evidenced  by  the  placenta  not  falling  into  the  basin),  gentle, 
steady  traction  is  made  on  them  without  twisting.  One  grasps  the  membranes 
near  the  vulva  from  above,  to  avoid  contact  vnth  the  suspected  perineal  and  anal 
regions.  If  the  membranes  start  to  tear,  greater  gentleness  is  to  be  used,  and  if 
they  should  break  off,  the  proximal  end  should  be  grasped  with  an  artery  forceps. 
Five  minutes'  time  may  be  required  to  remove  the  secundines  in  an  intact  condi- 
tion. Now  the  uterus  is  given  a  brisk  massage,  and  the  patient,  one  dram  of  ergot. 
This  is  not  always  necessary,  but  the  author  has  never  seen  any  harm  from  its  use, 


Fig.  326. — Early  Expression. 
Uterus  is  used  ouly  as  a  medium  to  exert  pressure  on  placenta. 


and  often  felt  that  the  uterus  got  harder  and  remained  so  more  continuously  when 
it  was  administered.     Ergot  is  never  given  before  the  placenta  is  delivered. 

If  the  first  "early  expression"  does  not  bring  the  after-birth,  a  mistake  has 
been  made  as  to  the  placental  separation,  and  the  attendant  waits  for  more  definite 
sign.s  to  appear,  when  the  simple  expression  is  repeated.  Unless  the  woman  bleeds, 
there  is  no  danger,  and  one  may  safely  wait  even  eight  or  ten  hours.  If,  after  one 
hour,  during  which  time  two,  or  at  most  three,  simple  expressions  have  been 
attempted,  the  placenta  fails  to  come,  a  Crede  expression  is  performed,  since  the 
third  stage  is  pathologic.  Crede's  expression  differs  from  the  simple  form  in  that 
the  uterus,  at  the  same  time  that  it  is  forced  down  into  the  pelvis,  is  squeezed  from 
ail  sides,  so  that  its  contents  are  expelled  "like  the  stone  from  a  cherry"  (Fig.  327). 


THE   THIRD   STAGE 


313 


Being  assured  that  the  ])lu(l(l('r  is  empty  and  the  uterus  contracted,  the  fundus  is 
grasped  in  the  full  hand  with  the  thumb  in  front,  and,  while  the  fingers  are  pressed 
together,  the  uterus  is  firmly  Init  gently  forced  down  in  the  line  of  the  axis  of  the 
pelvis.  One  Crede  expression  properly  executed  will  almost  always  force  the  pla- 
centa into  the  vagina,  and  now  the  woman  expels  it  or  it  may  i)e  delivered  by  simple 
expression.  The  further  treatment  of  such  a  pathologic  third  stage  belongs  in  the 
chapter  on  Postpartum  Hemorrhage,  p.  77G. 

Other  Methods  of  Treatment  of  Third  Stage. — Savage  tribes  and  the  ancients  pulled  on 
flic  cord,  prcssccl  on  llic  Ixlly,  fjavc  emetics  or  tickled  tlie  nose,  to  provoke  sncjezing,  had  the 
woman  blow  iiit(j  a  gourd,  a  bottle,  or  into  the  closed  fist,  to  evoke  the  abdominal  pressure,  or 


Fig.  327. — Credo's  Expression. 
Placenta  is  squeezed  out  of  uterus,  from  which  it  has  not  yet  been  fully  detached.     Note  the  direction  of  the  pressure. 


even  removed  the  placenta  by  hand.  Hippocrates  blew  irritating  powders  into  the  nose,  a  prac- 
tice that  some  physicians  carry  out  today.  The  French,  even  now,  exert  traction  on  the  cord, 
together  with  pressure  on  the  fundus,  after  the  placenta  is  loosened  and  slippeil  from  the  uterus — a 
practice  which  is  not  dangerous  in  a  skilled  hand.  The  author  would  unreservedly  condemn  it, 
however,  because — (1)  Most  of  the  deliveries  are  conducted  by  midwives  who  blindlj-  imitate  the 
physicians;  (2)  it  is  inefficient  if  the  placenta  is  adherent  or  incarcerated;  (3)  the  cord  maj^  tear 
off,  or  only  pai't  of  the  placenta  may  come  with  it ;  (4)  traction  on  the  placenta  may  cause  inversion 
of  the  uterus;  (5)  there  is  danger  of  infection  from  the  fingers  inserted  into  the  vagina;  (6)  it  is 
not  necessary.  In  1861  Crede  formulated  a  method  which  was  given  his  name,  and  consisted  in 
the  rapid  expression  of  the  placenta  by  squeezing  the  uterus  through  the  abdomen  during  the  first 
after-pain,  that  is,  from  four  to  eight  minutes  after  the  delivery  of  the  child.  Dohrn  and  Ahlfeld, 
in  1880  and  1882,  showed  the  dangers  of  this  method — In)  It  is  unphysiologic;  (5)  the  uterus  is 
emptied  too  rapidly — it  has  not  time  to  retract  properly,  it  fills  up  vrith  clots,  and  the  tendency  to 
late  hemorrhage  is  increased;  (c)  the  primary  hemorrhage  is  great ;  (d)  retention  of  the  membranes, 


314  THE   HYGIENE   AND    CONDUCT    OF    LABOR 

of  decidua,  and  e^'en  of  pieces  of  placenta  are  more  common;  (e)  the  uterus  is  bruised;   painful 
after-pains  and  puerperal  infection  are  invited. 

Alilfeld,  in  1SS2,  proposed  a  purely  expectant  plan  of  treatment  of  the  third  stage.  The 
uterus  is  not  even  touched  after  deli\'ery  unless  interference  is  necessary  because  of  very  profuse 
hemorrhage;  the  cord  is  drawn  over  the  thigh,  a  bed-pan  put  under  the  vulva,  or  the  patient 
is  put  over  a  hole  in  the  mattress,  the  escaping  blood  is  caught  in  a  funnel  leading  to  a  graduated 
^'essel  under  the  bed,  and  the  attendant  sits  at  the  bedside,  watching  her  face  and  counting 
her  pulse,  occasionally  taldng  note  of  the  amount  of  blood  lost  externally.  If  the  placenta  is  not 
born  spontaneously  in  two  hours,  the  woman  is  asked  to  bear  down,  and  if  she  fails  to  expel  it, 
the  placenta  is  expressed  as  already  indicated.  As  a  rule,  the  placenta  is  spontaneously  expelled 
in  three  or  four  hours,  but  without  aid  it  might  remain  until  putrefaction  sets  in.  Ahlfeld  claims 
for  his  method  that  the  loss  of  blood  is  less  than  with  Crede's;  that  the  deciduse  are  usually  ex- 
pelled complete;  that  the  tearing  and  retention  of  the  membranes  and  placenta  are  less  frequent; 
that  the  puerperium  is  less  likely  to  be  morbid — with  all  of  which  the  author  cannot  agree.  In 
60  consecutive  cases  in  which  this  method  was  tried  the  author  found  the  hernorrhage  greater 
than  mth  the  method  first  described  in  this  chapter,  and  there  was  no  difference  in  the  frequency 
of  retention  of  pieces  of  membrane  or  decidua.  Other  investigators  have  confirmed  these  findings. 
Outside  of  the  greater  loss  of  blood,  wliich  may  signify  much  to  a  small  or  anemic  woman,  the  con- 
stant anxiety  of  the  patient  throughout  the  long  hours  of  waiting,  the  prolongation  of  the  possi- 
IjiUties  of  infection,  and  the  useless  expenditure  of  the  physician's  time,  condemn  the  method. 
In  Dublin,  since  1783,  and  in  England,  since  1775  (John  Harvie),  a  method  of  treatment  was 
practised  whose  essentials  were  the  guarding  of  the  uterus  with  the  hand  and  the  expression  of  the 
placenta  by  gentle  force  exerted  on  the  fundus  from  the  abdomen  fifteen  to  tliirty  minutes  after 
the  cliild  was  deUvered.     The  plan  recommended  by  the  author  is  based  on  the  Dubhn  method. 

One  of  the  important  functions  of  the  obstetrician  is  to  save  the  woman's 
blood.  Even  though  the  obstetric  patient  can  lose  enormous  quantities — as  much 
as  three  liters,  according  to  Ahlfeld — without  succumbing  to  hemorrhage,  these 
great  losses  leave  the  woman  debilitated,  anemic,  neurasthenic,  and,  if  not  these,  at 
least  protract  her  recovery  decidedly.  The  author  aims  to  conduct  all  labors  as 
nearly  bloodlessly  as  possible,  and  is  strongly  convinced  that  the  women  recuperate 
much  quicker,  suffer  less  infections,  nurse  their  babies  better,  and  altogether  are 
more  healthy  and  vigorous  than  those  who  have  suffered  the  losses  which  are  given 
as  physiologic  in  most  text-books.  Excessive  hemorrhage  is  produced  by  improper 
conduct  of  the  third  stage.  The  accoucheur  should  hurry  the  process  of  separation 
of  the  placenta  only  in  the  presence  of  an  indication;  rough  massage  of  the  uterus  is 
to  be  avoided,  since  it  mashes  the  soft  placenta  to  a  pulp,  and  a  uterus  that  is  be- 
having well  should  not  be  excited  to  irregular  action.  All  these  conduce  to  re- 
tention of  pieces  of  placenta,  hemorrhage,  and  infection.  The  same  is  true  of  im- 
properly performed  and  frequent  Crede  expressions. 

Examination  of  the  Placenta. — This  is  a  part  of  a  physician's  work  which  may 
never  be  omitted,  hurried,  nor  delegated  to  another.  A  minute  and  systematic 
inspection  of  the  after-birth  is  made  as  soon  as  it  is  delivered,  while  the  hands  are 
still  sterile  and  the  patient  ready  for  operation.  If  postponed  until  the  physician 
is  about  to  leave  the  house  and  the  patient  already  comfortably  settled  in  bed,  one  is 
loath  to  disturb  her  and  may  neglect  a  small  piece  of  placenta  which  may  be  found 
wanting,  and  trust  its  removal  to  nature,  when,  if  everything  were  aseptically  pre- 
pared, the  uterus  would  be  properly  emptied  of  its  contents,  and  late  hemorrhages, 
polypi,  subinvolution,  and  puerperal  infection  thus  avoided.  It  is  well  to  repeat  the 
inspection  of  the  placenta  before  it  is  destroyed.  Some  country  women  make  it  a 
practice  to  preserve  the  placenta  for  five  days,  in  order  that  the  physician  may 
inspect  it  if  fever  develops.  Under  a  good  light,  and  gently  rubbing  the  blood- 
clots  off  the  maternal  surface  with  a  piece  of  cotton  without  producing  new 
injuries,  the  accoucheur  goes  carefully  over  each  cotyledon  separately  and  success- 
ively. Beginning  at  one  point  in  the  periphery,  the  edge  is  followed  all  around  three 
times,  and  if  it  is  smooth  and  even,  in  all  likelihood  nothing  is  missing,  but  the 
center  of  the  placenta  must  also  be  examined  carefully.  A  gray,  smooth,  shiny 
surface  (the  decidua  serotina)  is  a  positive  indication  that  that  portion  is  not  miss- 
ing, but  a  rough  place  requires  careful  attention.  If  the  torn  and  roughened  sur- 
faces fit  smoothly  without  forcing  the  cotylefJons  together;  if  the  broken  and  jagged 
edges  of  the  thin  decidua  serotina  mortise  into  each  other  perfectly,  one  may  decide 


THE   THIRD    STAGE 


315 


that  nothing  is  missing  from  that  ixiiiit.  Every  rougliened  portion  of  the  placenta 
should  bo  washed  with  water,  and  if  the  vilh  an;  seen  free  and  floating,  one  may  be 
certain  that  a  hirger  or  smaller  portion  of  the  organ  has  remained  attaclied  to  the 
uterus. 

Turning  the  organ  inside  out,  the  fctui  .sui'face  is  scrutinized,  tiie  j^resence  of 
cysts  noted,  but  especially  the  distribution  of  vessels.  If  the  vessels  all  disappear 
before  they  reach  the  edge,  one  may  be  fairly  sure  that  a  placenta  suecenturiata 
has  not  been  left  b(>hind.  If  a  large  vessel  l)reaks  off  sharply  at  the  edge  of  the 
after-birth,  search  should  be  made  for  the  portion  it  supplied  (Fig.  320). 

The  membranes  also  must  be  studied.  If  the  opening  through  which  the  infant 
came  is  round  and  complete,  usually  all  the  membranes  are  delivered.  The  empty 
ovum  sac  may  be  filled  with  water.  If  the  membranes  are  in  shreds,  the  parts  may 
be  fitted  together  or  spread  on  a  sterile  towel.     If  torn  from  the  edge  of  the  pla- 


FiG.  32S. — Inspection  of  the  Placenta. 

Before  being  taken  from  the  bedside,  a  careful  scrutiny  of  the  placenta  is  made,  all  blood-clots  being  wiped  away  with 

dry  gauze.     Note  posture  of  patient  and  the  fact  that  the  uterus  is  contracting. 


centa,  they  must  be  readjusted  and  notice  taken  if  like  fits  like  structures.  The 
amnion  is  now  studied  separately  from  the  chorion.  Pieces  of  missing  chorion 
always  carry  decidua  with  them,  and  are  especially  important  because  they  ma}- 
also  carry  a  placenta  suecenturiata  or  placenta  spuria  with  them. 

Discovery  of  the  Absence  of  a  Placenta  Suecenturiata. — The  possibility  of  the 
retention  of  an  extra  placenta  is  invariably  to  be  l^orne  in  mind,  especially  since 
even  the  minutest  examination  of  the  delivered  portion  may  fail  to  give  rise  to 
suspicion  of  such  an  occurrence.  High  authorities  have  testified  to  this  point  in 
court.  Still,  an  investigation  with  this  i^articular  ol3Ject  will  rarely  fail  to  discover 
the  true  conditions. 

If  the  membranes  are  torn  from  the  edge  of  the  placenta,  leaving  the  latter 
jagged,  thick,  and  rough;  if  a  l)lood-vessel  runs  to  the  edge  of  the  placenta  and 
breaks  off  sharply;  if,  with  velamentous  insertion  of  the  cord,  not  all  the  vessels 


316 


THE   HYGIENE   AND    CONDUCT   OF    LABOR 


ened  and  vascular  margin;,  if    l' e°"  L„l''*  '°  **■,?  "'^T™  '"  '°™'',  witli  tliick 

should  demand-one  mly  feel      asofa.lv "ureTh    "  *''f"  ^""^  ''''  °'  t^e  child 

retamed  in  the  uterus.     In  cases  of  real   loubttL.f  '  P'""™*"  ^uecenturiata  is 

So  complete  an  examination  of  ttelX^sT^r  IV^f^L^  XuS; 


Vessel 
which  sup- 
plied the 


&::■:;!;.  "™  *'-  ---^^  ^--"^  ^^^  --.  -'--atin,  it  to  contraction  ,y 

vein'rZhrflr  ^f'a'^l^rr^^^Z  ull'V,r^'^*'' ^"^    *■"■  P'-^^a  through  the 

.  When  to  Invade  the  ijte^Z^Zt  "t"""""^ ''''  ">'  themissingportion 

"g'c  part,  but,  owing  to  its  importance  ^'ttnT'''*'?  """"'  "^  '"  *•>«  P^^H'o- 

nvasion  of  the  uterine  cavity  afTerpartun'tinnT        '"■  ''">"""'  "■Prtition.     The 

■'  -a". -MS  more  dange^  -"> ^^  "  a^^^X^'^:' tTe^u^^^^ 


TlIK     I'lllliD    STAGE  317 

are.  Done  as  laparotoniics  arc  usually  done,  the  introduction  of  the  hand  is  not 
dangerous. 

In  his  recommendations  for  general  practice,  therefore,  a  teacher  is  bound  to 
consider  the  conditions  there  met,  and  the  qualifications  and  limitations  of  the 
attendant  physician. 

In  general  practice  it  is  safest  to  leave  the  membranes,  if  retained,  for  nature  to 
dispose  of,  which  she  usually  does — they  come  away  with  the  lochia,  in  pieces  or  as 
a  whole,  by  the  end  of  one  or  two  weeks.  Severe  after-pains,  fetid  lochia,  a  slight 
rise  of  temperature,  a  moderate  bleeding,  often  accompany  this  condition,  but  the 
puerpera  recovers,  though  a  chronic  endometritis  may  remain.  Even  if  all  the 
membranes  are  retained,  the  plac(nita  being  "decrowned,"  most  authorities  recom- 
mend non-interference  in  the  absence  of  hemorrhage.  A  missing  piece  of  placenta, 
unless  it  is  larger  than  the  thumb-nail,  or  unless  it  causes  hemorrhage,  is  also  left 
to  the  natural  resources  of  the  woman.  The  hand  may  be  introduced  into  the 
uterus  only  under  the  strictest  indication,  vast  experience  having  shown  that,  under 
the  conditions  in  which  most  of  human  births  occur,  the  woman  is  safer  if  the  above 
rules  are  applied  and  much  trusted  to  nature. 

On  the  other  hand,  where  the  parturient  is  in  an  aseptic  maternity  hospital, 
and  where  the  accoucheur  has  at  his  service  all  the  accoutrements  of  aseptic  opera- 
tion, he  may  make  the  attempt  to  spare  the  woman  the  ills  that  follow  the  retention 
in  the  uterus  of  membrane,  shreds  of  thick  decidua,  scraps  of  placental  tissue,  and 
firm  blood-clots.  Persistent  oozing  of  blood,  which  sometimes  causes  decided  gen- 
eral anemia  before  it  ceases  spontaneously,  severe  after-pains,  fetid  lochia,  slight 
saprophytic  infections,  prolonged  lochial  discharge,  persistence  of  lochia  rul^ra, 
protracted  convalescence,  late  puerperal  hemorrhages,  subinvolution  of  the  uterus, 
which  may  result  in  chronic  metritis,  with  sterility  and  permanent  invalidism,  mild 
parametritis  with  later  shrinking  of  the  uterine  ligaments — all  these  may  be  avoided 
by  leaving  the  uterine  cavity  emptj^  and  the  walls  smooth  after  delivery.  It  must 
be  again  repeated,  however,  that  unless  the  conditions  for  aseptic  operation  are 
perfect,  the  primary  danger  of  infection  far  outweighs  the  advantages  to  be  gained. 

The  Asepsis  and  Antisepsis  of  the  Second  and  Third  Stages. — Antiseptic 
surgery  has  \'er>'  properly  given  way  to  aseptic  surgerj'.  The  principle  of  aseptic 
surgery  has  been  carried  over  to  obstetrics,  but  a  few  of  the  old  antiseptic  practices 
have  been  and  must  be  retained.  An  example  will  illustrate  this:  A  parturient  is 
ideally  prepared  for  delivery,  with  sterile  night-gown,  sterile  leggings,  sterile  sheets 
and  towels,  all  safely  (?)  pinned  together,  -with  a  sterile  towel  under  the  buttocks, 
leaving  only  the  vulvar  orifice  exposed;  the  accoucheur  is  dressed  as  for  a  major 
laparotomy.  What  happens?  The  woman,  in  her  throes  of  pain,  tosses  about, 
disarranging  all  the  sterile  covers;  she  grasps  the  hand  of  the  attendant,  or  puts  her 
hand  over  the  sterile  towels  to  the  vulva;  with  the  pressing  efforts  feces  escape  from 
the  rectum,  and  soil  the  towel  under  her  or  the  towel  at  the  side  of  the  buttock,  and 
with  her  next  motion  these  are  spread  all  over  the  region  about  the  vulva;  the  sec- 
ond stage  drags  on,  one,  two,  or  three  hours,  dust  settles  on  the  extensive  area  of 
sheets,  leggings,  towels,  gloves,  gowns,  Ijasins,  etc.,  which  are  supposed  to  be  sterile. 
How  many  of  these  things  are  really  sterile  when  the  actual  time  of  delivery  ar- 
rives and  may  safel}'  be  touched?  In  view  of  these  experiences,  and  because 
the  immense  majority  of  confinements  must  be  conducted  ^\'ithout  so  many  con- 
veniences, the  author  practises  and  teaches  a  very  simple  system  of  antisepsis. 
The  bed  is  dressed  with  sterile  sheets;  the  patient  is  in  a  sterile  night-gown;  sterile 
leggings  are  put  on;  a  sterile  towel  lies  under  the  buttocks;  another  covers  the 
belly,  but  nothing  is  draped  near  the  vulva,  and  the  only  towel  which  is  considered 
aseptic,  and  kept  so  by  frequent  changes,  is  the  one  on  the  belly.  If  it  is  impossible 
to  obtain  the  sterile  clothes,  clean  ones,  fresh  from  the  laundry,  are  as  good,  for 
they  are  not  touched  anyway  (Fig.  330).     The  accoucheur  must  put  on  a  sterilized 


318 


THE    HYGIENE    AND    CONDUCT    OF    LABOR 


gown,  which  is  not  considered  sterile  after  it  is  on,  and  use  sterilized  rubber  gloves, 
but  these  must  be  considered  sterile  and  must  be  kept  so  by  very  frequent  dipping 
in  activel}^  antiseptic  solutions. 

The  inside  of  basins  carrying  antiseptic  solutions,  the  hands  (gloved),  the 
region  immediately  around  the  vulva,  and  the  towel  on  the  belly  are  the  only  ob- 
jects which  are  considered  sterile,  and  which  the  accoucheur  tries  to  keep  sterile. 
If  feces  issue  from  the  rectum,  they  are  caught  in  sponges  wrung  out  of  1 :  1500 
bichlorid,  and  the  region  of  the  anus  washed  with  the  same.     If  the  woman  touches 


Fig.  .330. — Patient  Dressed  for  Delivery. 
Only  the  area  of  skin  indicated    by  black  line  is  considered  aseptic.     The  towel  on  the  belly  (shown  folded  to 
one  side)  is  sterile.     The  rest  of  the  dress  was  sterile  when  put  on.     Only  the  towel  on  the  belly  (which  is  changed 
frequently)  and  the  area  indicated  may  be  touched  by  the  sterile  hand. 


the  abdominal  towel,  a  new  one  replaces  it,  and  during  the  second  stage  the  vulva 
and  introitus  vaginae  are  frequently  sponged  with  1  per  cent,  lysol  and  1:1500 
bichlorid  solutions.  Since  the  child  is  delivered  "inter  feces  et  urinas,"  the  field 
can  never  be  considered  aseptic.  The  author  has  never  seen  ill  effects  from  the  liberal 
use  of  these  antiseptic  solutions  on  the  introitus  vulva  and  perineum,  and,  since 
investigations  have  proved  that  the  greatest  danger  of  infection  arises  from  this 
region,  the  above  practice  is  justified.  Experience  in  his  own  private  and  consulta- 
tion practice  and  in  the  large  service  of  the  Chicago  Lying-in  Hospital  and  Dis- 


THE   THIRD    STAGE  319 

pensary  has  also  convinced  him  that,  if  the  region  of  the  vulva  is  kept  aseptic  with 
antiseptic  solutions;  if  the  gloves  are  ke[)t  sterile  \)y  fn^jucnt  immersions  in  the 
samci,  and  if  the  few  objects  that  must  necessarily  be  introduced  into  the  genitalia 
are  absolutely  aseptic,  one  can  conduct  the  most  difficult  and  prolonged  obstetric 
manipulations  in  the  dirtiest  hovel  with  brilliant  results. 

Wherever  possible,  naturally  and  in  obstetric  operations,  the  precautions  and 
technic  of  the  laparotomy  are  practised. 

When  the  child  is  delivered,  the  hand  follows  the  uterus  through  the  sterile 
abdominal  towel.  After  the  cord  is  tied  the  accoucheur  rinses  his  gloves  very 
thoroughly  in  both  solutions  (1  :  1500  bichlorid  and  1  per  cent,  lysolj,  which  are 
then  made  up  fresh,  with  fresh  pledgets.  For  the  conduct  of  the  third  stage  he 
removes  the  gloves,  sterilizes  the  hands,  and  draws  on  fresh  sterile  gloves.  If 
there  is  no  time  for  this,  the  author  washes  his  gloves  with  pure  lysol.  New  gloves 
are  put  on  when  one  has  inadvertently  touched  some  unsterile  object  or  perforated 
the  first  pair.  After  the  placenta  is  delivered  the  vulva  and  parts  about  it  are 
sponged  gently  wdth  1  :  1500  bichlorid,  taking  care  that  nothing  is  washed  into  the 
perineal  wound.  If  one  is  called  to  a  case  of  injury  to  the  perineum,  where  no  prep- 
aration of  the  patient  had  been  previously  made,  it  would  be  an  error  of  technic  to 
scruli  the  vulva  with  soap  and  water,  etc.,  and  thus  carry  infection  into  the  wound. 
One  should  treat  such  a  case  as  one  would  a  compound  fracture,  that  is,  clean  well 
around  the  edges,  guarding  carefully  against  carrying  anything  into  the  freshly 
opened  surfaces.  The  contiguous  sldn  is  painted  with  tincture  of  iodin  by  some 
operators. 

Examination  of  the  Parts  for  Injuries. — Lacerations  of  the  outlet  may  be  ob- 
served during  the  delivery  of  the  child,  but  the  attendant  must  also  inspect  the 
parts  carefully  after  the  third  stage.  Having  sponged  the  blood  away,  the  fingers, 
holding  two  dry  pledgets,  gentl}^,  under  good  light,  separate  the  labia  so  that  a 
perfect  view  of  the  vagina  and  perineum  is  obtained.  Thus  the  kind  and  extent 
of  the  birth  lacerations  are  discovered.  Unless  there  is  hemorrhage,  the  author 
does  not  search  for  cervical  tears  after  spontaneous  deliveries.  In  all  breech,  in 
excessively  rapid,  and  in  all  operative  deliveries  the  author  insists  on  a  careful 
exploration  of  the  whole  parturient  canal,  followed  by  catheterization  and  rectal 
examination,  to  determine  the  integrity  of  all  the  structures  involved  in  the  labor 
process. 

SUMMARY  OF  THE  CONDUCT  OF  THE  THREE  STAGES 

During  the  First  Stage. — (1)  Asepsis  and  antisepsis.  (2)  Diagnosis  of  the  case. 
(3)  The  prognosis  of  the  mechanism  of  labor.  (4)  Watchful  expectancy  and  recog- 
nition of  impencUng  danger  to  mother  and  babe.  (5)  Attention  to  bladder,  bowels, 
and  general  health  of  patient. 

During  the  Second  Stage. — (1)  Asepsis  and  antisepsis.  (2)  Relief  of  pain. 
(3)  Protection  of  life  of  infant  and  watching  for  complications  vv'hich  threaten  the 
mother.     (4)  The  preservation  of  the  perineum. 

During  the  Third  Stage. — (1)  Prevention  of  postpartum  hemorrhage.  (2) 
Delivery  of  the  placenta.  (3)  Asepsis  and  antisepsis.  (4)  Tying  the  cord.  (5) 
Care  of  the  eyes.  (6)  Examination  of  the  placenta.  (7)  The  search  for  birth 
injuries. 

The  accoucheur  stays  in  the  house  at  least  one  hour  after  the  placenta  is  de- 
livered, time  which  may  be  profitably  employed  watching  the  mother  for  hemor- 
rhage, eclampsia,  etc.,  in  cleaning  instruments  and  packing  satchel  ready  for  the  next 
case,  the  filling  out  of  the  history  sheet  or  card  and  birth-certificate,  w^eighing  and 
measuring  the  baby,  giving  instructions  as  to  after-care,  etc.  Before  leaving  the 
house  the  attendant  must  have  assured  himself  on  these  seven  points:  (1)  That 
the  uterus  is  in  firm  tonus — that  is,  well  retracted  and  not  inverted;  (2)  that 


320  THE   HYGIENE   AND    CONDUCT   OF   LABOR 

there  is  no  hemorrhage  from  the  vulvar  orifice  and  no  internal  hemorrhage;  (3) 
that  the  placenta  and  membranes  are  complete;  (4)  that  the  bladder  is  empty; 
(5)  that  all  perineal  tears  are  attended  to ;  (6)  that  the  child  is  in  good  condition — 
no  hemorrhage  from  the  cord,  and  that  it  breathes  freely;  (7)  that  the  mother  is 
in  good  condition,  with  good  pulse,  no  headache  (eclampsia),  no  vomiting. 

Let  us  pause  here  to  take  a  glance  back  at  the  treatment  of  labor  as  a  whole. 
It  should  be  regarded  as  a  surgical  operation:  it  really  is  such,  and  the  obstetrician 
is  really  a  surgeon.  He  considers  every  labor,  therefore,  first,  as  to  the  ability  of 
the  patient  to  stand  the  shock;  second,  he  provides  for  asepsis  and  antisepsis; 
third,  he  carefully  watches  for  and  guards  against  complications. 

During  the  labor  the  accoucheur  observes  the  powers  and  estimates  the  resist- 
ances, judges  whether  the  powers  are  sufficient  to  overcome  the  latter;  he  watches 
the  mechanism  of  labor  as  its  various  phases  pass  under  the  eye  and  hand;  he  is 
always  alert  to  any  abnormality  in  the  mechanism,  and  keenly  alive  to  the  possi- 
bility of  some  outside  complication  occurring,  which  may  throw  either  or  both 
patients  into  acute  danger.  Through  all,  he  throws  around  both  patients  the  pro- 
tection from  infection  which,  of  recent  years,  has  become  almost  perfect. 

The  conduct  of  labor  is  not  a  simple  matter,  safely  intrusted  to  every  one. 
Let  the  people  know  that  having  a  child  is  an  important  affair,  deserving  of  the 
deepest  solicitation  on  the  part  of  the  friends,  needing  the  watchful  attention  of  a 
qualified  practitioner,  and  that  the  care  of  even  a  normal  confinement  is  worthy 
the  dignity  of  the  greatest  surgeon. 


CHAPTER  XXIII 
THE  CONDUCT  OF  THE  PUERPERIUM 

After  the  delivery  of  the  i)hu'eiita  tlie  vulvar  region  is  cleansed  of  blood,  etc., 
by  the  physician,  and  a  sterilized  vulvar  pad  applied,  which  is  held  in  place  by  a 
T-binder.  An  abdominal  binder  is  generally  used  to  hold  the  pad  and  to  relieve 
the  puerpera  from  the  feeling  of  emptiness.  Such  a  binder  cannot  be  applied 
tightly  enough  to  compress  the  uterus  and  thus  prevent  postpartum  hemorrhage, 
and  it  should,  therefore,  only  support  the  abdominal  wall,  and  be  loose  enough  to 
allow  the  nurse  to  put  her  hand  underneath  for  the  palpation  of  the  fundus. 

No  douches  are  given  postpartum  except  for  some  special  indication,  e.  g., 
hemorrhage.  When  the  soiled  sheets  are  drawn  from  the  bed  and  the  patient's 
night-dress  changed,  the  woman  should  be  moved  with  great  gentleness,  and  one 
nmst  insist  that  the  legs  be  kept  close  together  and  that  the  uterus  be  hard — these 
precautions  to  prevent  air-embolism.  If  the  uterovaginal  tract  has  been  tam- 
poned, the  moving  of  the  puerpera  is  slowly  and  gently  done,  because  of  the  danger 
of  tearing  the  uterus  over  the  tampon.  The  bed  is  now  set  to  rights,  the  room 
cleared  and  darkened,  the  mother  warmly  covered  up,  a  warm-water  bag  placed 
at  her  feet,  a  hot  drink  given,  and  she  is  allowed  to  get  the  repose  and  sleep  she  has 
so  well  earned.  By  this  time  another  hour  has  passed,  and  if  hemorrhage  has  not 
begun  and  the  third  stage  was  conducted  properly,  few  complications  need  to  be 
feared,  though  it  is  wise  for  the  nurse  to  take  an  occasional  look  at  the  patient. 

The  treatment  of  the  puerperium  falls  almost  entirely  to  the  nurse,  but  it  is 
well  for  the  accoucheur  to  have  his  own  ideas  on  the  subject  and  to  be  able  to  carry 
them  out  if  necessary.  In  a  book,  ''Obstetrics  for  Nurses,"  the  author  has  de- 
scribed all  the  details  of  such  treatment,  which  would  hardly  find  a  place  in  a 
text-book  for  practitioners. 

Aseptic  Care  During  the  Puerperium. — This  is  as  important  as  during  the  labor, 
for  many  cases  have  been  successfully  delivered  only  to  be  infected  in  the  puer- 
perium. The  vulva  is  treated  as  an  open  wound — indeed,  it  is  beset  by  the  same 
dangers  as  an  open  Avound.  This  point  is  to  be  remembered  when  comparing  ob- 
stetric with  surgical  practice.  The  pads  lying  on  the  vulva  are  changed  as  often  as 
they  become  soiled  with  blood  or  lochia,  and  the  parts  are  dressed  after  each  urina- 
tion or  defecation,  also  as  a  routine  three  or  four  times  a  day.  For  this  purpose  the 
patient  is  placed  on  a  sterile  bed-pan,  the  nurse  sterilizes  her  hands  or  wears  sterile 
gloves,  and  gently  pours  from  a  narrow-lipped  pitcher  a  solution  of  1  :  2000  bi- 
chlorid  over  the  vulva.  The  excess  is  dried  off  without  rubbing,  by  touching  with 
dry  sterile  cotton,  and  a  fresh  sterile  vulvar  pad  is  applied.  Simple  sterilized  water 
may  be  used.  If  there  is  any  odor  to  the  lochia,  2  per  cent,  carbolic  solution  is 
more  deodorant.  These  attentions  are  needed  for  ten  days.  No  douches  are  given 
(see  Pathology  of  the  Puerperium,  p.  873),  and  the  patient  is  instructed  never  to 
touch  the  genitals  nor  her  nipples.  Internal  examinations  are  not  made  by  the 
physician  except  under  strictest  indication.  The  parts  are  left  severely  alone.  If 
there  are  stitches  in  the  perineum,  extra  care  and  greater  watchfulness  are  required 
on  the  part  of  the  nurse  and  accoucheur,  since  unclean  bed-pans,  non-sterile  cloths, 
and  filthy  bed-covers  may  come  in  direct  contact  with  the  wound. 

The  Diet. — There  is  no  ground  for  the  old  notion  that  errors  of  diet  cause  puerperal  in- 
fection, but  even  a  healthy  person,  put  to  bed  with  a  full  dietary,  will  soon  complain  of  headache, 
lassitude,  tympany,  etc.,  because  the  food  without  exercise  is  not  properly  oxidized. 
21  321 


322  THE  HYGIENE  AND  CONDUCT  OF  THE  PUERPERIUM 

During  the  first  eighteen  hours  after  the  labor  the  patient  should  have  liquids  in  amounta 
sufficient  to  quench  her  thirst.  After  a  few  hours  a  cup  of  broth  or  tea  and  a  small  shoe  of  but- 
tered toast  may  be  given.     Milk,  plain  or  with  seltzer,  is  also  allowable. 

On  the  second  day  tea,  coffee,  milk-toast,  oyster-stew,  salt  wafers,  and  chocolate  may  be 
added.  On  the  tliird  day,  after  the  bowels  ha^-e  moved  freely,  the  amounts  may  be  increased,  and 
the  patient  may  have  soups,  thickened  with  rice,  barley,  etc.,  bread  and  butter,  cereal  foods,  and 
stewed  fruits,  omitting  the  strongly  acid.  In  summer  ice-cream  and  ices  are  allowable.  On  the 
fourth  clay  a  small  piece  of  meat,  as  a  chop,  the  breast  of  chicken,  or  squab,  may  be  given  at  noon. 
Fresh  fish  is  also  now  allowable.  The  other  meals  are  prepared  from  the  dietary  of  the  preceding 
days.  On  the  fiifth  day  a  small  piece  of  tender  steak,  eggs,  light  puddings,  blanc-mange,  baked 
apple,  jelhes,  and  other  delicacies  may  be  given.  Tea  and  coffee  are  given  sparingly  and  should 
not  be  strong.  Fresh  vegetables  are  allowed,  mth  salt  or  cream  dressing,  not  vinegar.  Baked 
potatoes,  beans,  and  peas  are  best  omitted,  as  they  may  produce  tympany.  Stewed  fruits,  as 
prunes,  dried  apples,  and  peaches,  are  gi^^en  for  their  laxative  effect.  After  the  fifth  day  the  diet 
is  as  above  and  tliis  has  been  found  sufficient  for  the  patient  until  she  is  up  and  about. 

Three  meals  a  day  are  served.  At  ten  in  the  morning  a  glass  of  cool  milk,  and  at  three  in  the 
afternoon  a  cup  of  chocolate  with  a  wafer,  are  given.  Occasionally  an  eggnog  is  prepared  instead 
of  the  chocolate  at  three.  At  midnight,  after  the  nursing,  a  glass  of  hot  milk  or  malted  milk  is 
usually  administered. 

Throughout  the  puerperium  the  nui'se  will  see  that  the  patient  drinks  pure  water  freely,  to 
make  up  the  loss  caused  by  the  free  action  of  the  skin  and  kidneys  and  the  fluids  required  for 
making  milk. 

Foods  to  be  Avoided. — Acid  fruits,  as  lemons,  grape-fruit,  oranges  (sour),  plurns,  strawberries, 
boiled  tomatoes,  onions,  are  to  be  avoided.  These  are  likely  to  cause  cohc  in  the  infant,  but  after 
a  few  weeks  the  mother  should  gradually  add  these  to  her  diet,  to  accustom  the  infant  to  them. 
Potatoes,  beans,  peas,  lentils,  and  turnips  cause  flatus  and  tympany  in  the  mother  and  sometimes 
in  the  child,  and  should  also  be  avoided  until  the  mother  is  up  and  about.  Highly  spiced  dishes, 
heavy  or  spiced  sauces,  dressings,  such  as  French  and  mayonnaise,  are  all  to  be  avoided — they 
throw  too  much  work  on  the  kidneys. 

If  the  breasts  are  engorged,  the  liquids  are  to  be  restricted.  If  the  patient  has  had  con- 
vulsions (eclampsia),  a  water  or  milk  and  water  diet  is  ordered. 

The  Bladder. — The  necessity  for  frequent  emptying  of  the  bladder  during 
labor  has  been  emphasized.  During  the  third  stage  it  may  fill  rapidly,  incarcerate 
the  placenta,  and  cause  postpartum  hemorrhage.  The  bladder  must  always  be 
emptied  within  the  first  ten  hours  after  delivery,  and  thereafter  at  least  three  times 
a  day.  Owing  to  the  bruising  of  the  neck  of  the  bladder,  the  edem.a  of  the  neck  and 
the  urethra,  and  spasm  of  the  sphincter,  plus  the  horizontal  position,  the  patient 
may  not  be  able  to  urinate.  Before  the  catheter  is  resorted  to,  these  methods 
should  be  tried:  (a)  Have  the  nurse  put  the  woman  on  a  bed-pan  containing  steam- 
ing hot  water,  and  leave  her  alone;  (6)  the  same,  and  allow  the  water  to  run  in  the 
wash-stand;  (c)  let  the  patient,  while  lying  on  the  bed-pan,  smell  a  bottle  of  sal 
volatile;  (d)  lay  a  large  pad,  dripping  with  warm  sterile  water,  on  the  pubis  (the 
warm  solution  imitates  the  flow  of  urine) ;  (e)  place  a  hot  fomentation  over  the  blad- 
der; (/)  give  the  patient  an  enema:  often  the  bowels  and  bladder  act  simultane- 
ously; ig)  gentle  pressure  on  the  bladder  may  start  the  flow;  (h)  let  the  patient 
sit  up  on  the  pan,  this  being  less  dangerous  than  catheterization.  With  all  these 
measures  a  little  suggestion  may  be  used,  and  the  patient  is  to  be  left  alone.  Many 
people  cannot  urinate  in  the  presence  of  another.  If  the  bladder  must  be  cathe- 
terized,  it  is  wisest  for  the  accoucheur  to  do  this  himself,  unless  he  has  a  trustworthy 
nurse,  because  many  cases  of  cystitis  take  origin  at  this  time.  After  the  bladder  is 
once  thus  emptied,  the  patient  can  usually  urinate  herself  thereafter,  but  if  the  oper- 
ation must  ])C  repeated,  it  should  not  be  done  oftener  than  every  eight  hours,  and 
hexamethylenamin,  5  grains  thrice  daily,  should  be  administered  prophylactically. 

Method. — The  patient  is  arranged  on  a  clean  bed-pan  imder  good  light,  as  for  a  dressing,  all 
the  necessary  solutions  and  soft-rubber  catheters  being  close  at  hand.  The  nurse  sterilizes  her 
hands,  sponges  the  vulva  generously  with  1  :  2000  bicihlorid,  and  wipes  out  the  mouth  of  the  ure- 
thra with  1  per  cent,  lysol  solution  on  a  cotton  applicator.  Wit  h  the  urethral  opening  in  full  sight, 
the  catheter  is  gently  passed  intcj  the  bladder,  and  the  urine  collected  in  a  clean  vessel  for  inspection. 
If  the  first  pass  finds  the  catheter  in  the  vagina, — owing  to  the  greatly  bruised  and  swollen  con- 
dition of  the  parts  it  is  not  always  easy  to  find  the  opening, — another  catheter  must  be  used  or 
the  first  one  resterilized. 

The  Bowels. — Custom  immemorial  gives  a  cathartic  on  the  third  day  after 
labor.     The  author  prefers  to  give  it  on  the  morning  of  the  second  day,  and  usually 


THE  CONDUCT  OF  THE  PUERPERIUM  323 

prescribes  castor  oil.  The  oil  is  said  to  favor  tiic  .secretion  of  milk:  ut  least  it  does 
not  reduce  the  flow,  as  do  the  saline  cathartics.  Castor  oil  was  cultivated  and  used 
in  Egypt  seventeen  hundred  years  before  Christ.  The  oil  is  administered 
in  sherry  and  whisky,  in  orange-juice,  in  the  froth  of  beer,  or  in  gelatin  capsules. 
After  the  bowels  are  once  thoroughly  evacuated,  a  daily  enema  is  sufficient  to  un- 
load the  rectum,  but  these  movements  are  often  unsatisfactory,  and  an  occasional 
dose  of  cascara  at  bedtime  ought  also  to  l)e  given.  Constipation  is  the  rule  for  two 
or  three  weeks  postpartum,  but  usually,  when  the  patient  resumes  her  customary 
duties,  the  condition  improves.  When  the  patient  has  a  complete  perineal  lacera- 
tion, the  attention  to  the  bowels  becomes  a  very  important  item  of  treatment. 
(See  p.  738.)  If  the  woman  has  too  much  milk,  or  if  the  breasts  are  engorged 
and  painful,  salines,  Rochelle  salts,  effervescent  citrate  of  magnesia,  or  mag- 
nesium sulphate  may  be  prescribed. 

The  Breasts. — After  the  mother  has  slept,  usually  about  eight  hours,  the  nurse 
prepares  the  breasts.  They  are  gently  washed  with  soap  and  water,  then  with  bi- 
chlorid  1  :  1500,  which  is  allowed  to  dry  in.  A  loose  breast-binder  is  now  applied, 
simply  to  prevent  the  glands  from  sagging.  Tertullian  tells  us  that  the  Roman 
women  used  a  breast-binder  made 
in  the  temples  and  possessing  mystic 
powers. 

A  short  time  after  this  the  baby 
is  applied  to  the  nipple.  Before 
and  after  each  nursing  the  nipple  is 
washed  with  saturated  boric-acid 
solution,  poured  fresh  from  a  bottle, 
not  kept  in  a  glass,  using  sterilized 
cotton  pledgets  on  toothpicks,  known 
as  "applicators"  (Fig.  331).  The  fin- 
gers do  not  come  in  contact  with  the 
nipple  at  all ;   if  it  is  necessary  to  do 

...       .,       1  1  ,    ,  T    •     c      i     1  Fig.  331. — Cotton-wrapped  Tooth-picks,  Known  as  Appli- 

this,  the  hands  must  be  dismiected.  catohs. 

The  baby  is  put  to  the  breast  every 

four  hours  until  the  milk  comes,  then  every  three  hours  during  the  day  and  once 
during  the  night.  The  first  nursing  is  at  7  a.m.,  the  last  at  10  p.m.  Later  in  the 
puerperium  the  child  is  allowed  to  sleep  as  long  as  it  will,  and  finally  it  is  habituated 
to  sleep  all  night  through.  When  the  milk  *'  comes  in,"  which  usually  occurs  on  the 
third  day,  the  breasts  need  more  support  from  the  breast-binder.  The  treatment 
of  cracks,  engorgement,  and  other  conditions  of  the  breast  will  be  taken  up  in  the 
chapter  on  Complications.  Too  much  care  and  too  careful  asepsis  cannot  be  given 
to  the  breasts,  as  infection,  with  resulting  abscess  and  impaired  nipples,  with  re- 
sulting necessary  weaning  of  the  child,  must  be  avoided. 

The  question  of  nursing  is  an  important  one.  Every  mother  should  nurse  her 
child,  for  her  own  good,  because  it  favors  involution  of  the  genitalia  and  develops 
the  maternal  instinct,  but  principally  because  it  reduces  the  terrific  mortality  of  the 
first  months  of  hfe.  Fully  25  per  cent,  of  children  die  in  the  first  year  of  fife,  and  a 
large  proportion  of  the  deaths  is  due  to  bottle-feeding. 

It  has  been  said  that  a  bottle-fed  baby  never  became  great,  a  statement  which 
appears  reasonable,  but  has  never  been  proved.  Without  doubt  the  public  is 
awakening  to  the  importance  of  maternal  nursing,  and  now  it  is  considered  by  most 
women  a  real  calamity  if  they  cannot  give  their  offspring  the  breast.  Certain 
contraindications  to  nursing  exist.  General  diseases,  tuberculosis,  pernicious  anemia, 
cancer,  contraindicate  it,  because  the  disease  is  likely  to  become  very  active  during 
lactation.  Severe  hemorrhage  in  labor  retards  the  nursing,  but  with  full  diet  the 
patient  may  give  her  breast  to  the  child  for  half  or  more  of  its  feedings.  Syphilis 
does  not  forbid  nursing.     Only  its  o^^'n  mother  may  nurse  a  sj^jhilitic  child.     A 


324  THE  HYGIENE  AND  CONDUCT  OF  THE  PUERPERIUM 

healthy  child  never  comes  from  a  syphilitic  mother.  The  new  serum  tests  for 
syphilis  have  proved  this. 

]\Ialformation  of  the  breasts,  as  deformed,  inverted,  cracked,  and  split  nipples, 
may  preclude  nursing.  The  latter  often  are  healed  by  proper  treatment.  Mastitis 
commands  the  suspension  of  nursing  for  a  few  days,  and  an  abscess  forbids  it  per- 
manently from  the  affected  breast.  A  weak,  puny,  or  hare-lipped  child  may  not 
be  able  to  nurse,  and  in  these  cases  the  milk  is  to  be  pumped  and  fed  to  the  infant. 

Remarkable  as  it  may  seem,  the  milk  of  some  mothers  may  act  like  an  irritant 
poison  to  the  infant  and  maj^  produce  enteritis  or  even  death.  The  milk  in  the  next 
puerperimn  may  be  normal;  or  the  milk  may  be  poor  in  quality,  not  agreeing  well 
with  the  child,  but  agreeing  with  another;  or  there  may  be  a  scarcity  of  milk.  At- 
tempts specifically  to  alter  the  quality  of  the  milk  have  been  unsatisfactory.  The 
patient's  general  health  must  be  improved.  If  there  is  a  scarcity  of  mother's  milk, 
one  may  try  to  stimulate  the  glands — first,  by  daily  massage,  cold  bathing  of  the 
whole  body,  giving  much  fluid  to  drink,  especially  milk,  water,  cocoa,  gruels,  and 
03'ster-stews,  but  no  tea,  coffee,  beer,  or  malt  liquors.  The  last  two  fatten  the 
patient  and  reduce  the  milk-supply.  A  strong  baby  is  the  best  stimulant  to  the 
breasts,  and  if  this  fails  to  bring  milk,  usually  there  is  no  gland  tissue  there  and  all 
efforts  %vill  be  futile.  Occasionally  the  milk-supply  is  not  abundant  until  the  pa- 
tient is  up  and  about  and  takes  outdoor  exercise. 

Artificial  feeding  is  not  resorted  to  unless  the  mother  is  palpably  unable  to  meet 
the  demands  made  on  her,  and  when  it  is  demonstrated,  by  the  condition  of  the  baby, 
that  the  breasts  are  inefficient.  Before  attempting  substitute  feeding  it  is  best  for 
the  baby  that  a  wet-nurse  be  obtained. 

Pulse  and  Temperature. — The  nurse  should  take  the  pulse,  temperature,  and 
respiration  at  least  morning  and  evening,  better,  every  six  hours, — at  6,  12,  6,  and 
12, — and  record  the  same  on  a  carefully  kept  history  sheet.  The  pulse  may  be 
counted  frequently  during  the  first  five  days,  and  the  temperature  taken  if  it  shows 
any  increase  in  rate.  The  pulse  is  a  more  sensitive  indicator  of  abnormalities  than 
the  temperature,  but  the  latter  is  more  certain,  since  the  pulse  is  very  mobile.  Any 
temperature  above  99.5°  F.  should  be  considered  abnormal  and  its  cause  sought. 
Chills  normally  are  absent  from  the  puerperimn.  The  author  is  very  suspicious  of 
"nervous  chills" — they  usually  are  not  nervous,  but  due  to  infection.  The  pulse 
normally  ranges  from  66  to  80;  a  decrease  below  66  is  not  pathologic,  but  an  increase 
over  90  should  direct  our  attention  to  the  patient.  If  the  patient  has  no  nurse,  the 
temperature  is  taken  by  the  physician  during  his  visit,  and  he  leaves  a  thermometer 
with  the  patient,  instructing  her  to  hold  it  in  her  mouth  at  a  certain  time,  then  to 
lay  it  aside  for  him  to  read  at  his  next  visit. 

The  Doctor's  Visit. — A  daily  visit  to  the  puerpera  is  desirable,  but  not  necessary 
if  slie  has  a  good  nurse.  It  is  important  that  the  patient  be  seen  on  the  third,  fourth, 
and  fifth  days,  because  these  are  the  critical  ones.  The  nurse  will  keep  a  record  of 
all  the  happenings  to  both  mother  and  child.  The  nurse  is  supplied  by  the  author 
with  special  blanks  for  this  purpose,  and  she  also  fills,  for  his  files,  the  card  shown 
herewith  (Fig.  332).  It  is  well  for  the  physician  himself  to  inspect  the  vulva,  the 
pads,  the  breasts,  and  the  nipples  for  evidences  of  disease,  and  to  palpate  the  uterus 
to  determine  its  state  of  involution.  He  must  watch  the  retrogressive  changes  of  the 
puerperium,  and  be  alert  to  the  first  beginning  deviation  from  the  normal,  as  infec- 
tion, subinvolution.  He  must  study  the  progress  of  the  repair  of  the  puerperal 
wounds  to  discover  early  any  al)normality  here,  like  necrosis  of  tissue,  inflammatory 
infiltration,  exudate,  and  he  must  be  acquainted  with  the  general  state  of  health  of 
the  puerpera,  so  as  to  be  able  to  recognize,  before  they  occur,  impending  accidents, 
as  eclampsia,  yellow  atrophy  of  the  liver,  septicemia,  puerperal  insanity.  Very  few 
medicines  are  prescril)cd  in  a  normal  puerperium — really  none  save  cathartics  and 
an  occasional  remedy  for  after-pains. 

After-pains. — Multiparse  suffer  more  with  painful  uterine  contractions  than  do 


THE  CONDUCT  OF  THE  PUERPERIUM 


325 


])riiiiii);ira'.  Occurriiiji;  in  llic  latter,  they  ^'vc  ris(!  to  tlic  suspicion  of  infection  (^r 
tlic  retention  oi  clots  ov  placental  fragments  in  the  uterus.  They  are  due  to  lack  of 
tonus  of  the  uterine  muscle.  Unless  very  severe,  keeping  the  patient  awake,  rnor- 
phin  is  not  given,  a  trial  first  being  made  with  a  combination  of  phenacetin,  sodium 
bicarbonate,  and  caffein,  or  sodium  bromid,  or  local  applications,  hot  fomentations, 
camphorated  oil,  or  a  hot  saline  enema. 

Sleep. — It  is  highly  important  that  the  j)uerpera  obtain  sufficient  real  sleep  as 
well  as  rest.  One  of  the  symptoms,  and  perhaps  a  contributory  cause,  of  puerperal 
insanity  is  lack  of  sleep. 

After  the  patient  has  l)een  cared  for  on  the  completion  of  labor,  she  is  allowed 
to  sleep  as  long  as  p(jssible,  and  the  room  is  darkened  and  cjuieted  to  favor  this. 
Subsequently  the  nurse  nmst  arrange  the  duties  of  the  day  so  that  the  puerpera  has 
a  little  nap  in  the  afternoon,  and  at  least  eight  hours'  good  sleep  at  night.  If  the 
puerpera  is  persistently  sleepless,  the  physician  should  be  notified.  The  cause  of 
the  sleeplessness  must  be  investigated,  and  if  there  is  a  family  history  of  mental 
disease,  the  condition  must  be  cured  at  once.     The  author  lias  tried  suggestion  with 


PUERPERIUM 


.,^U/ytJt>  /f-//'    NAME    ^Ki^.       ^■UJ3LA,'^^\Jg^^  . 


A    /    H      A3.P     I     A3    P     I     t   V-P     I     A^ 


7P      a^Tp       a^p      a/«p    "az/p  I   A/^p   I   A/jp   I   a/Vp   I,'^','"; 


lA    /?.  jr  „        /  '/,  I  BOWELS   gr       y   .  '0.       ^   ^»  ~  ,     _ 


/cL-t-cC.      ^.^'-'i^^vA-/^ 


CATHETERIZED? 


/^'a^^.    <^.  f.  ^MiMUL^e^^    r^/CsL^. 


(SctUL-     <^^.     /'S^c/oA^^ ^ ytJL^^L.CiAJii/^il'-^ilju^^  Y^L.,*^ 


Fig.  332. — A  Filled  Postpartum  Card.     Reverse  is  Used  for  the  Child's  Record  (Fig.  335). 


good  effect,  also  sodium  bromid  in  20-grain  doses,  veronal  in  o-gTain  doses,  and 
chloralamid,  5  to  15  grains,  but  where  the  woman  is  tired  out,  nervous,  excited,  and 
evidently  under  a  strain,  a  hypodermic  of  3^  grain  morphin  with  yl-o  grain  atropin 
should  be  given.  The  danger  of  inaugurating  the  morphin  habit  is  always  to  be 
borne  in  mind,  and  the  patient  properly  guarded  against  it.  Much  can  be  done  by 
the  nurse  to  procure  sleep,  as  giving  a  warm  alcohol  sponge-bath,  a  glass  of  hot 
malted  milk,  cultivation  of  a  regular  habit  of  sleep,  removal  of  the  infant  from  the 
room,  and  a  constant  cheerful,  hopeful  demeanor,  withholding  worries  of  all  kinds 
from  the  patient's  mind. 

General  Treatment. — This  is  the  same  as  for  any  bed  patient  as  regards  bath- 
ing, changing  bed,  and  so  forth.  Unless  the  weather  makes  it  agreeable,  a  full  bath 
is  not  needed  every  day,  but  may  l^c  given  twice  or  thrice  a  week.  Daily,  however, 
the  whole  body  may  be  sponged  with  alcohol  and  water,  one  part  to  three,  paA'ing 
especial  attention  to  the  axillae.  There  should  be  plenty  of  light  and  fresh  air  in  the 
hnng-in  chamber.  Sun  and  air  are  not  harmful  by  any  means.  In  the  olden  time 
both  were  feared,  and  the  puerpera  was  kept  in  semi-darkness  all  the  time,  and  all 


326  THE  HYGIENE  AND  CONDUCT  OF  THE  PUERPERIUM 

air  excluded  to  prevent  her  from  catching  cold.  It  was  thought  that  "catching 
cold"  caused  puerperal  infection  and  mastitis,  but  now  we  know  these  complications 
are  due  to  infection,  and  are  in  high  degree  preventable  by  proper  asepsis.  Free 
ventilation  and  light  are  strong  opponents  to  infection.  The  nurse,  while  providing 
both,  must  see  that  at  no  time  either  mother  or  child  is  exposed  to  a  direct  draft, 
and  that  the  bright  light  does  not  fall  directly  on  the  eyes  of  either. 

After  the  first  week  the  nurse  may  give  the  patient  a  general  light  massage. 
She  should  avoid  the  inside  of  the  legs,  where  there  are  veins,  and  the  uterus  and 
breasts.  Passive  motions  of  the  arms,  legs,  and  trunk  are  also  sometimes  recom- 
mended. Systematic  motions  of  the  arms  and  legs,  such  as  extending  and  flexing 
them  against  a  slight  resistance,  may  be  practised.  These  exercises  while  away  the 
tedium  of  the  bed,  improve  the  circulation,  strengthen  the  abdominal  muscles,  and 
hasten  the  return  of  the  patient's  strength.  She  is  less  likely  to  be  faint  and  weak 
when  first  gotten  out  of  bed. 

Visitors. — The  lying-in  room  should  be  quiet  and  restful.  The  puerpera  must 
be  given  opportunity  to  recover  from  the  strain  of  labor  and  recuperate  her  strength 
from  the  exhaustion  of  pregnancy  and  delivery.  Therefore  only  the  nearest  relatives 
are  to  be  allowed  in  the  lying-in  chamber  during  the  first  week.  Even  these  visits 
should  be  very  short.  Aside  from  the  nervous  disturbance  caused  by  too  many 
visitors,  there  is  the  danger  of  the  introduction  of  contagion. 

The  Time  of  Getting  Up. — The  author  allows  a  normal  puerpera,  after  normal 
labor,  to  sit  up  in  bed  on  the  eighth  or  ninth  day,  get  out  of  bed  into  a  large  chair  for 
an  hour  on  the  tenth  day,  for  three  hours  on  the  eleventh,  and  before  the  end  of  the 
second  week  she  has  the  freedom  of  the  floor,  going  downstairs  on  the  fifteenth  to 
eighteenth  day.  Operative  cases,  perineorrhaphies,  and  women  who  have  had  fever 
during  the  puerperium  require  special  regulations — usually  a  prolongation  of  the 
stay  in  bed  and  slower  resumption  of  active  movements.  But  the  women  are  not 
condemned  to  such  absolute  quiet  in  the  bed  as  formerly.  For  the  first  two  or 
three  hours  the  puerpera  should  lie  quietly  on  her  back,  but  after  this  she  may  be 
turned  gently  on  the  side,  the  nurse  supporting  the  heavy  uterus.  Next  day  the 
position  may  be  changed  oftener,  and  by  the  third  day  only  ordinary  care  is  neces- 
sary, and  the  changes  may  be  made  as  frequently  as  comfort  demands.  These 
changes  facilitate  drainage  and  better  the  pelvic  circulation.  The  puerpera  after 
the  fourth  day  may  be  propped  up  with  pillows  or  back-rest  for  her  meals,  bowel 
movements,  and  urinations,  may  sit  up  straight  on  the  fifth  or  sixth  day,  but  her 
perfect  condition  and  her  frequent  requests  to  be  let  out  of  bed  should  not  lead  the 
physician  to  permit  it  until  the  ninth  or  tenth  day.  It  is  wise,  too,  to  forbid  too 
early  resumption  of  household  duties,  responsibihties,  and  social  functions. 

This  time-honored  custom  of  keeping  the  woman  in  bed  nine  days  or  more  has  been  assailed 
by  late  writers.  Ktistner,  in  1899,  and  White,  as  far  back  as  1775,  advocated  the  practice  of 
allowing  the  women  to  leave  the  bed  as  soon  as  they  felt  able  to  do  so,  and  claimed  that  no  evil 
results  followed,  but,  on  the  contrary,  the  women  recovered  strength  quicker,  had  less  fever,  less 
frequent  thrombophlebitis,  less  coprostasis,  less  necessity  for  catheterization,  better  lactation,  and 
no  greater  frequency  of  prolapse  of  the  uterus  and  vagina. 

It  is  probable  that  those  physicians  who  keep  their  puerperse  in  bed  two,  three,  or  even  four 
weeks  err  in  the  opposite  direction,  and  it  is  certain  that  one  can  let  the  women  get  up  too  soon. 
The  best  plan  will,  as  usual,  be  a  compromise  between  the  two,  and  the  limits  be  applied  to  special 
cases.  One  mast  hesitate  long  before  allowing  a  principle,  grounded  in  thousands  of  years  of 
empiricism,  to  be  overthrowTi  by  a  new  theory,  and,  indeed,  the  early  getting  up  does  not  possess 
all  the  advantages  claimed,  nor  is  it  free  from  the  dangers  it  is  said  to  be.  In  the  first  place, 
theoretic  coasideration  of  the  condition  of  the  pelvis  postpartum  will  indicate  the  necessity  for 
rest  in  the  horizontal  position.  The  bruised,  suggillated  condition  of  the  pelvic  floor  has  already 
been  referred  to.  It  stands  to  reason  that  such  an  impaired  pelvic  floor  should  not  be  given  the 
task  of  supporting  the  large  heavy  puerperal  uterus  and  the  whole  intra-abdominal  pressure  before 
it  has  regained,  in  a  measure,  its  strength  and  elasticity.  The  ancient  idea  that  too  early  getting 
up  leads  to  prolapse  of  the  vagina  and  uterus  has  anatomic  foundation,  and,  further,  clinical  ex- 
perience proves  it.  Prolapse  is  more  common  in  the  poor  women  who  have  to  get  up  early  after 
delivery  and  do  heavy  work. 

It  is  claimed  that  fever  is  less  common.  The  author  believes  that  fever  is  more  common. 
In  the  service  of  the  Chicago  Lying-in  Hospital  Dispensary,  in  nearly  every  case  where  the  puer- 
pera is  reported  to  have  fever  the  history  reads  that  the  patient  had  gotten  out  of  bed  and  soon 


THE  CONDUCT  OF  THE  PUERPERIUM  327 

after  sickened.  We  know  that  tlu;  streptococcus — and  a  virulent  strain  too — normally  inhabits 
the  puerperal  vagina.  When  the  puerpera  gets  up,  th(;  heavy  uterus  falls  to  and  fro  and  tears 
open  the  granulating  surfaces,  giving  the  germs  access  to  the  lymph-spaccjs.  Statistics  have  not 
proved  all  the  claims  for  the  new  treatment.  More  about  this  interesting  subject  must  be  sought 
in  the  literature,  of  whi(-h  nmch  has  accumulated  in  the  last  few  years.     (See  Mosher  and  Kiistner.*) 

The  Binder. — Ancient  custom  prescribes  the  application  of  an  abdominal 
binder  directly  posti)arttnn.  Van  Swicten  (1754)  recommended  it  for  the  preven- 
tion of  syncope,  the  raising  up  of  the  uterus,  and  postpartum  hemorrhage.  It  does 
rei:)lace  the  feeling  of  emptiness  of  which  the  women  complain  after  delivery,  but  it 
will  not  prevent  the  uterus  from  rising  in  the  belly  or  from  Ijleeding,  no  matter  how 
tightly  aj^plied.  The  women  insist  on  the  application  of  the  binder  throughout  the 
puerperium,  with  a  view  to  preserving  the  figure  and  preventing  "high  stomach." 
In  the  author's  opinion,  the  binder  will  do  neither.  Enteroptosis,  nephroptosis, 
relaxed  abdominal  wall,  are  the  results  of  congenital  deformity,  pathogenic  conditions 
acquired  before  or  during  pregnancy, — for  example,  overstretching  of  the  ab- 
dominal walls, — and  very  little  may  be  done  during  the  puerperium  to  correct  these 
evil  effects.  The  author  applies  the  binder  postpartum  to  relieve  the  feeling  of 
emptiness  of  the  abdomen,  to  help  steady  the  uterus  when  the  patient  is  moved,  and 
to  satisfy  her  whims.  Hardly  any  objection  can  be  offered  to  its  use.  It  is  almost 
impossible  to  apply  it  tightly  enough  to  force  the  uterus  backward,  but  it  maj^  if 
tympany  develops,  interfere  with  the  passage  of  flatus  and  feces,  which  is  especially 
true  after  cesarean  section.  During  the  second  week  of  the  puerperium  a  very 
gentle  superficial  abdominal  massage  and  mild  gymnastics  are  used  to  strengthen 
the  muscles.  By  preventing  the  accumulation  of  gas  in  the  bowels  and  providing  a 
daily  alvine  evacuation,  the  above  treatment  is  aided.  After  the  patient  assumes 
the  erect  posture,  the  abdominal  binder  may  assist  greatly,  by  supporting  the  weight 
of  the  viscera  for  a  short  time  until  the  recti  and  obliqui  have  regained  sufficient 
tonus  and  power.  The  abdominal  binder  used  after  laparotomy  may  be  applied, 
or  a  jockeystrap  may  be  worn.  The  latter  furnishes  also  some  slight  perineal  sup- 
port. Corsets  may  be  resumed  after  five  weeks,  and  the  variety  which  holds  up  the 
lower  abdomen  should  be  preferred. 

Final  Examination. — The  patient  is  instructed  to  appear  for  examination  at 
the  office  of  the  accoucheur  with  her  baby  eight  weeks  after  delivery.  By  this  time 
involution  is  complete,  the  woman  has  had  the  first  menstruation,  if  it  was  to  occur, 
and  one  can  better  judge  of  the  condition  of  the  parts.  Special  attention  is  directed 
to  the  size  and  position  of  the  uterus,  the  presence  of  exudates  in  the  broad  liga- 
ments, the  condition  of  the  adnexa,  the  firmness  of  the  levator  ani  and  perineum, 
and  the  state  of  the  bladder  and  vaginal  walls  as  regards  prolapse.  If  the  uterus  is 
retroverted,  it  is  to  be  replaced  and  a  pessarj-  inserted,  which  the  patient  should  wear 
three  months.  If  the  perineal  floor  is  relaxed,  the  patient  is  instructed  how  to 
exercise  the  levator  ani,  to  take  the  knee-chest  position  for  ten  minutes  three  times 
a  day,  and  is  given  a  prescription  for  hot  vaginal  douches.  Other  gynecologic 
treatment  or  operation  is  advised  if  necessarj^,  and  the  opportunity  is  used  to  dis- 
cover the  very  beginnings  of  postpuerperal  disease  and  to  correct  them.  If  the 
woman  has  had  a  severe  labor,  she  is  advised  as  to  a  subsequent  pregnane}'. 

The  child  is  examined  for  umbilical  hernia,  and  its  nutritional  state  determined. 
These  points  are  all  to  be  noted  on  the  puerperium  card,  which  entry  closes  the  ob- 
stetric history  of  the  particular  case. 

SUMMARY  OF  THE  PRINCIPLES  OF  TREATMENT  OF  THE  PUERPERIUM 

1.  Antisepsis  and  asepsis  of  the  open  genital  wounds. 

2.  Asepsis  of  the  breasts. 

*  Kiistner:  Verh.  der  Deutsch.  Gesell.  f.  Gj-n.,  vol.  viii.  p.  530.  "^Miite:  The  Treatment  of 
Pregnant  and  Puerperal  Women,  1775.     jMosher:   Amer.  Jom-.  Obstet.,  1911,  vol.  xUv. 


328  THE  HYGIENE  AND  CONDUCT  OF  THE  PUERPERIUM 

3.  Attention  to  the  emunctories,  bowels,  urinary  tract,  and  skin, 

4.  Provisions  for  comfort,  sleep,  and  relief  of  pain, 

5,  Watchfulness  for  complications, 

6,  General  treatment  to  facilitate  recovery, 

7,  The  time  of  getting  up, 

8.  Final  examination  to  prevent  future  invalidism. 

THE  DIAGNOSIS  OF  THE  PUERPERIUM 

Chiefly  in  legal  cases  is  the  accoucheur  required  to  give  an  opinion  as  to  the 
existence  of  the  puerperal  state.  At  postmortems  on  women  dead  after  an  illegal 
operation,  as  criminal  abortion,  it  is  usually  easy  to  determine  the  exact  condition, 
from  the  macroscopic  and  microscopic  appearance  of  the  parts.  If  a  woman  pleads 
the  puerperal  state  for  the  purposes  of  blackmail  or  for  the  substitution  of  an  infant, 
it  is  usually  a  simple  matter  to  discover  the  fraud,  but  if  a  labor  has  actually  taken 
place  and  the  patient  wishes  to  hide  her  condition,  as,  for  example,  in  cases  of  child 
murder,  it  is  not  so  easy  to  prove  incontestably  that  gestation  has  preceded  the 
examination.  Naturally,  the  difficulties  increase  with  the  length  of  time  since  de- 
livery, A  full-term  labor  also  leaves  greater  and  more  permanent  traces  than  an 
abortion.     No  reliance  may  be  placed  on  the  statements  of  the  patient  or  her  friends. 

The  examination  includes  a  search  for  the  changes  of  the  puerperium,  especially 
for  the  presence  of  a  functionating  breast  (not  traces  of  milk  or  colostrum)  and  for 
the  evidences  of  fresh  wounds  in  the  genital  tract.     The  vulva  has  a  quite  charac- 
teristic, reddish  purple,  velvety,  succulent  appearance  for  the  first  four  weeks  post- 
partum, and  the  presence  of  the  typical  birth  injuries  undergoing  the  usual  changes 
of  wound  healing  lends  great  weight  to  the  diagnosis.    Absence  of  such  injuries  does 
not  ehminate  the  possibility  of  previous  delivery,  because  the  fetus  may  have  been 
small  or  macerated,  or  the  parts  especially  elastic.     The  presence  of  vestiges  of  the 
hymen — carunculse  myrtiformes — is  indicative,  not  conclusive.     Cervical  tears  are 
usually  due  to  child-birth,  but  sometimes  come  from  instrumentation,  as  dilatation 
for  dysmenorrhea  or  sterihty.     The  enlargement  of  the  uterus,  directly  or  shortly 
after  labor,  its  consistence,  its  contractions,  and  its  rapid  decrease  in  size,  deter- 
mined by  repeated  bimanuals  and  measurements  with  the  sound,  give  valuable  in- 
formation, both  as  to  the  fact  and  to  the  time  of  a  previous  confinement.     If  the 
cervix  is  patulous,  a  finger  may  be  inserted  and  feel  the  placental  site.     Less  re- 
liance than  one  would  expect  may  be  placed  on  a  study  of  the  lochia  and  scrap- 
ings.    One  must  find  ovular  remnants  to  clinch  the  diagnosis.     Vernix  caseosa, 
meconium,  but  especially  pieces  of  placenta  or  chorionic  villi  are  positive.     Decidual 
cells,  when  in  very  large  numbers,  are  presumptive  evidence,  but  one  must  find  villi 
to  arrive  at  positiveness.     Opitz*  believed  he  could  diagnose  a  preexisting  pregnancy 
from  the  construction  of  the  uterine  glands  thus  removed.    Later  investigations  have 
disproved  this,  but  a  study  of  the  scrapings  will  give  very  strong  evidences  of  puer- 
peral changes  if  done  early  enough.     The  presence  of  hyaline  remnants  of  blood- 
vessels in  the  scrapings  even  six  months  postpartum  is  said  to  be  good  evidence.  (See 
changes  in  the  uterine  mucous  membrane  during  involution,  p.  208.)     Since  the 
patient  may  refuse  to  permit  a  curetage  on  the  ground  that  it  is  dangerous  to 
her,  and  justifiably,  we  are  usually  without  this  kind  of  information.     Abortion  in 
progress  or  a  fibroid  may  simulate  the  puerperium.     After  an  early  abortion  it  may 
be  impossible  to  distinguish  the  puerperal  uterus  from  one  that  is  menstruating. 
It  behooves  the  obstetric  expert  to  be  very  thorough  and  systematic  in  his  examina- 
tion, very  deliberate  in  his  consideration  of  the  findings,  and  very  circumspect 
in  his  statements  on  the  witness-stand  in  such  cases  as  the  above.     A  full  record 
is  to  be  made  of  every  examination.     These  should  be  gotten  up  in  legal  form,  the 
help  of  an  attorney  being  asked  if  necessary. 

*  Opitz:  Zeitschr.  f.  Geb.  u.  Gyn.,  vol.  xlii. 


SECTION  V 
THE  NEW-BORN  CHILD 


CHAPTER  XXIV 
PHYSIOLOGY  OF  THE  NEW-BORN  CHILD 

At  no  period  during  the  life  of  the  individual  does  he  undergo  such  violent 
and  fundamental  changes  as  at  birth  and  during  the  two  weeks  after  it.  Not  a  few 
children  fail  to  survive  the  shock  of  delivery,  and  a  great  many  succumb  in  the  first 
few  weeks  because  of  their  inability  to  meet  and  overcome  the  adverse  conditions 
surrounding  their  lives.  The  new-born  must  now  do  its  own  digesting,  must 
oxygenate  its  own  blood  from  the  air,  which  is  of  varying  temperature,  must  keep 
up  its  body  warmth  in  spite  of  violent  external  variations,  and,  besides  other  func- 
tions, must  take  care  of  hosts  of  bacteria  which  assail  it  from  every  port  of  entrance. 
True,  it  brings  into  the  world  certain  acquired  immunities  against  infection,  but 
it  must  develop  a  great  many  itself. 

The  changes  of  the  fetal  to  the  extra-uterine  circulation  and  the  establishment 
of  respiration  have  already  been  considered. 

Respiration. — At  first  the  breathing  is  very  irregular  and  abdominal  in  type; 
later  it  becomes  more  even  and  more  thoracic,  becoming  abdominothoracic  during 
crying  efforts.  The  respirations  are  both  superficial  and  deep,  occasionally  inter- 
mittent, and  vary  from  35  to  60,  even  in  health.  The  child  inspires  from  20  to 
40  c.c.  with  each  breath,  the  amount  increasing  rapidly  each  day.  The  exchange  of 
gases  in  the  lungs  is  more  than  twice  as  active  as  in  the  adult.  Oxidation  in  the 
body  is  also  more  active,  assimilative  processes  and  growth  being  so  vigorous  and 
marked.  At  first  only  a  small  portion  of  the  lung  is  expanded,  and  it  requires  a 
month  or  more  to  expand  it  all.  The  chest-wall  is  so  poorly  developed  that  when 
the  pleural  cavities  are  opened,  the  lungs  do  not  collapse,  as  in  the  adult. 

Crying  is  good  for  the  child,  because  it  expands  the  lungs.  A  whining,  grunting 
expiration  is  a  sign  that  the  alveoli  are  not  developed,  as  occurs  in  premature; 
asphyxiated,  or  injured  children.  Mucus  in  the  trachea  causes  rattling;  it  may 
come  from  congestion  of  the  throat  the  result  of  labor,  or  from  aspiration  of  vaginal 
or  other  discharges  during  the  delivery.  This  is  dangerous  on  the  score  of  mechani- 
cal obstruction  of  the  air-passages  (atelectasis)  and  infection,  bronchopneumonia, 
and  enteritis. 

The  blood  is  more  concentrated  than  that  of  adults  (specific  gravity,  1060  to 
1080),  and  contains  more  hemoglobin  and  salts.  It  clots  feebly,  and  contains  no 
diastatic  ferment,  as  in  the  adult  (Bial).  The  amount  varies  from  250  to  350  gm., 
depending  on  the  size  of  the  child  and  the  time  of  ligation  of  the  cord,  being,  with 
late  ligation,  about  one-eleventh  of  the  bodj-weight.  Leukoc\i:osis  is  the  rule  for 
the  first  few  days — up  to  23,000;  later,  an  average  of  about  10,000  to  12,000  is 
attained.  The  polynuclears  are  in  the  majority  early,  but  after  the  twelfth  day 
the  lymphocytes  preponderate.  Owing  to  the  thickening  of  the  blood  in  the  first 
days  the  reds  are  increased  in  number — from  5,000,000  to  7,500,000,  but  soon  the 
normal  is  reestablished,  because  of  the  destruction  of  about  10  per  cent,  of  them. 

329 


330 


THE    PHYSIOLOGY    OF   THE    NEW-BORN    CHILD 


The  size  of  the  red  corpuscles  varies  very  much,  there  being  many  microcytes. 
Poikiloc}i:osis  also  may  be  found,  and,  for  four  to  nine  days,  nucleated  reds. 

Halban  and  Landsteiner  studied  the  serum  of  the  child,  and  found  that  it 
possesses  less  antitoxic,  bactericidal,  and  hemolytic  properties  than  the  adult's, 
and  that,  therefore,  the  blood  is  not  complete. 

The  circulation,  studied  by  Seitz,  of  Munich,  shows  marked  changes.  During 
fetal  life  the  pulse-beats  number  120  to  150;  after  delivery,  150  to  190;  sinking  to 
110,  then  rising  to  120  to  130  a  minute  on  the  fourth  to  sixth  day,  with  many  varia- 
tions of  frequenc}^,  and  rhythm,  and  strength,  caused  by  sleep,  waking,  crying, 
colic,  etc.     The  blood-pressure  varies  from  75  to  100  mm.,  and  since  the  arteries 


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Fig.  333. — Temperature,  Pulse,  and  Respiration  Chart  of  New-bohn. 
The  average  readings  of  ten  apparently  healthy  children  were  taken.     The  pulse  and  respiration  in  everj'  instance 
were  counted  with  the  stethoscope.     Records  were  made  at  6  a.  m.,  12  noon,  0  p.  m.,  and  12  midnight.     Dotted  line 
is  the  respiration,  the  lowest  line,  the  temperature. 


and  capillaries  of  the  child  are  large,  the  peripheral  resistance  is  less,  allowing  a 
more  active  and  rapid  circulation  of  the  blood.  This  is  needful  for  the  rapid  de- 
velopment of  all  the  organs,  the  active  digestion,  and  tissue  growth  of  the  child. 

The  Temperature. — Owing  to  the  fetus'  own  metal^olism,  the  intra-uterine 
temperature  is  one-half  degree  higher  at  birth  than  that  of  the  mother  (Fig.  333). 
As  the  result  of  the  exposure  following  delivery,  the  temperature  sinks  1  to  33^ 
degrees — greater  in  premature  and  asphyxiated  children.  After  twelve  to  twenty 
hours  the  normal,  98°  F.,  is  reached.  After  a  week  or  so  the  temperature  remains 
around  98.6°  F.  Bathing,  nursing,  exposure,  lack  of  food,  etc.,  easily  alter  the 
temperature  of  the  child.     Diurnal  variations  are  not  usual. 


THE  PHYSIOLOGY  OF   THE    NEW-BOUN    CHILD  331 

The  Urine. — Reusing  presents  this  table  of  tlio  daily  average  amounts  of  urine: 


1 

2 

3 

4 

5 

6 

7 

8 

day 

Breast-fed        

18.9 

38.6 

64.9 

84.0 

121.5 

147.0 

175.5 

217.2 

c.c. 

Bottk'-fi'd 

28.8 

59.7 

111.4 

153.8 

198.9 

237.7 

278.7 

371.0 

c.c. 

From  7}/2  to  9  c.c.  of  urine  may  be  found  in  the  bladder  at  l)irth.  Later, 
daily  amounts  vary  very  much  with  the  size  of  the  child,  prematurity,  the  room 
temperature  and  moisture  (incubator  children  pass  less  urine),  the  food  (mother's 
milk,  less  urine),  icterus,  and  illness.  If  the  baby  is  a  water-tippler,  the  bed  may 
be  wet  all  the  time.  The  specific  gravity  is  from  1006  to  1008;  color,  clear,  watery, 
later  a  light  straw;  reaction  acid.  Urea  shows  highest  on  the  seventh  day — 0.8 
per  cent.,  from  0.1  per  cent,  on  the  first  day.  The  percentage  of  uric  acid  is  large, 
as  is  shown  by  the  frequency  of  uric-acid  infarct  of  the  kidney.  It  is  nearly  thrice 
as  much  as  in  the  adult.  Uric-acid  infarct  of  the  kidney  occurs  in  50  per  cent,  of 
children,  and  may  be  assumed  from  a  microscopic  examination  of  the  urine  showing 
the  crystals.  Often  the  crystals  (ammonium  urate  principally)  are  found  on  the 
diaper  as  a  reddish  brick-dust.  When  a  kidney  containing  the  infarct  is  cut,  it 
grits  under  the  knife,  and  yellowish  or  brownish  streaks  are  seen  radiating  from  the 
papilliB.  The  deposit  occurs  oftener  in  premature  children,  after  prolonged  or 
instrumental  deliveries,  after  asphyxia,  in  cases  of  delayed  lactation,  with  icterus 
and  febrile  complications.  The  granules  may  cause  pain  in  their  passage.  Neph- 
ritis is  not  uncommon  in  early  infancy  (Jacobi).  Albuminuria  is  verj^  common — 
almost  constant  for  four  to  seven  days. 

The  Intestinal  Tract. — Shortly  after  birth  the  meconium  which  has  accumulated 
in  the  large  intestine  is  discharged.  Occasionally  a  plug  of  mucus  which  filled  the 
rectum  precedes  the  green,  thick,  pasty  meconium.  There  are  70  to  90  gm.  of 
meconium  (Camerer),  and  it  is  usually  all  passed  by  the  third  or  fourth  day. 
The  colostrum  has  a  laxative  action,  and  air  and  gas  in  the  bowel  aid  the  active 
peristalsis  of  the  first  days.  The  green  discharge  is  followed  by  brown,  then  j^el- 
low  movements,  if  the  child  is  fed  at  the  breast,  but  the  discharges  are  whitish  and 
curdy  if  the  child  is  fed  by  the  bottle.  Meconium  contains  epithelium  from  the 
intestine,  bilirubin,  cholesterin  crystals,  stearic  acid,  fat,  bile,  lanugo,  skin  epithe- 
lium, and  sel^aceous  matter  from  swallowed  liquor  amnii. 

Within  twenty-four  hours  the  whole  intestinal  canal  is  infected  by  the  Bac- 
terium coli  commune  and  other  bacteria  present  in  the  air,  the  bath-water,  the 
vagina  of  the  mother,  and  on  the  fingers  and  hps  of  the  mother  and  nurse. 
Without  doubt  many  infections  of  serious  nature  originate  at  this  time,  and,  too, 
the  germs  introduced  may  be  beneficial,  since  they  aid  the  process  of  digestion. 
Ordinarily  the  child's  intestine  is  inhabited  mainly  by  tw^o  forms — the  Bacterium 
coli  and  the  Bacillus  lactis  aerogenes. 

Normally,  the  infant  has  two  stools  daily — more,  if  Ijottle  fed.  In  the  latter 
the  odor  is  not  that  of  sour  milk,  as  it  is  with  healthy  infants,  and  one  is  more 
likel}^  to  find  clumps  of  fat,  formerly  thought  to  be  casein,  m  the  movement. 

The  stomach  contains  pepsin;  the  pancreas,  trj^Dsin  and  a  fat-sphtting  fer- 
ment, ]:)ut  no  diastatic  ferment  (Zweifel). 

The  Weight. — During  the  first  four  days  the  infant  loses  in  weight — on  the 
average,  six  to  eight  ounces.  The  loss  is  more  in  bottle-fed  babies  and  those  getting 
scanty  food.  The  liirth  weight  is  regained  by  the  tenth  day,  and  from  then  on  the 
normal,  breast-fed  infant  should  gain  about  an  ounce  a  day.  The  initial  loss  is 
due  to  excretion  of  meconium,  urine,  evaporation,  and  to  the  fact  that  the  new- 


332 


THE   PHYSIOLOGY    OF   THE    NEW-BORN    CHILD 


born  gets  very  little  nourishment  in  the  first  few  days.  Such  losses  do  not  occur 
in  animals,  and  they  have  important  bearing  on  the  diseases  of  early  infancy. 
The  table  from  Beuthner  gives  the  average  amounts  of  food  taken  by  children  from 
the  breast  for  the  first  fourteen  days : 


Average  birth-weight,  3126  gm. 


17 


91 


3 
190 


4 
302 


5 

348 


6 

381 


7 
450 


476 


9 

476 


10 

476 


11 

476 


12 


476 


13 

476 


14 

476 


If  more  food  is  given  the  child  in  the  first  days,  the  initial  loss  in  weight  is 
not  so  great  or  may  be  avoided.  Premature  infants  lose  relatively  more  and  re- 
gain their  birth-weight  very  slowly,  often  requiring  a  month.     The  same  is  true  of 


fTame  ■■ 
Application  JVo-- 


Chicago  Lying-in  Hospital     co«/.  •«>.    -_ 

INFANT'S  WEIGHT   CHART  (j^Lt^, -y*' 

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f 

Fig.  334. — Chart  Showing  Average  Weight  of  10  Apparently  Normal  Breast-fed  Infants. 


excessively  large  children.  Children  fed  on  cow's  milk  lose  more  weight  and 
regain  flesh  less  rapidly  than  breast-fed  infants.  Since  nearly  as  large  a  percentage 
of  cow's  milk  as  of  human  milk  is  absorbed  (93  and  96  per  cent.),  there  must  be 
other  reasons  for  the  inferiority  of  cow's  milk  as  an  infant  food.  It  is  well  known 
that  breast-fed  children  grow  faster,  are  more  vigorous,  resist  infections  better, 
throw  off  disease  quicker,  suffer  less  from  rickets,  etc.,  than  the  bottle-fed.  Human 
milk  is  easier  to  digest.  Fewer  calories  of  it  are  required.  Its  albumin  is  partly  in 
solution  as  a  homologous  albumin,  ready  for  absorption  into  the  blood  without  the 
preparatory  stages  of  propeptone,  peptone,  and  albumose;  it  contains  phosphorus 
in  very  assimilable  form,  as  nuclein,  lecithin,  and  opalisin.  It  is  not  a  dead  secre- 
tion, but  a  live  tissue,  and  carries  ferments  which  render  the  milk  easily  absorbed, 
and  which,  added  to  cow's  milk,  will  even  render  the  latter  much  more  assimilable. 
This  fact,  known  clinically  for  many  years,  has  been  emphasized  by  Marfan  and 


TIIK    PHYSIOLOGY    OF    THE    NEW-JJOKN    CHILD  333 

Esclicricli,  who  call  these  t'eniieiits  or  enzymes,  trophozymases.  Human  milk 
also  contains  diastatic,  proteolytic;,  fibrin-  and  fat-splitting  ferments,  alsrj  alexo- 
genic  ferments  (Moro).  The  latter  causes  alexins  to  be  devehjped  in  the  child's 
blood,  which  give  it  immunities  against  disease.  Ehrlich  proved  that  immune 
bodies  jiass  from  the  mother  to  the  fetus  and  from  mother  to  child  t}iroufi;h  the 
milk  (Seit/). 

General  Condition. — Observing  the  child  alter  birth,  it  is  seen  to  be  in  a  half- 
sleeping  state.  The  eyes  are  opened  once  in  a  ^vhile,  but  immediately  closed,  the 
arms  move,  also  the  legs,  sometimes  (luite  vigorously.  The  difference  between 
sleep  and  waking  is  not  very  well  marked  until  the  end  of  the  first  week  or  even  later. 
Of  the  special  senses,  touch  and  tast(;  are  already  well  developed.  Siglit  is  prob- 
ably, the  light  reflex  is  certainl}',  present.  Hearing  is  sometimes  determinable  as 
early  as  the  first  day,  but  usually  is  positively  present  only  toward  the  end  of  the 
first  week.     The  sense  of  smell  develops  later. 

The  spinal  nervous  system  is  in  a  state  of  hyperexcitability,  the  infant  jumping 
on  even  slight  jarring,  and  the  will  is  certainly  developed  early,  as  one  may  judge 
from  the  rapid  acquisition  of  bad  ha})its.     Reaction  to  electric  stimulation  is  slow^er. 

The  Skin. — At  first  the  child  is  cyanotic,  especially  about  the  face  and  ex- 
tremities, and  the  eyelids  may  be  swollen.  After  thirty  or  forty  minutes  the  normal 
rosy  pink  of  the  new-born  appears,  unless  the  infant  is  premature,  when  the  color 
is  a  dusky  red.  Over  the  back  and  in  the  creases  of  the  body  a  thick  white  paste 
is  often  found — the  vernix  caseosa.  This  consists  of  fatty  skin  secretions,  epider- 
mis, and  lanugo,  and  is  usually  removed  by  oiling  with  the  first  bath.  In  many 
children  the  epidermis  exfoliates  in  branny  scales,  or  there  may  be  pronounced 
desciuamation.  In  the  latter  cases,  which  may  be  toxemic,  the  skin  looks  a  little 
raw  at  first  and  may  crack,  but  later  a  healthy  pink  or  white  appears.  During  the 
first  weeks  the  skin  is  subject  to  various  eruptions,  especially  vesicular  and  pustular. 
They  are  called  strophulus — red,  if  the  border  of  the  vesicles  is  red,  and  white,  if 
simply  vesicular.  These  are  usually  affections  of  the  sweat-glands.  There  may 
also  be  a  generalized  erythema.  A  pustular  eruption  is  generally  due  to  infection 
with  the  Staphylococcus  albus.  In  summer  the  tendency  to  skin  affections  is 
marked,  vesicular  intertrigo  being  an  annoying  complication,  and  in  general  the 
skin  is  more  sensitive  to  the  action  of  soap  and  water,  irritating  clothing,  insuffi- 
ciently rinsed  diapers,  etc. 

Icterus  Neonatorum. — About  40  per  cent,  of  children  show  slight  icterus  during 
the  first  week.  Two  varieties  must  be  distinguished — icterus  simplex  and  icterus 
gravis.  The  latter  is  a  symptom  of  sepsis,  syphilis,  Buhl's  disease,  the  hemorrhagic 
diathesis,  congenital  obstruction  in  the  bile-passages,  etc.  A  peculiar  and  fatal 
form  of  icterus  affecting  the  ganglia  of  the  brain  is  described.  Here  onl}-  the  benign 
form  will  be  considered — the  simple  jaundice  or  icterus  neonatorum. 

Most  authors  place  the  percentage  of  jaundiced  infants  at  about  80,  but  the 
experience  of  the  writer  is  that  even  40  per  cent,  is  too  high.  "With  the  aseptic 
care  of  the  new-born  and  more  physiologic  treatment  the  minority  of  infants  de- 
velop even  a  trace  of  icterus.  On  the  second  or  third  clay  one  notices  a  shght 
yellowish  tinge  of  the  skin  of  the  body  and  face,  which  may  be  better  seen  if  the 
usual  redness  be  pressed  away  by  the  finger.  In  marked  cases  even  the  sclera  may 
be  yellow,  the  nasal  discharges  and  the  urine  also  sho^\'ing  the  discoloration,  bile- 
pigment  having  been  found  in  them.  Autopsy  shows  that  the  intima  of  the  arteries, 
the  cartilages,  and  the  interstitial  tissues  are  stained,  but  the  brain  and  cord,  the 
liver  and  the  kidneys,  very  slightly,  if  any.  The  kidneys  often  contain  the  uric- 
acid  infarct.  Icteric  children  usually  are  thin,  grow  less  vigorously,  show  signs 
of  gastiO-intestinal  inflammation,  are  colicky,  su]:)ject  to  febrile  disturbances, 
intertrigo  of  the  buttocks,  and  generally  are  poorer  than  the  others,  for  which 
reasons  the  author  cannot  call  the  affection  a  physiologic  manifestation.     The 


334  THE    PHYSIOLOGY    OF   THE    NEW-BORN    CHILD 

excretion  of  urea  and  uric  acid  is  greater,  more  albumin  is  used  up,  oxidation  is 
more  rapid  (Hofmeier). 

After  the  first  week  the  jaundice  has  usually  disappeared,  but  if  it  was  severe, 
three  to  five  weeks  may  be  necessary.     Much  depends  on  the  cause. 

Etiology. — The  cases  occur  with  equal  frequency  in  hospital  and  private 
practice,  in  town  and  city.  Jaundice  is  more  common  in  the  children  of  primi- 
parse,  after  long  and  hard  instrumental  deliveries,  breech  cases,  in  premature  or 
atelectatic  infants;  it  is  more  common  in  boys  than  in  girls,  and  in  the  children 
of  young  mothers;   it  may  be  a  familial  characteristic. 

The  jaundice  is  probably  due  to  the  action  of  several  causes.  Since  bile  acids 
have  been  found  in  the  pericardial  fluid,  the  liver  must  be  causative  of  the  icterus. 
This  hepatogenic  action  is  aided  by  the  increased  destruction  of  red  blood-cor- 
puscles, which  occurs  in  the  first  weeks,  though  most  authors  do  no,t  believe  that 
the  jaundice  is  entirely  hematogenic  in  origin. 

There  are  many  theories,  for  example — (1)  Obstruction  of  the  ductus  chole- 
dochus  by  mucus  or  epithelium;  (2)  edema  of  Glisson's  capsule;  (3)  changes  in  the 
circulation  of  the  blood  in  the  liver;  (4)  absorption  of  the  bile  from  the  intestines, 
which  maj^  take  place  directly  into  the  blood  or  the  general  circulation,  as  a  result 
of  the  persistence  of  the  ductus  Arantii ;  deficient  excretion  of  bile  (Hess) . 

Infection  has  been  given  as  a  cause,  and  for  severe  cases  is  usually  active. 
Gessner  believes  that  infection  of  the  umbilicus  will  explain  many  cases,  and  in 
this  the  author  fully  agrees.     Intestinal  infection  will  explain  more  of  them. 

The  prognosis  is  good  in  the  simple  icterus,  but  one  should  reserve  expression 
of  opinion  until  the  severe  forms  of  disease  are  excluded.  It  is  wise  to  regard  all 
cases  of  jaundice  as  significant,  and  examine  the  infant  carefully  to  exclude  syphilis, 
sepsis,  etc. 

The  treatment  is  symptomatic.  It  has  seemed  to  the  author  that  the  cases 
get  better  quicker  on  treatment  directed  to  intestinal  disinfection — castor  oil, 
followed  by  calomel,  with  gastric  and  colonic  lavage. 


LOCAL  CHANGES 

Separation  of  the  Cord. — At  the  insertion  of  the  cord  into  the  belly  the  amnion 
covering  the  cord  passes  into  the  skin.  If  the  skin  runs  up  onto  the  cord,  it  is 
called  "skin  navel";  if  the  amnion  runs  down  onto  the  abdomen,  ''amnion  navel," 
the  latter  being  rare.  Vessels  from  the  arteries  of  the  abdomen  make  a  circle 
around  the  navel  and  send  up  tiny  branches  which  end  yV  to  ^  inch  on  the  cord 
itself.  The  piece  of  cord  not  in  connection  with  this  circulation  must  necrose  and 
fall  off. 

After  a  few  hours  one  can  see  evidences  of  a  reactive  inflammation  at  the  point 
of  union  of  dead  and  living  tissue,  the  skin  around  the  insertion  of  the  cord  becoming 
red  and  swollen.  White  blood-corpuscles  wander  out  and  soften  the  cord  at  its 
junction  with  the  body  until  a  layer  of  granulations  is  fully  formed  separating  the 
cord  at  its  base.  The  dried  stump  finally  drops  off,  the  arteries  giving  way  first, 
and  then  the  vein.  The  surface  of  the  navel  is  covered  with  very  fine  granulations; 
the  center  is  retracted,  the  sides  falling  in;  epithelium  forms  over  the  surface  very 
quickly,  and  the  navel  is  thus  cicatrized.  The  cord  drops  off  from  the  fourth  to  the 
twelfth  day.  The  majority  of  authors  give  the  average  as  the  fifth  day.  Our 
ex-perience  has  been  much  different.  With  the  older  methods  of  treatment  of  the 
stump  it  was  exceptional  for  the  cord  to  drop  off  before  the  end  of  the  week.  Now 
the  cord  is  tied  close  to  the  insertion  in  the  skin  (but  not  involving  it),  and  under 
a.septic  treatment  it  falls  off  in  three  to  six  days — seldom  later  than  the  eighth. 

There  are  two  ways  in  which  the  cord  behaves — mummification  and  moist 
gangrene.     The  first  occurs  when  the  cord  is  kept  warm  and  dry,  the  second  when 


THE    PHYSIOLOGY    OF   THE    NEW-BORN    CHILD  335 

it  is  wrapped  in  oilv'  diossings  and  evaporation  is  prevented.  The  drying-up  of 
the  cord  is  more  conunoii,  less  dangerous,  and  is  to  befavor(;d.  A  large,  thick  cord 
dries  up  late,  and  some  authors  advise  to  strip  all  the  jelly  of  Wharton  from  the 
cord,  so  as  to  favor  the  rapid  mummiiication. 

The  umbilical  vein  collapses,  the  walls  adhere,  and  normally  there  is  no  throm- 
bosis. The  hypogastric  arteries  collapse,  and,  owing  to  the  thick  muscular  layer, 
are  (iuit(;  ol)literate(l,  but  a  small  clot  almost  always  is  found  in  them.  This  should 
not  i)resent  the  appearance  of  pus. 

The  staphylococcus,  streptococcus,  and  various  non-pathogenic  bacteria  have 
been  found  in  a  large  proportion  of  cords  of  healthy  children.  They  were  much 
more  in  number  and  much  earlier  found  in  the  days  when  moist  gangrene  of  the 
cord  commonly  occurred.  The  method  of  dressing  the  navel  had  a  great  deal  to 
do  with  it. 

Separation  of  the  cord  takes  place  earlier  in  large,  strong  children,  later  in 
premature  childnni;  earlier  in  healthy  children,  later  in  sick  children;  later  if  wet, 
earlier  if  dry,  gangrene  of  the  cord  occurs. 

The  sinking  in  of  the  center  of  the  wound  is  due  to  the  retraction  of  the  intra- 
abdominal part  of  the  arteries.  The  healing  of  the  navel  is  complete  on  the  third 
or  fourth  day  after  the  dropping  of  the  cord. 

The  breasts  of  some  new-born  children  show  an  interesting  phenomenon.  On 
the  third  or  fourth  day  they  enlarge,  become  hard,  and  occasionally  secrete  a  little 
watery  milk,  with  yellowish  streaks.  Microscopically,  it  resembles  the  colostrum, 
and  colostrum  corpuscles  may  be  found.  On  the  fifth  or  sixth  day  a  fluid  resem- 
bling milk  in  color  and  taste  may  be  pressed  out.  This  continues  for  two  to  four 
weeks  if  the  gland  be  irritated,  but  if  let  alone,  the  secretion  dries  up  and  disappears. 
In  rare  cases  a  little  fluid  can  be  expressed  after  a  year.  This  condition  must  be 
distinguished  from  true  mastitis  of  the  infant,  a  disease  which  does  occur.  The 
secretion  is  called  by  the  Germans  "Hexen-Milch,"  witch's  milk,  and  occurs  in 
boys  as  well  as  in  girls — really  it  seems  to  occur  oftener  in  boys  than  in  girls;  in 
weak  as  well  as  in  strong  children.  The  cause  of  the  action  of  the  breasts  is  un- 
known. Bayer  believes  it  is  due  to  the  presence  of  the  same  ferment  which  causes 
the  maternal  milk  secretion.  He  has  found  also  an  enlargement  of  the  uterus  of 
the  new-born  girl,  which  he  also  ascribes  to  maternal  influence.  The  breasts  should 
be  let  alone.  Wash  them  with  soap  and  water,  pad  them  lightly  with  cotton, 
and  tie  a  bandage  over  them.     Do  not  squeeze  them. 

In  about  1  case  out  of  20  the  female  infant  will  present  a  phenomenon  resem- 
bling menstruation.  The  flow  may  last  from  one  to  six  days,  and  be  very  slight  or 
profuse.  It  usually  is  not  attended  with  symptoms,  but  if  very  free,  may  produce 
evident  malaise  in  the  child.  This  pseudo-menstruation  is  more  common  in  the 
children  of  primiparse,  after  prolonged  and  operative  and  breech  deliveries,  and  may 
be  associated  as  a  symptom  with  hemorrhage  into  the  brain.  Its  causes  are  vari- 
ous. Perhaps  it  may  be  the  result  of  stimulation  of  the  ovaries  by  parturition, 
and  have  analogy  with  the  enlargement  of  the  l;)reasts  and  uterus  aliove  referred  to. 
Perhaps  the  child  has  absorbed  some  of  the  internal  ovarian  secretion  of  the  mother. 


CHAPTER  XXV 
THE  CARE  OF  THE  CHILD 

While  the  third  stage  of  labor  is  being  conducted,  and  the  accoucheur  and 
nurse  are  devoting  their  attention  to  the  mother,  the  infant  hes  in  its  crib,  securely 
and  warmly  wrapped  up,  or  is  given  in  the  care  of  a  relative  or  neighbor,  who  is  in- 
structed to  look  at  the  navel  occasionally  for  possible  bleeding  and  see  that  the  infant 
does  not  choke  with  mucus.  After  the  confinement  room  is  set  to  rights,  the  nurse 
takes  the  baby  and  dresses  it,  preferably  in  an  adjoining  apartment,  to  avoid  dis- 
turbing the  sleeping  mother.  First  the  whole  body  is  rubbed  with  warm,  sterile, 
solid  albolene  or  benzoinated  lard,  paying  particular  attention  to  the  places  where 
the  vernix  accumulates.  The  fat  dissolves  the  vernix,  and  the  little  body  is  now 
smoothly  rubbed  clean  with  a  soft  towel.  No  bath  is  given.  Next  the  stump  of 
the  cord  and  the  navel  region  are  washed  with  1  :  2000  bichlorid  or  95  per  cent, 
alcohol,  and  the  wound  dressed  with  sterilized  gauze,  a  sterile  belly-band  being 
put  over  this  primary  surgical  dressing.  Then  the  eyes  are  treated  after  Crede's 
or  some  prophylactic  method,  if  this  has  not  been  clone  before,  and  the  child  quickly 
and  warmly  dressed,  after  which  it  is  placed  in  its  crib,  with  a  warm-water  bag  at 
its  feet.  All  this  must  be  done  near  a  fire,  away  from  chilling  drafts,  and  the  navel 
must  be  dressed  with  sterile  hands  if  the  wound  is  touched  with  the  fingers. 

The  Bath. — Long  custom  prescribed  a  daily  bath  for  the  child.  This  is  not 
to  be  recommended,  because  the  infant  is  likely  to  be  chilled  and  the  wash-water 
may  get  to  the  eyes,  navel,  vulva,  and  mouth,  causing  infections;  further,  the  poor 
soaps  often  used  may  cause  eczema  and  various  skin  eruptions. 

Until  the  umbilicus  is  healed,  the  child  should  not  be  given  a  tub-bath.  The 
head  and  face  are  sponged  daily  with  lukewarm  water,  using  a  little  Castile  soap, 
if  necessary.  The  buttocks,  when  soiled,  are  sponged  with  cool  water.  The  body 
is  gently  rubbed  with  benzoinated  lard;  this  is  removed  by  means  of  a  soft  towel, 
and  this  is  usually  all  that  is  needed  to  keep  the  infant  sweet  and  clean.  After  the 
cord  is  off  and  the  navel  cicatrized,  the  child  is  given  a  full  bath.  In  summer  the 
child  may  be  given  a  sponge-bath  instead  of  the  oiling,  because  the  perspiration  and 
fat  macerate  the  skin. 

Dusting-powders  are  usually  not  needed,  as  with  good  care  the  infant  will  not 
chafe.  One  of  the  best  of  these  is  stearate  of  zinc.  In  hospitals  the  nurses  must 
be  made  aware  of  the  dangers  of  carrying  skin  diseases  and  infections,  especially 
syphilis,  from  one  child  to  another,  and  they  should  be  instructed  to  report  at  once 
any  evidences  of  disease  on  the  child. 

Attention  to  the  Cord. — The  navel  is  treated  like  any  surgical  open  wound. 
While  the  binder  is  changed  as  often  as  it  becomes  soiled,  the  dressing  of  the  cord 
is  not  disturbed  unless  it  has  been  dislodged  or  gotten  wet.  After  soaking  off  the 
gauze  with  1 :  2000  bichlorid,  the  stump  is  washed  with  95  per  cent,  alcohol,  and  a 
new  dry  gauze  dressing  applied.  Dusting-powders  are  not  used  unless  the  stump 
shows  signs  of  moist  gangrene,  when  a  mixture;  of  1  part  salicylic  acid  to  20  parts 
f)f  starch  (sterilized)  is  applied.  A  wet  dressing  of  50  per  cent,  alcohol  applied  for 
six  hours  will  usually  cure  it,  and  is  recommended  especially  for  signs  of  infection 
around  the  stump.  During  all  these  manipulations  the  nurse  does  not  touch  the 
wound  unless  she  sterilizes  her  hands.     Sterile  applicators  are  used. 

The  Eyes. — Only  the  outside  of  the  eyelids   is  washed  with  a  little  sterile 

336 


THE    CAUK    (^1'    TIIK    CHILD  337 

water,  or,  what  is  just  as  j^ood,  sterile  boric  solution.  Unless  there  is  some  irrita- 
ti(Mi  or  infection  of  the  eyes,  the\'  do  not  need  any  treatment.  The  nurse  is  to  be 
instructed  to  report  at  once  by  telephone  or  messenger  the  first  sign  of  inHanmiation 
of  the  conjunctiva. 

The  Bowels. — The  author  recommends  the  routine  administration  of  10  drops 
of  castor  oil  to  the  infant  on  the  day  after  the  day  of  birth.  This  evacuates  the 
meconium  and  any  matters  swallowed  during  delivery,  and  does  nuich  to  prevent 
colic.  Later  an  occasional  repetition  of  the  dose,  and  salt  solution  colonic  flush- 
ings, given  with  a  funnel  attached  to  a  soft-rubber  catheter,  will  keep  the  intestinal 
tract  in  order.  The  mouth  and  tongue  are  not  cleansed  unless  required,  and  then 
with  gentleness,  to  avoid  rubbing  off  the  delicate  epithelium.  Wounds  thus  pro- 
duced may  form  the  atrium  of  infection,  especiallj^  at  the  pillars  of  the  fauces 
(Bednar's  aphtha;).  Excoriation  of  the  anal  region  seldom  occurs  with  breast- 
feeding, ])ut  is  usual  mth  bottle-feeding.  Absolute  cleanliness  of  the  parts,  fre- 
quent change  of  the  diaper,  the  invariable  use  of  washed,  well-rinsed,  and  ironed 
diapers,  cool  ablutions,  avoidance  of  friction,  moderate  use  of  dusting-powders, 
as  stearate  of  zinc,  will  do  much  to  prevent  and  cure  the  intertrigo,  but,  best  of 
all,  will  be  the  procuring  of  a  proper  food  for  the  infant. 

Urination. — If  the  infant  does  not  urinate  within  twelve  hours,  the  parts  are 
to  be  examin(>d  for  congenital  deformity.  A  tight  prepuce  is  almost  never  the  cause. 
Either  the  infant  has  not  had  enough  water  or  food,  or  it  passes  water  unobserved 
in  its  bath,  or  has  an  attack  of  renal  congestion,  perhaps  even  nephritis.  In  such 
cases  uric-acid  infarct  is  usually  found.  Sepsis  may  also  cause  anuria,  also  absorp- 
tion of  toxins  from  the  bowel  and  all  febrile  affections.  The  treatment  is  on  general 
lines — free  catharsis,  administration  of  much  -water,  moderate  use  of  mother's 
milk,  warm  fomentations  over  the  bladder  and  kidneys,  a  sitz-bath,  a  prolonged 
colonic  flushing,  and,  finally,  the  catheter.  The  author  had  one  case  where  a  female 
child,  apparently  healthy,  passed  no  urine  for  three  days.  Catheterization  brought 
a  few  drams  of  thick,  highly  colored  urine,  after  which  the  function  became  normal. 
The  brick-dust  sediment  in  the  urine  and  on  the  diaper  consists  of  uric-acid  crj'stals 
or  ammonium  urate.  They  may  cause  pain  during  voiding  and  they  indicate  the 
need  of  more  water. 

The  Feeding. — Eight  to  twelve  hours  after  birth  the  child  is  put  to  the  breasts, 
as  usually  l)y  this  time  the  mother  has  rested.  Thereafter,  until  the  milk  comes  in, 
the  infant  nurses  every  four  hours,  and  then  every  three  hours  for  the  first  two  weeks, 
after  which  the  period  is  lengthened  to  three  and  one-half  hours.  No  attempt  is 
made  to  sterilize  the  child's  mouth  by  washing,  because  it  is  impossible  and  harm- 
ful, and  invites  the  infection  it  seeks  to  avoid.  The  nursing  lasts  ten  to  fifteen 
minutes,  and  the  nurse  must  be  sure  that  the  infant  really  swalloAvs  the  milk.  It 
is  occasionally  necessary  to  give  water  between  the  feedings,  but  the  nurse  is  to  be 
advised  of  the  uselessness  and  dangers  of  the  habit  of  water-tippling.  The  child 
really  needs  little  extra  liciuid.  If  the  child  does  not  take  the  breast  willingly,  an 
investigation  may  reveal  a  poorly  shaped  nipple,  a  too  full  breast,  difficult  flow  of 
milk,  milk  that  does  not  agree  with  the  child,  and  which  it  instinctively  refuses,  salty 
or  bitter  milk,  or,  finally,  there  may  be  none  in  the  breast.  Much  patience  is 
required  to  teach  the  infant  how  to  suck,  and  wide  differences  exist  in  the  capa- 
bilities of  nurses  to  do  this.  If  there  is  any  doubt  of  the  child  getting  enough 
nourishment,  it  should  be  weighed  before  and  after  each  feeding. 

For  the  first  few  daj'S  water,  an  ounce  every  two  hours,  and  the  colostrum  from 
the  lireasts  usually  suffice  for  the  wants  of  the  infant,  but  if  it  should  cry  from 
hunger,  a  dram  of  cream  to  an  ounce  of  water  or  a  very  weak  milk  of  ''peptogenic 
powder"  may  be  given.  In  hospitals  the  infant  may  obtain  an  occasional  feeding 
from  one  of  the  other  mothers  until  its  own  mother  has  milk.  The  possibility  of 
the  contagion  of  syphilis  in  maternities  must   never  be  forgotten.     The  author 


338 


THE    PHYSIOLOGY    OF   THE    NEW-BORN    CHILD 


is  very  skeptical  regarding  the  "starvation  fever"  so  often  mentioned  as  occurring 
at  this  period.  Probably  most  of  such  temperatures  are  due  to  infection — intes- 
tinal, bronchial,  faucial,  or  from  the  navel. 


AHLFELD'S  TABLE 


Number  of 
Nursings 

1st  day 2 

2d  ••    5 

3d  ••    6 

4th  "    7 

oth  •■    G 

6th  '■    7 

7th  '•    6 

Sth  "    7 

9th  "    6 

10th  "    7 

11th  "    6 

12th  "    6 

13th  "    7 

14th  "    7 

15th  "    6 

16th  "    7 

17th  "    7 

18th  "    6 

19th  "    7 

20th  "    6 

21st  "    7 


Average  Amount 

Drunk  at 

Each  Nursing 

2.5  grams 

29.0  " 

41.0  " 

58.8  " 

67.5  " 

73.0  " 

92.2  " 

97.0  " 

93.0  " 

86.0  " 

96.0  " 

93.0  " 

86.0  " 

91.0  " 

93.0  " 

90.0  " 

92.0  " 

96.0  " 

105.0  " 

112.0  " 

102.0  " 


Total 

Grams 

5.0 

grams 

149.0 

246.0 

" 

401.6 

11 

405.0 

ti 

511.0 

" 

553.2 

11 

589.0 

ti 

558.0 

It 

602.0 

it 

576.0 

a 

558.0 

a 

602.0 

" 

637.0 

u 

558.0 

u 

630.0 

it 

644.0 

<i 

576.0 

" 

735.0 

ti 

672.0 

it 

714.0 

tt 

Total 

Ounces 

1% 

dram 

4y2 

oz. 

81/4 

ISVs 

131/2 

17 

I81/2 

23 

18% 

20 

191/5 

18% 

20 

211,4 

18% 

21 

21^2 

191/5 

241/2 

22% 

23% 

Without  doubt  the  best  food  for  the  infant  comes  from  its  mother's  breasts, 
and  if  she  be  absolutely  unable  to  nurse,  before  employing  artificial  food  a  wet- 
nurse  should  be  obtained. 

Weighing  the  Infant. — The  child  should  be  weighed  directly  after  birth,  and 


J^-*--"*-  //^  -  /T 


URINE  ^    j:^        ~  '     I         V  t7- 


FiG.  .33.3. — Infant's  Record.     Dotted  Line  Shows  Weight. 


daily  for  several  weeks.  The  beautiful  "baby  scales"  on  the  market  are  quite 
impractical,  and  should  be  replaced  by  the  ordinary  grocers'  scale  with  a  scoop,  iron 
weights,  and  a  scale-bar  for  the  ounces. 

Temperature,  Pulse,  and  Respiration. — The  first  of  these  must  be  taken  twice 


THE    CARE    OF   THE    CHH.D  339 

daily,  and  the  others  occasionally,  all  of  which  is  to  Ix?  recorded  (Fig.  33o)  on  the 
history  sheet,  the  same  as  for  the  in(jthcr. 

General. — A  quiet,  undisturbed,  ordered  life  is  to  he  provided  the  new  indi- 
vidual, as  habits  formed  now  are  permanent.  Plenty  of  fresh  air  is  as  necessary 
for  the  infant  as  for  the  adult,  and  without  doubt  most  babies  are  cuddled  too  much. 
It  should  sleep  in  a  room  with  a  temperature  of  from  68°  to  72°  F.,  and  for  the  first 
f(nv  weeks  its  eyes  should  b(!  protected  from  bright,  glary  light.  It  is  not  to  l;e  dis- 
turbed except  for  attentions  to  itself,  and  when  being  lifted,  should  be  guarded 
against  injury.  The  nurse  must  be  instructed  not  to  let  the  nursling  get  into  bad 
habits — watcr-tijipling,  pepi)ermint-water  tippling,  whisky  and  water  and  creme-de- 
menthe  tippling,  sucking  on  the  finger,  nursing-bottle,  or  nipple,  slecjping  with 
mother,  being  taken  up  when  it  cries,  or  rocked,  held,  and  carried  except  w'hen  sick. 
By  proper  training  the  child  can  be  taught  regular  habits,  to  sleep  all  night  and  be- 
tween nursings,  and  to  cry  only  when  hungry,  uncomfortable,  or  sick. 

During  his  professional  visit  the  physician  pays  some  attention  to  the  infant 
also.  He  must  especially  discover  the  first  signs  of  malnutrition,  because,  unless 
this  is  early  remedied,  structural  changes  occur  in  the  intestinal  mucosa  and  the 
general  sj'^stcm  which  may  leave  an  impress  for  bad  on  the  child's  whole  life.  This 
is  the  reason  the  author  insists  so  strongly  on  the  wet-nurse  when  the  mother  can- 
not nourish  her  offspring.  The  physician  watches  the  physiologic  changes  which 
adapt  the  child  to  extra-uterine  existence,  and  decides  each  day  if  they  are  pro- 
ceeding normally.     The  condition  of  the  navel  claims  his  special  attention. 

Summary  of  the  Care  of  the  Infant 

1.  Asepsis  and  antisepsis  of  the  navel,  eyes,  and  orifices  of  the  body. 

2.  Watching  for  evidences  of  sickness. 

3.  Attention  to  emunctories — bowels,  kidneys,  and  skin. 

4.  Feeding  and  nutrition. 

5.  The  healing  of  the  navel. 

Literature 

Halban  and  Landsteiner:  Miinch.  med.  Woch.,  1902,  No.  12,  p.  473. — Hess:  Amer.  Jour.  Children's  Diseases, 
May,  1912.— Sei^^;  Die  fetalen  Herztone,  Tiibingen,  1903;  Handbuch  der  Geb.,  vol.  ii,  1,  306.— TFar^eW; 
American  Medicine,  September  20,  1902. 


PART  II 

THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE 

PUERPERIUM 


CHAPTER  XXVI 
THE  PATHOLOGY  OF  PREGNANCY 

It  would  be  surprising  if  a  function  which  causes  such  marked  general  and  local 
changes  as  gestation  does  should  be  completed  without  the  production  of  conditions 
that  might  be  considered  pathologic.  Pregnancy  does  not  confer  immunity  against 
am'  disease;  on  the  contrary,  it  makes  the  woman  susceptible  to  certain  general 
diseases,  and  almost  always  aggravates  existing  general,  and  especially  local, 
affections.  Only  seldom  do  we  hear  that  patients  feel  better  during  pregnancy: 
the  majority  suffer  more  or  less  discomfort.  Many  conditions  formerly  classed 
as  normal  are  now  called  pathologic. 

The  affections  of  pregnancy  are  broadly  divided  into  those  of  the  mother  and 
those  of  the  ovum.  Of  diseases  of  the  mother,  two  grand  divisions  are  made — 
the  general  and  the  local,  the  latter  taking  in  all  the  affections  of  the  uterus,  decidua, 
vagina,  etc.  Both  general  and  local  diseases  may  be  classified,  first,  as  to  whether 
they  are  only  morbid  exaggerations  of  conditions  natural  to  normal  pregnancy — 
that  is,  they  are  incidental  to  pregnancy,  are  disorders  of  pregnancy;  and,  second, 
as  to  whether  the  diseases  are  accidental  complications,  either  preexistent  or  de- 
veloped during  pregnancy.  The  general  diseases  incident  to  pregnancy  are  most 
likely  to  be  disorders  of  those  functions  most  concerned  by  gestation,  for  example, 
the  general  metabolism,  the  liver  and  kidneys,  the  blood.  Examples  of  accidental 
diseases  are  smallpox,  tuberculosis,  and  syphilis. 

Local  diseases  incident  to  pregnancy  manifest  themselves  in  pathologic  in- 
crease of  the  congestion  of  the  parts,  abnormal  tissue  growth,  deformation  of  the 
uterus,  displacements,  unusual  location  of  the  ovum,  etc.  Of  diseases  of  the  ovum, 
we  must  consider  those  of  the  child  and  those  of  the  fetal  envelops,  the  chorion, 
the  amnion,  the  placenta. 

Most  of  the  diseases  of  the  mother  and  child  have  close  relations — one  can 
hardly  be  ill  without  affecting  the  other.  A  great  many  general  diseases  have  local 
manifestations  in  the  genitalia,  and  many  diseases  accidental  to  pregnancy  aggra- 
vate the  affections  incidental  to  pregnancy.  The  reader  may  thus  appreciate  the 
difficulties  of  making  a  classification  of  them  and  adhering  to  it  in  the  subsequent 
discussion  of  the  subjects. 

Classification — Pathology  of  Pregnancy 

Diseases  of  the  Mother  Incidental  to  Pregnancy. — General. — Toxemia;  hy- 
peremesis  gravidarum;  ptyalism;  gingivitis;  eclampsia;  the  kidney  of  preg- 
nancy; acute  yellow  atrophy  of  the  liver;  chorea;  l)lood  affections;  skin  diseases, 
such  as  pruritus,  fibroma  molluscum,  herpes  gestationis,  impetigo  herpetiformis. 

Local. — Varicosities;    relaxation  and  softening  of  the  pelvic  joints;     extra- 

340 


THE  PATHOLOGY  OF  PREGNANCY  341 

uterine  prej^naiu'y;  angular  pregnancy;  retroflexion  (jf  the  gravid  uterus;  ante- 
fixation  of  the  uterus;   abortion;   abruptio  i)hicentie;   jjiacenta  pricvia. 

Diseases  of  the  Mother  Accidental  to  Pregnancy. — General. — The  exantlie- 
mata — measles,  scarlatina,  typhoid,  etc.;  sepsis;  syphilis;  diseases  of  the  lungs — 
tuberculosis,  pneumonia,  etc.;  of  the  heart;  of  the  kidneys;  of  the  liver;  traumatism. 

Local. — Deformities  of  the  uterus;  tiie  local  inflammations — vulvitis,  vaginitis, 
cervicitis,  endometritis,  peritonitis,  gonorrliea;  tumors,  as  fibroids,  carcinoma, 
ovarian  cysts. 

Diseases  of  the  Ovum. — The  Child. — Monsters  (teratology);  disorders  of  the 
mother  which  affect  the  child;   the  injuries  of  the  fetus.  , 

The  Membranes. — Hydatidiform  mole;    polyhydramnion;   oligohydramnion. 

Placenta. — Abnormal  shape,  size,  and  number;  the  white  infarct;  syphilis; 
edema;  calcification. 

Naturally,  in  a  work  of  this  size  it  will  be  impossible  to  treat  all  the  above 
affections,  nor  ^^dll  the  scheme  here  given  be  strictly  followed.  Diseases  duplicated 
under  different  headings  will  be  considered  together — for  example,  sjqohilis  of  the 
mother,  of  the  child,  of  the  placenta,  and  of  the  decidua  will  be  treated  as  one  sub- 
ject. The  author  also  considers  it  best  to  treat  a  disease  which  afTects  pregnancy, 
labor,  and  the  puerperium  consecutively  in  a  single  chapter,  rather  than  to  discuss 
it,  as  it  influences  each  stage  separatel}'',  in  three  different  parts  of  the  volume. 


CHAPTER  XXVII 
THE  TOXEMIAS  OF  PREGNANCY 

Toxemia  is  a  term  which  has  obtained  very  general  usage,  though  Httle  is 
positively  known  about  the  conditions  it  represents.  It  means  that  the  blood 
contains  toxins  or  poisons  of  an  alkaioidal  nature,  leukomains,  or  substances  similar 
to  these.  These  toxins  are  supposed  to  be  the  result  of  deficient  or  abnormal  general 
metabolism,  or  morbid  processes  occurring  in  special  organs,  as  the  liver,  the  kid- 
ney's, the  thyroid;  again,  the  poisons  are  supposed  to  come  from  the  fetus  or  the 
placenta,  from  abnormal  chemism  occurring  here.  As  a  result  of  the  deficient 
action  of  some  organs  of  the  body,  for  example,  the  liver,  the  kidneys,  the  thyroid, 
and  perhaps  others  of  the  ductless  glands,  these  poisons  are  retained  in  the  body, 
or  they  are  not  sufficiently  oxidized  or  changed  so  as  to  be  rendered  harmless  and 
eliminable  by  the  emunctories. 

Such  is  the  theory,  and  to  explain  why  and  how  these  changes  originate  we 
have  other  theories.  Many  authors  believe  that  every  pregnancy  is  attended  by 
an  auto-intoxication,  due  to  the  mighty  changes  in  the  general  metabolism  incident 
to  the  condition,  the  active  chemism  required  for  the  transfer  of  materials  for  the 
growth  of  the  fetus,  the  presence  in  the  maternal  blood  of  the  waste  of  the  child, 
the  by-products  of  the  exaggerated  eliminative  action  of  the  special  organs,  liver, 
kidneys,  spleen,  etc. 

The  constitution  of  a  perfectly  healthy  woman  might  meet  all  these  demands 
without  any  external  symptoms  or  signs  of  disease,  but  such  individuals  are  very- 
rare,  and,  therefore,  evidences  of  impaired  function,  of  toxemia,  are  quite  common. 
Predisposing  elements  for  toxemia  are  neurasthenia,  anemia,  vicious  heredity, 
especially  one  of  toxic  neuroses,  antecedent  liver,  kidney,  thyroid,  intestinal,  or 
other  organic  disease.  Insufficient  internal  secretion  by  the  ovary  has  been  cited 
as  a  cause.  Intestinal  auto-intoxication  is  generally  admitted,  and  perhaps  the 
liver  here  is  at  fault,  not  arresting  nor  elaborating  the  absorbed  poisons  as  it  should. 

Veit  says  the  transportation  and  dissolution  of  syncytial  elements  of  the  placenta  produce 
syncytio-toxins,  which,  if  not  properly  met  by  antibodies  in  the  patient's  blood,  act  injuriously. 

Kxperiments  by  Engelman  and  Frankel  have  shown  that  the  placenta  contains  thrombo-. 
genie  ferments  which  are  rapidly  fatal  to  rabbits,  but  that  when  these  are  neutralized  by  hirudin 
(leech  extract),  the  juice  of  the  placenta  is  non-poisonous. 

Bacterial  action  is  also  said  to  cause  the  toxemia — plausible,  but  lacks  proof.  Albert  be- 
lieves that  endometritis,  infective  in  origin,  produces  toxins  which,  absorbed,  may  cause  toxemia, 
hypereraosis,  and  even  eclampsia.     Some  cases  seem  to  favor  belief  in  this  theory. 

The  name  of  Bouchard  is  most  often  associated  with  these  studies  on  autointoxication,  for 
he  has  done  a  great  deal  of  work  on  the  subject.  He  sought  to  prove  a  relation  between  the  toxi- 
city of  the  blood  and  of  the  urine — deficient  excretion  showing  increase  in  the  former.  Animals 
into  which  filtered  urine  of  pregnant  women  was  injected  had  convulsions  and  died,  autopsy  show- 
ing the  .same  conditions  observed  in  the  human. 

Later  experiments  disproved  these  assumptions.  Pinard  and  Bouffe  de  St.  Blaise  ascribed 
the  symptoms  to  a  hepatotoxemia. 

We  have  as  yet  very  few  scientific  facts  on  which  to  base  all  these  hyjootheses, 
but,  while  desirable  for  practice,  it  is  not  unconditionally  necessary  to  have  every 
theory  proved.  The  general  applicability  is  sometimes  proof  itself.  We  recog- 
nize many  groups  of  symptoms  which  can  Ix'  most  satisfactorily  explained  by  this 
theory  of  toxemia,  and  treatment  directed  in  appropriate  lines  is  successful  in  re- 
lieving the  conditions.  Some  of  the  affections  bear  resemblance  to  certain  phe- 
nomena explained  as  being  anaphylactic. 

342 


THE  TOXKMIAS  ()V    PREGNANCY  343 

Symptomatology.-  'I'wo  j^ioiips  of  symptoms  may  bo  distinguished — tli<' miid 
and  the  severe,  but  triinsitiou  lonns  lire  coinnuni. 

As  mild  toxemias,  many  of  the  minor  comj)laints  of  pregnancy  may  be  classed. 

The  Nervous  System. — Headaclu?,  dizziness,  hyperexcitability,  lassitude,  ten- 
dency to  melancholia,  exaggeration  of  reflexes,  nmscular  twitchings,  cramps  in  mus- 
cles, neuralgias,  neuritis,  aberrations  of  the  special  senses,  as  of  taste  (pica),  of  sight 
(restricted  vision),  and  of  smell. 

The  Skin. — Edema,  i)ruritus,  ])igMientati(ju,  various  erui)tioiis,  for  examjjje, 
herpes,  pruriginoid  lesions,  ixcno,  red  nose.  Graver  symptoms  will  be  considered 
later. 

Digestive  Canal. — Nausea,  vomiting,  constipation,  colic. 

Circulatonj  Syste??!. — Palpitations,  syncope,  varices,  enlarged  thyroid,  symp- 
toms resembling  "formes  frustes"  of  Basedow's  disease,  anemias. 

Respiratory  System. — Cough,  asthmatic  attacks. 

Bones. — The  puerperal  osteoph^i^es,  softening  of  the  bones,  similar  to  osteo- 
malacia, pains  in  the  bones,  perhaps  due  to  alteration  in  the  hematopoietic 
system  (?). 

The  Urinary  System. — The  kidney  of  pregnancy  (Leyden),  albuminuria, 
oliguria,  decreased  urea  output. 

General  examination  of  th(^  patients  will  usually  show  the  evidences  of  deficient 
excretion,  pasty  or  muddy  skin,  even  subicterus,  with  perhaps  an  odor;  dry, 
coated  tongue,  reddened  gums,  pulse  of  low  tension,  tympany,  tender  liver,  and 
urinary  findings.  The  pathologic  anatomy  of  these  toxemias  has  never  been 
studied  because  they  are  not  fatal.  The  severer  toxemias  have  l)een  much  investi- 
gated, and  we  may  deduce  from  such  findings  the  probable  conditions  in  the  milder 
forms. 

The  treatment  of  mild  toxemias  is  symptomatic  and  general,  directed  toward 
the  increase  of  elimination,  restriction  of  nitrogenous  food,  and  hygienic  living. 
Prevention  of  the  graver  toxemias,  the  hint  of  w^hich  is  contained  in  the  milder 
manifestations,  is  important.  If  the  history,  family  or  personal,  points  to  such 
tendency,  closer  supervision  of  the  gravida  is  needed.  The  consistent  examination 
of  the  urine  throughout  pregnancy  and  the  watchfulness  over  the  patient,  fully 
described  under  the  Hygiene  of  Pregnancy,  will  disclose  threatening  dangers  if 
the  rules  laid  down  for  the  guidance  of  pregnant  women  have  not  prevented  such 
disease  altogether. 

The  graver  toxemias  of  pregnancy  are  hyperemesis  gravidarum,  eclampsia, 
hepatic  autolysis  (fulminant  toxemia),  impetigo  herpetiformis,  etc. 


HYPEREMESIS  GRAVIDARUM 

Nausea  and  vomiting  occur,  in  greater  or  less  degree,  in  half  of  all  pregnant 
women,  and  are  considered  normal.  They  may  be  so  marked  as  to  become  serious 
and  deserve  the  appellation  "pernicious,"  leading  not  seldom  to  abortion  or  death, 
or  both.  It  is  difficult,  in  a  given  case,  to  tell  when  the  vomiting  passes  from  the 
normal  to  the  pathologic.  The  disease  has  been  called  the  obstinate,  the  uncon- 
trollable, the  incoercible,  vomiting  of  pregnancy,  Init  the  term  hyperemesis  gravi- 
darum, though  a  hybrid,  is  the  one  generally  used. 

Soranus,  of  Ephesus  (20  a.  d.),  observed  the  disease,  but  Delorme,  in  the 
nineteenth  century,  called  attention  to  the  danger  of  the  affection.  Sinunond, 
in  1813,  was  the  first  to  interrupt  pregnancy  as  a  therapeutic  measure,  and  with 
success.  Paul  Dubois,  in  1852,  before  the  French  Academy  of  ]Medicine,  pre- 
sented a  thesis  on  the  subject  which  is  still  classic.  It  is  said  that  Charlotte  Bronte 
died  of  this  affection. 

Symptoms. — The  disease  usually  begins  in  the  second,   more  rarely  in  the 


344      THE  PATHOLOGY  OF  PEEGNANCY,  LABOR,  AND  THE  PUERPERIUM 

fourth,  month,  but  may  appear  in  the  sixth  month,  though  seldom  after  this,  and 
if  it  does,  one  suspects  nephritis.  It  lasts  from  six  weeks  to  three  months,  but  may 
take  so  violent  a  course  as  to  be  fatal  in  two  weeks.  It  may  also  intermit  for  a 
few  weeks,  then  recur,  growing  better,  then  worse. 

Dubois  distinguished  three  periods  in  the  sickness,  and  while  clinically  the 
lines  of  separation  are  never  sharp,  such  a  division  of  symptoms  is  useful  for  purpose 
of  description.  At  first  attention  is  not  called  to  the  gravida  because  nausea  and 
vomiting  are  such  frequent  occurrences  in  the  early  months,  but  when  the  intoler- 
ance of  the  stomach  for  all  liquids  and  foods  becomes  apparent  and  the  patient 
loses  her  appetite,  one  is  forced  to  recognize  that  the  state  of  the  gravida  is  serious. 
The  anorexia  may  become  an  actual  loathing  of  food,  and  nausea,  with  retching, 
may  occur  at  the  mere  mention  or  sight  or  smell  of  it.  Emesis  is  caused  by  a  mere 
change  of  position  of  the  person,  the  entry  of  another  one  into  the  room,  even  by  the 
sight  of  the  husband.  It  continues  during  the  night,  robbing  the  distressed  woman 
of  sleep,  and  contributing  to  the  exhaustion  caused  by  the  constant  retching. 
Hiccup  may  be  a  troublesome  symptom,  as  may  pyrosis.  Thirst  is  harassing. 
The  patient  complains  of  a  constant  boring  pain  in  the  stomach  and  of  soreness  of 
the  ribs  and  adjoining  muscles.  Salivation  is  occasionally  a  concomitant;  consti- 
pation is  the  rule,  but  sometimes  there  is  diarrhea. 

The  vomit  at  first  is  composed  of  undigested  food,  mucus,  and  a  little  bile, 
later  of  mucus  and  bile;  finally  it  becomes  bloody,  bright,  or  of  coffee-ground  con- 
sistence. In  one  of  the  writer's  cases  the  odor  was  almost  fecal.  The  blood  may 
come  from  the  mouth,  pharynx,  or  stomach,  and  carries  significance  only  if  from  the 
last.  The  urine  is  scanty,  high  colored,  contains  albumin,  casts,  sometimes  blood, 
bile,  acetone,  diacetic  acid,  indican,  and  even  sugar.  It  may  also  show  the  diazo- 
reaction.  The  urea  is  usually  high,  even  4  per  cent.,  but  Williams  believes  that  in 
such  cases  a  large  part  of  the  nitrogen  excretion  is  in  the  form  of  ammonia. 

During  the  second  stage  the  symptoms  become  aggravated,  and  everything  is 
rejected  by  the  stomach;  the  patient  complains  of  intolerable  thirst,  is  extremely 
irritable  and  weak,  has  frequent  fainting  spells,  and  loses  weight  rapidly — in  severe 
cases,  as  much  as  a  pound  a  clay. 

Examination  shows  the  skin  pale,  waxy,  sometimes  icteric,  non-resilient, 
shrunken,  the  patient  emaciated  (only  in  the  chronic  cases ;  the  toxemic  cases  may 
die  before  emaciation  is  pronounced).  The  heart  and  lungs  usually  are  normal, 
the  pulse-beat  is  rapid, — 100  to  140,  weak,  'Hhe  pulse  of  empty  arteries,"— the 
aljdomen  is  scaphoid;  one  can  trace  the  aorta  from  the  epigastrium  to  beyond  its 
bifurcation;  great  tenderness  is  elicited  over  the  cardia  and  sometimes  over  the 
liver.  The  irritating  vomit  has  eroded  the  lips  and  lower  face;  the  gums  are  red- 
dened and  covered  with  sordes;  the  tongue  is  red,  dry,  brown  in  the  middle,  and 
cracked,  sometimes  to  bleeding;  the  pharynx  is  dry,  red,  sometimes  infiltrated 
with  minute  hemorrhages;  the  breath  is  fetid,  and  may  have  a  penetrating  or  a 
soft,  fruity  odor.  Fever  of  a  low  grade,  l)ut  continuous,  is  now  determinable, 
and  symptoms  referable  to  the  nervous  system  usher  in  the  third  stage.  In  some 
cases  the  temperature  remains  subnormal  until  just  Ijefore  death,  when  there  is 
an  agonal  rise.  Dehydration  of  the  blood — thickening — is  shown  by  the  hyper- 
gloh)ulism,  both  reds  and  whites,  and,  when  intense,  may  indicate  the  time  for 
terminating  the  pregnancy  (Devraigne). 

Third  Stage. — Mental  aberration,  delirium,  headache,  somnolence,  stupor, 
and  coma  occur  invariably.  The  vomiting  usually  ceases,  leading  the  attendants 
to  raise  false  hopes,  but  the  pulse  increases  in  frequency,  the  general  prostration 
rapidly  augments,  and  the  patient  dies  under  the  clinical  picture  of  uncontrollable 
vomiting  and  acute  starvation. 

The  length  of  the  three  stages  varies  very  much — the  first  is  long;  the  second, 
longer;    the  third  is  usually  short,  the  patient  rapidly  going  down,  and  herein  fies 


THE   TOXEMIAS    OF    PREGNANCY  345 

a  warniiifi; — not  to  let  tlic  disease  |)roj>;ress  to  the  tliirtl  stage,  because  then  even 
therapeutic  abortion  cannot  stay  it;  on  the  contrar}',  the  interference  may  hasten 
tlie  end.  I'he  disease  lasts  from  four  to  twelve  weeks,  usually  six  weeks,  )jut  it 
may  be  acutely  fatal  in  ten  to  fourt(;en  days.  The  latter  cases  are  of  the 
toxemic  variety. 

During  all  this  disturljance,  local  and  general,  the  fetus  is  usually  alive,  and 
if  delivered  at  term,  may  be  large  and  fat.  If  the  vomiting  is  toxemic,  the  fetus 
is  more  likely  to  suffer,  and  abortion  is  more  apt  to  occur.  The  vomiting  often 
ceases  on  the  death  of  the  fetus. 

Causation.— Curiously,  more  cases  of  tliis  affection  arc  reported  from  the 
United  States  and  France  than  from  CJermany  and  England.  Carl  Braun,  in  an 
experience  of  over  150,000  obstetric  cases,  never  observed  one  of  hyperemesis 
that  was  fatal,  but  McClintock  was  able,  with  a  very  moderate  amount  of  search, 
to  collect  50  fatal  cases.  It  is  more  frequent  and  fatal  in  multiparee  than  in  primi- 
l)ane.  In  the  author's  19  cases,  12  were  multiparse,  and  of  Rosenthal's  100  cases, 
only  33  were  primiparee.  In  discussing  the  cause  of  hyperemesis,  one  must  not 
lose  sight  of  the  generally  increased  nervous  excitability  of  pregnancj^  which  would 
tend  to  exaggerate  the  action  of  any  irritant  located  at  any  part  of  the  body. 
Uncontrollable  vomiting  is  more  common  in  neurotic,  neurasthenic,  and  hysteric 
women,  but  it  is  particularly  likely  to  develop  if  there  is  some  irritant  which  may 
act  on  the  stomach  via  the  nervous  system  or  blood.  A  study  of  my  cases  of  hyper- 
emesis and  of  milder  gastric  chsturbances  shows  four  more  or  less  distinct  classes : 
(1)  Those  in  which  the  vomiting  is  a  reflex  from  the  genitalia;  (2)  when  it  is  due 
to  some  disease  of  the  stomach,  some  abdominal  disorder,  or  abnormal  condition 
of  the  blood;  (3)  where  the  nervous  system  is  at  fault;  (4)  where  the  general 
metabolism  is  disturbed,  the  chnical  picture  being  that  of  a  toxemia. 

1.  The  reflex  theory  of  hyperemesis  explains  many  cases,  and  appropriate 
treatment  often  is  curative.  Owing  to  the  close  nervous  connections  between  the 
genitalia  and  stomach  by  way  of  the  sympathetic  and  vagus,  reflexes  through  this 
arc  are  easy,  as  many  common  examples  show.  Examples  of  peripheral  irritants 
capable  of  causing  the  vomiting  are  excessive  distention  of  the  uterus  (Bretonneau), 
the  ovum  growing  more  rapidly  than  the  organ  can  bear,  as  in  metritis,  poly- 
hydramnion,  hydatid  mole,  twins,  displacement  of  the  uterus  (Grailly-Hewitt), 
acute  anteversions  and  retroversions  and  flexions,  the  nerves  being  pinched  or 
stretched;  under  this  heading  may  be  placed  inflammations  of  the  uterus,  metritis, 
endometritis  (Veit),  tumors  of  the  uterus,  diseases  of  the  adnexa,  pelvic  connective 
tissue,  and  peritoneum;  chronic  cervicitis,  with  or  without  erosions  (Bennett). 
The  plausibility  of  this  cause  is  shown  by  the  good  effect  of  treatment,  since  often 
when  the  pathogeny  is  corrected  the  vomiting  chsappears.  Without  doubt  a 
special  predisposition  on  the  part  of  the  gravida  must  be  assumed  to  explain  the 
excessive  gastric  reaction  to  the  irritant,  because  such  diseases  of  the  genitalia 
often  exist  in  marked  degree  without  causing  vomiting. 

2.  Where  no  lesion  of  the  genitalia  is  chscoverable,  but  other  disease,  usually 
attended  by  vomiting,  is  present,  pregnancy  added  to  the  condition  may  make  the 
vomiting  pernicious.  Such  diseases  are  gastric  ulcer,  carcinoma,  chronic  gastritis, 
enteritis,  helminthiasis,  large  fecal  concretions,  enteroptosis,  tuliercular  peritonitis, 
gall-stones,  in  fact,  many  intra-alxlominal  disorders.  Xasal  disease,  hypertrophied 
turbinates,  septal  spurs,  apical  and  laryngeal  tuberculosis,  anemia,  chlorosis,  all 
these  have  been  invoked,  and  in  occasional  instances  proved  causative.  If  not 
actually  causative,  they  may  act  as  predisposition.  Uremia  from  kidney  disease 
may  cause  vomiting,  but  usually  in  the  last  months  of  pregnancy. 

3.  The  nervous  system  is  frequently  at  fault,  either  ^sith  demonstrable  disease, 
as  brain  softening,  locomotor  ataxia,  tubercle  or  other  tumors,  meningitis,  poly- 
neuritis,— but  this  may  be  an  effect  of  toxemia, — or  as  the  result  of  functional 


3-i6      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

disturbances.  H^'peremesis  is  not  rare  in  hj^sterics,  but  in  all  probability  most 
cases  may  be  explained  as  a  neurosis,  a  view  prominently  placed  by  Kaltenbach. 
Ahlfeld  and  Oliver  explain  the  vomiting  as  a  cerebral  circulatory  disturbance 
similar  to  sea-sickness.  Much  may  be  said  in  favor  of  Kaltenbach's  contention,  e.  g., 
the  frequent  occurrence  of  the  disease  in  neurotic  women,  the  good  effects  of  sug- 
gestive treatment,  and  it  is  more  than  plausible  that  a  neurotic  element  is  the  basal 
cause  of  the  vomiting  in  all  the  conditions  previously  mentioned  under  this  heading. 
Treatment  of  a  displaced  uterus  or  of  a  diseased  cervix,  for  example,  simply  re- 
lieves the  patient  of  the  peripheral  irritant,  but  the  vomiting  ceases  because  the 
mobile  nervous  system  comes  again  into  equilibrium.  In  the  absence  of  actual 
local  disease,  pure  suggestion  may  cure  vomiting  in  these  neurotic  cases,  examples  of 
which  are  the  ice-bag  of  Chapman,  a  blister  applied  to  the  spine,  absolute  seclusion 
in  a  dark  room,  electricity,  some  drugs.  A  neurotic  constitution  is  usually  inherited 
from  parents  similarly  afflicted,  or  such  as  are  alcoholic,  insane,  or  debilitated. 
Unusual  stress  of  life  may  develop  it.  If  a  woman  dies  from  neurotic  vomiting, 
the  course  of  the  disease  is  very  chronic,  and  the  clinical  picture  and  pathologic 
findings  are  those  of  starvation. 

4.  Toxemia  best  explains  a  large  number  of  cases  of  hyperemesis,  and  the 
clinical  picture  as  well  as  the  pathogeny  seems  to  show  that  there  is  a  distinct  disease 
entity.  Dirmoser  believed  that  an  intestinal  auto-intoxication  causes  the  vomiting, 
a  view  which  is  supported  by  some  cases  in  practice.  That  the  liver  has  to  do  with 
this  disease  has  long  been  known,  but  the  changes  of  this  organ  have  only  recently 
been  studied.  These  changes  in  the  liver  are  probably  due  to  the  basal  cause  of 
the  toxemia,  the  disturbed  metabolism.  No  one  has  suggested  that  they  may  be 
due  to  an  infection.  Charpentier  relates  a  case  where  the  excessive  vomiting  ceased 
on  the  opening  of  a  peri-urethral  abscess,  and  Goldspohn  one  where  the  removal 
of  a  fetid  placenta  from  the  uterus  effected  a  cure. 

A  neurotic  constitution  may  cause  toxemia. 

Toxins  derived  from  the  solution  of  syncytium,  syncytiotoxin,  are  believed  by 
Veit  and  others  to  cause  hyperemesis,  the  blood  not  furnishing  enough  antitoxin 
to  neutralize  them.  Recently  injections  of  the  serum  of  healthy  gravidse  have 
been  used  as  a  curative  measure — i.  e.,  to  supply  the  deficient  antibodies  to  the 
patient's  blood  (Mayer,  1911).  The  thj^roid  gland,  the  adrenals,  defective  corpus 
luteum,  have  all  been  proposed  as  causes  of  the  disturbed  metabohsm  (Fieux). 

Toxemic  vomiting  cases  pursue  a  more  rapid  course,  without  much  emaciation, 
and  death  results  not  from  starvation,  but  from  the  profound  alterations  of  the 
general  metabolism. 

Pathologic  Anatomy. — At  autopsy  on  women  dead  of  hyperemesis  gravidarum 
the  most  marked  changes  are  found  in  the  liver  and  kidneys.  The  liver  may  be 
slightly  enlarged  in  the  acute  stages,  but  after  the  degeneration  has  progressed 
somewhat,  it  is  smaller.  There  may  be  a  diffuse  hemorrhagic  hepatitis,  with  all 
the  findings  of  acute  yellow  atrophy.  There  may  be  fatty  degeneration  of  only  the 
cells  around  the  central  lobular  veins,  or  extensive  areas  of  necrosis  (Fig.  336). 
Thromboses  may  occur  in  Ijranches  of  the  portal  vein.  Bile  stasis  is  the  rule. 
Hofbauer  says  the  glycerin  is  limited  to  the  periphery  of  the  lobule.  Pinard  claims 
that  slight  changes  of  this  kind  are  constant  in  pregnancy,  and  we  should  speak  of 
the  liver  of  pregnancy  as  well  as  of  the  kidney  of  pregnancy. 

The  kidney  suffers  all  the  changes  from  those  of  the  so-called  kidney  of  preg- 
nancy to  an  acute  parenchymatous  nephritis.  Fig.  338  shows  a  marked  fatty 
degeneration  of  the  epithelium  of  the  secreting  tubules.  The  glomeruli  are,  if  at 
all,  ])ut  little  affected.  Hemorrhages  are  often  found,  and  possibly  the  degenera- 
tion may  never  be  fully  corrected. 

The  heart  undergoes  fatt}'  degeneration  in  the  bad  cases,  as  in  sepsis.  The 
nerves  also  are  quickly  attacked  by  the  circulating  toxins. 


THE   TOXEMIAS    OF    PREGNANCY  347 

Diagnosis. — First  one  must  decide  when  the  vomiting  becomes  serious  enough 
to  he  Ciilled  pernicious.  When  the  stomach  rejects  everytliiug;  when  tlie  anorexia 
is  complete  unci  tlie  general  health  is  i)al]nibly  affected,  one  must  conclude  that  the 
so-called  physiologic  vomiting  has  passed  over  into  the  pathologic.  As  Gudniot 
has  shown,  the  diagnosis  is  not  so  simple  as  appears  at  first  glance.  It  consists — 
(a)  Of  the  diagnosis  of  pregnancy,  which  is  not  so  easy  in  the  first  trimester,  when 
the  cases  usually  present  themselves;  (b)  in  determining  the  causes  of  vomiting, 
basal  and  adjuvant;  (c)  the  differentiation  of  vomiting  due  to,  or  rendered  jx-r- 
nicious  by,  pregnancy,  from  vomiting  having  no  connection  with  an  existing  preg- 
nancy, such  as  would  occur  in  the  absence  of  pregnancy.  The  diagnosis  of  preg- 
nancy is  made  l)y  the  usual  methods,  and,  owing  t<j  the  emaciation,  bimanual 
examination  is  rendered  easier.  A  careful  study  of  the  genital  findings  ^vill  often 
lead  to  the  discovery  of  a  malposition  of  the  uterus  or  other  pelvic  anomaly  which 


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Fig.  336. — Lobule  of  Liver  in  HvPEREirEsis  (low  power). 

may  be  the  adjuvant  cause  of  the  excessive  vomiting — that  is,  the  peripheral 
irritant.  Stomach,  intestinal,  hepatic,  hemic,  nervous  diseases  aaiII  require  the 
careful  general  mecUcal  investigation  which  should  be  a  part  of  the  treatment  of 
all  cases.  An  underlying  neurosis  is  not  always  lightly  assumed.  The  toxic 
forms  of  vomiting  may  not  invariably  be  diagnosed  by  urinary  examination. 
Williams  beheves  that  high  ammonia,  even  to  40  per  cent.,  with  low  urea-nitrogen 
output  in  the  urine,  indicates  a  toxic  form  of  hj'peremesis,  but  his  results  have 
not  j^et  been  confirmed..  Jaundice,  fever,  rapid  prostration,  -^-ith  cerebral  symptoms, 
acidosis,  early  albuminuria,  ■v\dth  casts,  or  blood,  much  acetone  and  diacetic  acid, 
tenderness  over  the  liver,  bloody  vomit,  point  to  a  toxemia,  while  the  more  gradual 
development  of  starvation  sj'mptoms  leads  one  to  suspect  a  reflex  or  neurotic  cause 
for  the  vomiting. 

That  the  diagnosis  is  not  simple  is  proved  by  the  mistake  made  by  Trousseau, 


348 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


where,  after  induction  of  abortion  for  hyperemesis,  the  autopsy  showed  cancer  of 
the  stomach,  and  one  by  Caseaux,  where  a  woman  supposedly  dead  from  vomiting 
of  pregnancy  had  tubercular  peritonitis,  and  the  one  of  Beau,  where  a  tubercular 
meningitis  caused  the  death.  W.  E.  Morgan,  of  Chicago,  relates  the  case  of  a  girl 
who,  in  extremis  from  vomiting,  threw  up  a  ball  of  cotton  which  she  had  swallowed 
for  the  purpose  of  inducing  abortion.     Prompt  recovery  ensued. 

If  the  premises  are  made  very  broad,  the  patient  submitted  to  a  thorough  and 
complete  physical  examination,  and  sufficient  time  spent  on  the  consideration 
of  the  findings,  a  good  working  diagnosis  can  usually  be  made. 

Prognosis. — Gueniot  collected  118  cases,  with  46  deaths.  Statistics  are  un- 
certain because  the  ideas  of  observers  as  to  what  constitutes  hyperemesis  differ. 


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Fir,.   3.37. — Liver  Cells  in  Hyperemesis   (high  power). 
A,  Cells  in  center  of  lobule,  .showing  fat,  yellow  pigment,  and  crystals — tyrosin     (?)      (Hektoen).     B,  Cells  in  peri- 
phery of  lobule,  showing  granular  protoplasm,  pale  nuclei,  and  blood-pigment. 


Carl  Braun,  in  an  immense  experience,  never  saw  a  death  from  the  vomiting,  which 
is  a  remarkable  statement,  because  they  do  occur.  The  disease  lasts  ten  days  to 
three  months,  depending  on  the  variety.  Not  seldom,  either  because  of  some  at- 
tempt at  treatment  or  spontaneously,  the  patient  suddenly  ceases  to  vomit,  de- 
manrls  food  and  retains  it,  going  on  to  rapid  recovery — this,  too,  when  the  previous 
condition  was  such  as  to  excite  real  alarm.  More  often  the  disease  subsides  slowly, 
or  may  not  be  fully  cured  until  after  delivery.  If  the  fetus  dies  or  abortion  occurs, 
recovery  usually  begins,  but  not  invariably,  and,  too,  such  an  occurrence  is  rare, 
the  course  of  the  gestation  being  seldom  affected  by  the  general  disturbance.  If 
therapeutic  a])ortion  is  delayed  too  long,  it  cannot  prevent  death,  rather  may 
precipitate  the   impending  fatal   exhaustion.     The  toxemic   hyperemesis   is  less 


THE   TOXEMIAS    OF    PREGNANCY 


349 


ain('iial)l('  to  trcatiiicnl  than  the  rcllcx  or  neurotic  variotios,  but  those  cases  where 
some  i)atlioloKie  coiKlition  of  the  stoiuacli,  hraiii,  k'nhiev.s,  or  liver  is  aggravated 


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Fig.   .338. — Kidney  in   Hyperemesis   (low  power). 

by  the  pregnancy  are  most  fatal.  Death  comes  from  acute  starvation,  acute 
toxemia,  with  delirium  and  coma,  exhaustion,  which  may  come  on  suddenh'  during 
apparent  improvement,  from 
rupture  of  stomach  or  bowel 
because  of  the  constant  retch- 
ing, from  hematemesis,  and 
from  intercurrent  disease.  Hy- 
peremesis may  recur  in  sub- 
sequent pregnancies.  The 
toxemic  varieties  are  usually 
more  severe  when  they  recur, 
the  others  less. 

Treatment. — Careful 
search  having  revealed  the 
cause,  treatment  is  to  be  pur- 
sued along  the  lines  indicated. 
The  most  important  point  to 
determine  is  whether  or  not 
the  vomiting  is  toxemic.  Since 
the  exact  cause  is  not  invari- 
ably determinable,  one  may 
have  to  follow  empiricism. 

General. — Every  mild  case 
of  vomiting  during  jiregnancy 
should  be  cured  as  soon  as  pos- 
sible mth  a  view  to  preventing  an  aggravation  of  the  disease.     Attention  to  the 
bowels,  a  plain,  easily  digestible  dietary,  a  gastric  sedative,  e.  g.,   cerium  oxalate 


# 


a 


Fig.  33'J.— Kidney  Cells  in   Hyperemesis   (high  power). 


350      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

combined  with  scale  pepsin,  of  each  5  grains  thrice  daily  after  eating,  and  sug- 
gestive therapeutics  usually  suffice  to  make  the  gravida  comfortable.  Cognizance 
may  be  taken  of  the  capricious  appetites  of  pregnant  women,  and  the  bizarre 
"longings"  may  be  satisfied  when  the  desired  food  is  digestible.  Dewees  roused 
the  patient  early,  gave  hot  coffee  and  crackers,  and  then  had  her  lie  in  bed  an  hour 
or  so,  a  plan  that  is  often  successful.  Coitus  is  to  be  forbidden,  the  wife  being  best 
given  a  separate  room.  The  knee-chest  position  for  ten  minutes  three  times  a 
clay,  allowing  air  to  enter  the  vagina,  is  often  helpful.  Dyspepsia  or  symptoms  of 
gastric  disease  are  to  be  treated  on  general  medical  lines,  and  it  is  wise  to  search  for 
and  correct  all  abdominal  conditions  found  to  be  causative  of  hyperemesis. 

As  soon  as  a  given  case  shows  itself  to  be  obstinate  and  threatening,  the  woman 
should  be  put  to  bed,  isolated  as  far  as  possible,  and  a  thoroughly  competent  nurse 
put  in  attendance.  It  may  be  best  to  remove  the  patient  to  a  hospital.  The 
room  should  be  darkened  (ocular  disturbance  sometimes  causes  vomiting),  and  the 
horizontal  position  consequentially  insisted  upon,  even  while  taking  food.  In  one 
chronic  case  much  relief  was  obtained  by  the  patient  living  on  an  open  porch.  The 
bowels  must  be  emptied  thoroughly. 

Dietary. — Milk  and  lime-water  or  seltzer,  equal  parts,  ice  cold;  kumiss  or  matzoon;  a  strong 
beef  or  chicken  broth  served  in  a  cup  with  salted  wafers;  cold  custard;  rice  and  milk  with  cinna- 
mon; asliver  of  white  meat  of  chicken  with  buttered  toast;  a  strong  oyster  broth;  strained  oyster- 
stew;  toast  and  hot  milk  with  sugar;  ice-cream  and  ices ;  soda-fountain  drinks;  cream  soups  with 
wafers.  If  the  stomach  rejects  these,  liquid  diet  is  ordered;  milk,  milk  and  seltzer,  peptonized 
milk  flavored  with  cinnamon  or  nutmeg,  light  broths,  albumin-water,  rice-water,  barley-water, 
beef-juice.  Occasionally  food  introduced  with  a  stomach-tube  will  be  retained  when  that  swal- 
lowed is  rejected.     If  the  vomiting  is  toxemic;  the  patient  is  put  on  a  milk  and  water  diet  at  once. 

Should  the  stomach  prove  absolutely  refractory,  rectal  feeding  is  instituted — 
nothing  is  allowed  by  mouth.  Salt  solution  by  the  drop  method  containing  dex- 
trose, peptones,  peptonized  milk  and  eggs,  digested  beef,  and  emulsified  fats  may 
be  given.  Underhill  emphasizes  the  need  of  carbohydrates  in  the  economy  during 
hyperemesis,  claiming  that  proteids  are  not  so  necessary.  It  has  been  stated  that 
the  lack  of  carbohydrates  causes  the  marked  acetonuria. 

Suggestion  forms  a  large  part  of  the  treatment  of  cases  of  pernicious  vomiting, 
and  without  doubt  many  of  the  measures  here  advocated  depend  on  it  for  their 
success.  The  physician  should  determine  if  the  woman  is  suffering  from  a  neurosis, 
and  then  institute  a  course  of  treatment  with  a  view -to  impressing  her  with  his 
power  to  cure  her.     How  this  is  to  be  done  depends  on  individual  circumstance^. 

Medical. — There  is  no  specific  for  this  disease,  as  the  host  of  remedies  used 
with  apparent  success  and  disheartening  failure  testifies. 

1.  Local  Anesthetics. — Cocain  hydrochlorid,  3-^  grain  in  1  ounce  of  water  (has  little  in- 
fluence on  the  bad  nausea  and  vomiting,  but  may  help  to  retain  some  food  for  a  while) ;  menthol, 
J/g  to  H  grain  in  water;  volatile  oils — peppermint,  wintergreen — in  small  doses.  Cracked  ice 
swallowed  whole  may  relieve  thirst. 

2.  Mechanical  Drugs. — Bismuth,  cerium  oxalate,  soda-mint  tablets,  milk  of  magnesia,  etc., 
may  be  tried.  Digestive  ferments  do  not  act  so  well  as  in  the  non-pregnant  state,  but  pepsin  and 
ingluvin  may  Vjc  tried.  When  chronic  gastritic  or  atonic  dyspeptic  symptoms  appear,  tincture 
of  nux  vomica  and  hydrochloric  acid,  especially  if  an  alcoholic  basis  is  suspected.  Usually,  as 
the  disease  gets  worse,  drugs  are  more  harmful  than  good. 

3.  Depressomotors. — Sodium  bromid  may  be  given  in  30-grain  doses  by  rectum,  and  mor- 
phin,  }/[  grain  hypodermically,  for  temporary  relief.  The  effect  is  apparent,  but  the  drugs  may 
iat  or  increase  the  nausea.  A  hypodermic  of  morphin  may  be  given  just  after  the  feeding  and  it  may 
serve  to  retain  the  meal.  In  some  cases  of  centric  vomiting  alcohol,  in  the  form  of  dry  champagne 
or  brandy,  ser\'cd  in  cracked  ice,  has  a  good  effect.     If  it  is  retained,  we  may  go  on  with  other  food. 

4.  External  Remedies. — Ether  spray  and  pressure  on  the  stomach;  warm  flannel  band  or  ad- 
hesive straps  around  the  stomach,  tightly;  fly-blister  to  epigastrium;  Chapman's  ice-bag  (a  long 
cylindric  ice-bag)  to  the  spine,  or  a  blister  to  thf!  fifth  or  sixth  cervical  spine.  Electricity  is  of 
little  value,  but  may  be  used  as  a  suggestion.  ^Jlie  galvanic  current  may  be  employed  or  electric 
radiation  of  the  epigastrium. 

Kaltenbach  has  warmly  recommended  wa.shing  out  the  stomach.  In  certain  hysteric  cases 
it  does  great  good,  and  in  gastroptosis  and  gastritis  may  also  be  useful.  It  is  not  to  be  used 
if  the  patient  is  too  weak,  as  it  is  depressing,  or  if  a  gastric  ulcer  is  suspected. 


TIIK    TOXEMIAS    OF    PREGNANCY  351 

5.  I)iso:is('  of  the  luusopharynx  is  to  bo  troatcd.  'I'ciiiporary  rdif^f  is  ocoa-sionally  obtained 
by  spraying;  tlic  iiarcs  witli  4  jxt  cnnt.  .solution  of  cocaiu. 

(■).'  SdU  sohilion,  0.7  per  cciil.,  injected  subciitaiieou.sly,  is  a  valuable  addition  to  our  moans 
for  meeting  the  loss  of  body  fluids  from  tlio  constant  vomiting.  A  quart  may  bo  injected  every 
day  or  a  pint  several  times  a  ilay. 

The  extremities  may  be  wrapped  in  wet  towels,  and  inunctions  of  oil  or  lard  u.sod,  some  of 
these  beiii^i  absorbed.     Bed-sores  nmst  be  assiduously  i)rovented. 

T\\o  hit(>st  remedies  for  hyperemesis  arc  suprarenal  extract,  proposed  Ijy  Re- 
baiidi  ill  11)09,  and  the  serum  of  healthy  pregnant  women,  recommended  by  Preund 
in  1909  and  by  Mayer  in  1911.  I  have  used  adrenalin  many  times,  with  success  in 
half  of  the  cases.  Ten  drops  of  the  1 :  1000  solution  are  given  three  times  a  day  by 
mouth,  or  three  drops  hypodermically.  I  have  not  yet  used  the  sermn,  of  which 
20  c.c.  are  injected.     Pituitrin  has  not  yet  been  tried. 

Gynecologic  Treatment. — Examine  carefully  with  the  aid  of  a  speculum,  and 
anything  abnormal  must  be  remedied  if  possible. 

An  anteverted  or  a  retroverted  uterus  is  replaced — in  the  knee-chest  position, 
if  necessary — and  a  pessary  inserted.  In  one  of  the  writer's  cases,  the  wife  of  a 
colleague,  an  acutely  anteverted  uterus  was  raised  with  a  balloon  pessary,  with 
immediate  cessation  of  pronounced  nausea  and  vomiting.  Owing  to  a  pin-hole 
defect  in  the  bag,  the  air  slowly  escaped  and  the  symptoms  gradually  returned, 
to  disappear  permanently  when  a  perfect  instrument  was  substituted,  thus  proving 
that  the  effect  was  not  due  to  suggestion. 

An  erosion  of  the  cervix  is  treated  with  10  per  cent,  solution  of  silver  nitrate — 
indeed,  the  method  should  be  employed  on  empiric  grounds  even  if  the  cervix 
exhibits  no  alteration.  After  irrigation  of  the  vagina  with  sterile  water  a  small 
Ferguson,  speculum  is  introduced  and  the  cervix  engaged  in  its  end.  The  silver 
solution  is  poured  in  and  allowed  to  remain  five  to  ten  minutes  until  the  tissues  are 
whitened,  then  washed  out  with  1  per  cent,  salt  solution.  After  two  days  the  treat- 
ment may  be  repeated.  Its  rationale  is  not  understood,  but  it  is  often  efficacious, 
and  Carl  Braun  used  it  as  a  routine  practice.  Bennett,  the  inventor,  used  carbolic 
acid  and  iodin.  M.  O.  Jones,  of  Chicago,  recommended  the  silver,  but  J.  Marion 
Sims  drew  general  attention  to  the  remedy.  In  one  case  where  the  silver  apphca- 
tions  failed  the  author  employed  Bier's  suction  treatment  applied  to  the  cervix. 
The  woman  was  in  desperate  condition,  and  abortion  was  the  next  procedure,  but 
recovery  ensued  and  the  pregnancy  went  to  term.  How  much  the  local  treatment 
contributed  to  the  result  is  uncertain.  Copeman,  of  Norwich,  in  1875,  in  a  case  of 
h>i:)eremesis,  tried  to  induce  abortion  by  dilating  the  cervix  with  his  finger,  but 
failed;  his  patient,  however,  ceased  to  vomit.  Subsequently,  dilatation  of  the 
cervix  became  a  recognized  method  of  treatment,  to  be  employed  before  abortion 
was  induced,  as  a  next  to  the  last  resort.     The  author  has  never  used  it. 

Obstetric. — Therapeutic  abortion  Avill  cure  most. cases  of  hyperemesis  if  done 
early  enough.  It  will  cure  all  cases  of  neurotic  or  reflex  vomiting  unless  the  patient 
is  too  near  death  from  starvation  and  exhaustion  to  withstand  the  operation. 
Toxemic  vomiting,  being  an  expression  of  a  profound  systemic  alteration  of  the 
metabolism,  does  not  respond  so  quickly,  because  the  organs,  especially  the  Hver, 
may  have  been  too  much  damaged  by  the  poisons  circulating  in  the  blood.  Wil- 
liams' advice,  therefore,  to  empty  the  uterus  as  soon  as  the  vomiting  is  pronounced 
toxemic,  deserves  serious  consideration,  though  one  may  not  always  follow  it. 
In  the  first  place,  a  positive  cUagnosis  of  toxemia  cannot  always  be  made,  and, 
too,  many  cases  of  toxemic  vomiting  recover  under  the  usual  treatment. 

The  delicate  point  to  determine  is  when  to  empty  the  uterus,  and  the  general  ap- 
pearance of  the  patient  must  decide  it.  Hofbauer  says  that  if  glycosuria  results  after 
the  ingestion  of  2  ounces  of  levulose,  a  test  of  the  glycoh-tic  power  of  the  organ,  the 
time  is  at  hand,  because  this  proves  that  the  liver  is  already  attacked  by  toxins  and  has 
begun  to  suffer.     Examination  of  the  blood,  showing  intense  concentration  (hj-per- 


352      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

erythrocytosis  and  leukocytosis),  may  indicate  the  degree  of  starvation.  Pinard 
says  that  when  the  pulse  remains  above  100  one  should  not  delay  the  operation, 
and  many  accoucheurs  interfere  on  the  appearance  of  fever,  hematemesis,  jaundice, 
all:>uminuria,  mellituria,  acctonuria,  indicanuria,  the  diazo-reaction,  or  marked  loss 
of  weight.  Fieux  holds  that  polyneuritis  with  icterus  and  the  appearance  of  bile- 
pigment  in  the  urine  indicate  abortion.  Not  one  but  all  these  facts  must  be  con- 
sidered, together  with  one's  clinical  experience.  The  disease  is  so  treacherous  that 
it  is  better  to  interfere  earlier  rather  than  too  late,  because  often  many  remedies 
are  tried  in  succession,  using  up  much  time  and  then,  when  the  uterus  finally  has 
to  be  emptied,  the  patient  is  in  no  condition  to  stand  the  shock  of  operation.  Con- 
sultation must  always  be  had,  first,  to  verify  the  diagnosis  and  the  necessity  of  per- 
forming abortion;  second,  to  protect  the  attendant  from  the  imputation  of  criminal 
operation,  and,  third,  to  share  responsibility.  All  appearance  of  secrecy  is  to  be 
avoided,  the  operation  being  performed  in  a  hospital,  if  possible.  In  early  cases  the 
best  way  is  to  dilate  and  curet  the  uterus  in  one  sitting.  Later  in  pregnancy  it  may  be 
better  to  dilate  the  uterus,  insert  gauze,  and  complete  the  operation  the  next  day. 
When  great  haste  is  demanded,  anterior  vaginal  hysterotomy  is  the  operation  of  choice. 
Freund,  in  three  cases,  with  much  ado  pretended  to  do  abortion  and  thus  cured  the 
vomiting.  One  could  try  this  drastic  mode  of  suggestive  therapeutics  when  the 
hyjDeremesis  is  due  to  a  neurosis. 

Hj'peremesis  is  sometimes  feigned  so  as  to  mislead  the  accoucheur  into  per- 
forming an  abortion.  The  patient  will  exaggerate  her  symptoms  and  falsify 
statements.     In  all  cases  the  objective  signs  only  should  be  relied  upon. 

Literature  on  hyperemesis  gravidarum  is  to  be  found  in  article  by  Ingraham, 
Jour.  Amer.  Med.  Assoc,  1912,  page  28. 


PTYALISM 

Salivation  is  a  rare  complication  of  pregnancy  It  is  related  to  hyperemesis 
in  that  it  is  probably  caused  reflexly.  Hippocrates  noted  it  in  pregnancy.  It  is 
to  be  distinguished  from  the  ''cotton  spitting"  described  by  Dewees  as  one  of  the 
signs  of  pregnancy. 

Salivation  combined  with  nausea  and  vomiting  frequently  occurs,  but  may 
occur  alone.  It  usually  begins  in  the  second  month,  and  ceases  about  the  fifth 
or  at  quickening,  presenting  the  same  variations  as  the  vomiting.  It  almost  al- 
ways ceases  with  parturition,,  but  has  continued  for  a  few  weeks  thereafter.  It 
usually  occurs  but  once,  but  may  appear  in  successive  pregnancies,  and  may  be 
absent  in  one  and  recur  in  the  next.  The  flow  varies  in  amount,  excessive  quantities 
being  reported — over  two  quarts  a  day.  It  usually  lessens  during  the  night,  but 
may  continue  unabated.  The  saliva  is  very  watery,  tasteless,  odorless,  limpid, 
not  acid;  it  has  little  ptyalin.     The  patient  cannot  swallow  it:  it  nauseates. 

The  drain  (i  '"  ^lis  large  amount  of  fluid,  the  absence  of  digestive  power,  and  the 
loss  of  appetite  not  seldom  compromise  the  nutrition  of  the  patient,  and  a  condi- 
tion of  exhaustion  resembling  that  produced  l)y  incoercible  vomiting  has  proved 
an  indication  for  terminating  the  pregnancy  in  these  cases  (rare).  There  are  few 
changes  in  the  mouth  or  gums.  The  salivary  glands  may  be  a  little  swollen  and 
tender;  the  tongue  is  coated,  with  red  edges;  and  sometimes  a  gastric  catarrh 
exists.  The  patients  feel  miserable,  arc  always  thirsty,  have  difficulty  in  talking, 
and  the  chin  may  be  excoriated. 

Ptyalism  has  the  same  causation  as  hyperemesis,  and  occurs  most  often  in 
neurotic  women.     It  may  be  a  familial  characteristic. 

The  diagnosis  is  easy,  since  mercurial  salivation  is  attended  by  fetor  and 
stomatitis.  ^Montgomery  says  that  ptyalism  may  be  a  symptom  of  hysteria  and 
of  cancer  of  the  uterus. 


THE  TOXEMIAS  OF  PREGNANCY  353 

The  troatinciit  is  [)ursu('(l  nlouj;  tlic  suiiic  lines  as  in  hj-peremesis.  Of  the  many 
drugs  used,  sudiiun  hroniid  is  the  best — 20  grains  thrice  daily.  Piloeiir|)in  is  less 
efficient,  and  atropin  is  useless  and  dangerous. 


GINGIVITIS 

The  slight  tumefaction  and  hyperemia  of  the  gums  so  often  observed  in  preg- 
nancy (50  to  (K)  p(T  cent.)  may  Ije  aggravated  to  a  severe  affection.  Sixjnginess 
of  the  gums,  hemorrhage  into  them  and  from  them,  even  loosening  and  dropping  of 
the  teeth,  occur.  There  is  no  fetor,  no  salivation,  and  there  is  usually  littk;  pain 
in  the  parts,  though  mastication  is  chfficult.     There  is  no  periodontitis. 

Retlness  of  the  gingival  margins  and  hypertrophy  are  visi}:)le,  and  sometimes 
polypoid  excrescences  of  varying  size,  which  are  subject  to  ulceration,  appear  be- 
tween the  teeth.     The  region  of  the  molars  is  less  affected. 

Gingivitis  affects  primiparae  and  multiparse  ahke,  but  is  more  common  in  those 
who  neglect  the  teeth  and  person  and  in  women  of  poor  health.  It  begins  about 
the  fourth  month,  disappears  after  delivery,  Ijut  may  even  appear  in  and  be  aggra- 
vated by  lactation.  It  may  recur  in  each  jDregnancy.  Its  causation  is  obscure. 
Perhaps  the  altered  buccal  secretions  play  a  role,  or  the  altered  metabolism  of 
i:)regnancy  (toxemia?).  The  treatment  is  hygienic;  antiseptic  mouth-w^ashes, 
as  tincture  of  myrrh  in  water,  potassium  chlorate,  1  ounce  in  1  pint  of  water,  milk  of 
magnesia,  cleansing  the  gums  with  a  soft  cloth,  rubl^ing  precipitated  chalk  into  the 
crevices,  and  iron  and  calcium  tonics,  combined  with  outdoor  living.  Hemorrhage 
from  the  gums  is  treated  by  a  compress  of  gelatin  or  of  adrenalin,  or  cauterization. 
Polypoid  excrescences  may  be  removed  a  few  weeks  postpartum  if  they  do  not 
shrink  uj). 

Toothache  is  a  not  infrequent  occurrence  in  pregnancy,  and  it  is  especially 
troul^lesome  in  women  subject  to  neuralgia.  Carious  teeth,  also  common,  should 
be  cared  for  during  gestation;  even  extraction  under  gas  should,  if  indicated,  be 
made,  but  exhausting  gold  fillings  had  better  be  postponed,  temporary  cement  or 
inlays  being  inserted.  The  gravida  should  be  given  a  tonic  of  lime  and  h}-po- 
phosphites. 

ECLAMPSIA  AND  ALLIED  CONDITIONS 

One  of  the  most  dangerous  complications  that  may  befall  the  pregnant  woman 
is  convulsions  attended  by  coma.  Naturally,  a  gravida  may  suffer  from  the 
convulsive  seizures  to  which  any  woman  is  liable,  such  as  epilepsy,  hj'steria, 
meningitis,  etc.,  but  there  is  a  sj^nptom-complex  presented  by  pregnant  women, 
of  which  convulsions  are  the  most  prominent  manifestation,  to  which  the  term 
"eclampsia  parturientium "  is  applied.  There  are  several  varieties  of  sjanptom- 
groups  or  syndromes,  some  pointing  to  the  liver  as  the  main  seat  of  the  trouble, 
others  pointing  to  the  kidneys,  others  to  both.  Again,  the  en-  ,ulsions  may  be 
al)scnt,  the  condition  Ijeing  one  of  failure  of  one  or  the  other  o  5i,an.  Under  this 
heading  would  come  the  kidney  of  pregnancy  and  acute  yellow  atrophy  of  the  liver, 
because  the  first  often  leads  to  convulsions,  and  the  other  is  not  seldom  a  terminal 
condition  of  eclampsia. 

It  is  impossible  to  classify  these  diseases  because  the  causes  are  unknown. 
They  all  could  be  grouped  under  one  head,  toxicoses  or  toxemia,  if  it  were  kno^^Tl 
that  an  intoxication  of  the  ])lood  really  lies  at  the  base,  but  this  theory,  while  gen- 
erally believed,  and  indeed  very  plausible,  is  not  positively  proved.  One  would 
then  speak  of  a  nephritic  toxemia,'  a  hepatic  toxemia,  cerebral  toxemia,  depending 
on  which  organ  is  most  affected  by  the  circulating  poison,  or  whose  symptoms 
dominated  the  clinical  picture  or  postmortem  findings.  At  present  we  group  all 
cases  of  convulsions  and  coma  occurring  in  pregnant  women,  not  due  to  extraneous 
23 


354      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

medical  causes,  as  hysteria,  epilepsy,  tubercle  of  the  brain,  etc.,  under  the  term 
eclampsia.  Those  rare  cases  where  the  woman  has  all  the  symptoms  of  eclampsia 
•v^^thout  convulsions  we  call  eclampsia  just  the  same.  The  kidney  of  pregnancy  is 
generally  held  to  be  due  to  a  preeclamptic  toxemia  of  very  mild  degree.  The  neph- 
ritis of  pregnancy  is  the  next  step  in  the  gradation  to  the  real  nephritic  form  of 
eclampsia.  The  liver  is  always  involved  either  primarily  or  secondarily,  and  some 
cases  of  eclampsia  seem  to  be  due  entirely  to  hepatic  inefficiency,  the  renal  changes 
being  secondary,  and  such  cases  are  likely  to  terminate  under  the  clinical  picture 
of  acute  yellow  atrophy  of  the  liver,  presenting  the  classic  autopsy  findings. 

History. — Hippocrates  mentions  convulsions  of  pregnant  women  and  knew  that  they  most 
often  occurred  in  women  who  had  headache  and  a  tendency  to  sleep  (coma) .  The  word  eclampsia 
means  to  flash,  or  shine  out,  and  was  introduced  by  Boissier  de  Savages  in  1760  and  Gehler 
in  1776.     More  properly  it  should  be  eclactisma  (Kossman). 

Clinical  Course. — Prodromata. — The  eclamptic  attack  may  occur  suddenly  with- 
out warning,  but  this  is  not  the  rule — almost  always  there  are  premonitory  symp- 
toms, so  that,  with  ordinary  care,  the  accoucheur  is  not  taken  unawares.  These 
sjTnptoms  are  headache,  dizziness,  a  tendency  to  nervous  excitation  or  to  sleep, 
occasionally  slight  mental  unbalance,  twitchings  in  the  muscles,  cramps  in  the  calves, 
nausea,  voixiiting,  yain  in  the  epigastrium,  and  disturbances  of  the  special  senses — 
spots  before  the  eyes, — muscse  volitantes, — bright  lights,  sometimes  colored,  some- 
times described  as  spangles,  dimness  of  vision,  even  complete  blindness,  due  to  edema 
or  retinitis  and  sometimes  with  hemorrhages,  photophobia;  ringing  in  the  ears,  even 
deafness,  and  occasionally  anomalies  of  taste  and  smell.  Prodromata  are  present 
from  a  few  hours  to  several  weeks  before  the  actual  outbreak,  and  serve  to  draw 
attention  to  the  condition  of  the  patient. 

These  warnings  should  be  heeded  and  an  exhaustive  examination  of  the  patient 
made.  This  will  usually  show  edema  of  the  feet  and  eyelids,  or  more  or  less  marked 
general  anasarca,  with  pasty  skin,  a  coated  tongue,  fetid  breath,  tenderness  over 
the  pit  of  the  stomach  (the  site  of  the  pain)  and  over  the  liver,  high  vulse  tension 
with  accentuated  second  heart-sound,  intensely  exaggerated  reflexes,  diminished 
urine,  high  specific  gravity,  albumin  with  hyaline  and  granular  casts,  and  low  urea 
output.  Occasionally  the  urinary  findings  are  negative,  but  there  is  marked  edema, 
■with  or  without  symptoms,  and  sometimes  edema  fails,  but  marked  subjective 
manifestations  are  present.  Rarely  one  observes  a  slight  subicterus.  These  symp- 
toms may  be  called  those  of  preeclamptic  toxemia,  the  eclampsisme  of  the  French, 
and  a  patient  presenting  them  may  be  said  to  be  threatened  with  convulsions. 

The  Attack. — Wherever  the  patient  may  be,  she  falls  to  the  ground  unconscious. 
The  pupils  dilate,  the  eyes  are  turned,  and  the  head  also,  to  one  side;  the  patient 
opens  her  mouth,  then  the  jaw  is  pulled  laterally,  and  there  may  be  a  cry  or  a  sigh. 
The  whole  body  becomes  rigid;  the  features  are  distorted;  the  arms  flexed;  hands 
clinched;  the  feet  inverted;  the  toes  flexed,  and  the  whole  person  drawn  to  one  side 
in  a  tonic  spasm.  This  condition  lasts  for  a  few  seconds,  then  the  jaws  open  and 
close  violently,  the  eyelids  also,  the  twitchings  beginning  in  the  face,  then  usually 
one  arm,  then  the  leg,  and  now  the  whole  body.  This  is  a  violent  clonic  convulsion, 
which  may  throw  the  patient  out  of  the  })ed  against  any  object.  Severe  injuries  can 
result — even  fractures  of  the  skull  or  long  bones;  the  tongue  is  protruded;  the 
teeth  may  chop  it  up.  Foam,  often  tinged  with  })lood,  comes  from  the  mouth. 
The  respiration  is  completely  stopped,  the  chest  being  rigid.  The  pulse  is  high  and 
strong;  later  it  grows  weaker,  but  may  be  hard  to  feel  because  of  the  convulsion. 
In  rare  cases  the  pulse  is  weak  and  the  arterial  tension  low  from  the  start,  a  fact 
which  is  explained  by  degenerative  changes  in  the  heart.  The  blood-shot  eyes 
protrude,  the  face  is  swollen,  the  cyanosis  is  extreme,  the  lips  are  purple — altogether 
the  picture  is  a  horrible  one.  Gradually  the  convulsive  movements  remit,  a  few 
twitches  or  jerks  take  place,  the  patient  lies  quiet,  the  heart  thumping  violently 


THE  TOXEMIAS  OF  PREGNANCY  355 

against  tlio  chcst-uall.  lof  ;i  few  seconds  the  woman  appears  to  be  dying,  but 
there  is  a  long  sigh,  and  stertorous  breatiiing  l)econies  established,  coma  super- 
vening. Soon  tlie  respirations  quiet  down.  In  tlie  favorable  cases  the  patient 
wakes  up  after  a  short  time  bewildered,  severely  sore  in  all  the  muscles.  After 
from  a  f(;w  minutes  to  an  hour  another  fit  occurs,  or  she  may  have  no  more.  With 
recurring  convulsions  the  intervals  Ijecome  shorter  and  the  patient  lies  in  deep 
coma  all  the;  tim(\  Fever  now  begins;  the  pulse-rate  rises.  The  fits  may  occur 
every  five;  minutes,  but  usually  the  time  is  twenty  minutes  to  one  hour,  and  thej- 
may  show  some  regularity  of  recurrence.  Cases  are  on  record  of  81  (recovery)  and 
even  104  convulsions  (Olshausen).  These  cases  almost  invariably  die.  The  aver- 
age number  is  from  5  to  15  attacks.  The  convulsion  lasts  from  thirty  seconds  to 
two  minutes,  very  rarely  any  longer,  and  these  are  bad  eases.  Between  the  attacks 
the  patient  may  be  quiet  or  restless,  and  sometimes  there  is  great  jactitation,  with 
wild  and  exhaustive  delirium.  These  cases  usually  show  signs  of  severe  liver 
involvement. 

Pains  usually  l)egin  if  the  convulsions  are  at  all  severe,  and  laljor  is  often  rapid, 
when  once  l)egun.  After  labor  the  progress  of  the  cases  is  generally  more  favorable, 
but  the  convulsions  may  recommence  as  late  as  the  eighth  day.  Of  great  interest 
is  postpartum  eclampsia.  When  the  convulsions  begin  after  the  delivery  of  the 
child,  or  a  long  time  after  the  death  of  the  fetus,  it  is  probable  that  the  poison  was 
retained  some  place  and  finally  was  freed  so  that  it  could  unite  with  the  brain-cells 
(Liepman) . 

Marked  albuminuria  with  casts  and  blood  are  the  rule  in  true  eclampsia;  occa- 
sionally there  is  anuria.  Cases  of  eclampsia  without  albuminuria  are  due  to  apo- 
plexy, epilepsy,  meningeal  disease,  or  reflex  irritation.  Examination  of  eclamptic 
women  often  shows  tenderness  over  the  liver,  kidneys,  and  stomach,  wdth  greatly 
exaggerated  reflexes,  marked  leukocytosis,  and  often  complete  amaurosis. 

If  the  woman  is  to  get  well,  the  convulsions  grow  less  frequent  and  less  severe, 
the  coma  lightens,  the  temperature  goes  down,  the  pulse  slows,  the  cyanosis  dis- 
appears, the  mind  begins  to  clear,  and  after  from  six  hours  to  three  days,  rarely 
as  long  as  a  week,  consciousness  returns.  A  recrudescence  of  the  fever  usualh' 
means  that  sepsis  is  starting.  Recollection  of  what  happened  from  the  beginning 
is  completely  lost,  and  the  puerpera  may  deny  her  child  when  it  is  presented  to  her. 
This  amnesia  may  extend  as  far  back  as  a  w^eek  before  the  actual  attacks  began, 
and  occasionally  there  is  weakness  of  mentality  for  several  months  after  delivery. 
Puerperal  psychoses  are  not  uncommon  as  a  sequel  to  those  cases  having  had  many 
convulsions,  but  they  usually  offer  a  good  prognosis. 

In  rare  instances  the  convulsions  cease  ^^^thout  interrupting  pregnancy,  and 
the  patient  may  deliver  a  living  child  at  term.  The  author  had  a  case  where  the 
patient  had  two  attacks  during  pregnancy,  Avith  an  interval  of  three  weeks,  in  one 
of  which  attacks  the  convulsions  w^ere  so  severe  that  the  jaw  was  dislocated,  and 
yet  a  living  child  was  born  at  term.  More  usually  the  attack  kills  the  fetus,  the 
symptoms  abate,  and  the  product  of  conception  is  expelled  in  due  course  of  time. 

If  the  woman  is  going  to  che,  the  attacks  usually  increase  in  frequency  and 
force,  the  temperature  goes  up  to  103°  F.,  sometimes  to  107°F.,  or  it  sinks;  the  pulse 
increases,  becomes  weak  and  running.  Signs  of  edema  of  the  lungs  appear,  with 
rattling  and  pale  cyanosis,  even  between  the  convulsions,  or  death  may  take  place 
at  the  height  of  a  convulsion  from  apoplexy  or  heart  paralysis.  There  is  anuria 
or  hemoglobinuria,  or  one  obtains  a  few  drams  of  thick,  brownish  urine  from  the 
bladder,  which  solidifies  when  heated. 

Sometimes  the  woman  is  successfully  delivered,  but  the  pulse  does  not  improve, 
the  coma  deepens,  and  edema  pulmonum  closes  the  scene.  Some  cases  are  bad 
from  the  start,  the  patient  dying  after  one  or  two  convulsions  in  a  few  hours.  Some- 
times there  are  no  fits,  the  patient  falling  at  once  into  coma,  and  even  coma  may 


356      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

fail,  the  patient  dying  of  exhaustion  in  collapse  (Schmid) .  As  a  rule,  the  case  ends 
one  wa}'  or  the  other  within  three  days. 

Rarely  the  course  of  the  disease  is  that  of  acute  yellow  atrophy  of  the  liver, 
with  jauncUce,  petechias,  diminished  liver  dulness,  the  urinary  findings,  delirium, 
jactitation,  coma,  exitus. 

Other  Forms  of  Eclampsia. — Occasionally  after  a  severe  labor  or  during  the 
last  part  of  the  second  stage  the  parturient  will  have  a  single  convulsion  or  a  second 
milder  one,  without  or  Avith  very  slight  albuminuria.  This  is  called  eclampsia 
reflectorica,  and  is  the  discharge  of  the  overwrought  nervous  system,  but  in  all 
probability  there  is  a  toxemic  element  also. 

An  acute  collapse  after  labor,  simulating  internal  hemorrhage,  embolism,  or 
edema  of  the  brain,  and  attended  by  albuminuria,  is  of  the  same  nature  as  eclampsia, 
and  requires  careful  differentiation  from  the  other  conditions. 

Another  form  of  toxemia  occurs,  presenting  all  the  manifestations  of  eclampsia 
without  convulsions.  The  patient  sinks  at  once  into  coma,  which  is  almost  always 
fatal.     Marked  liver  autolysis  is  usually  found  at  autopsy. 

Nephritic  Eclampsia. — Women  with  chronic  nephritis  seldom  have  convulsions 
in  pregnancy  and  labor,  but  they  suffer  from  other  complications — anasarca,  uremia 
(usually  coma),  pulmonary  edema,  cardiac  paralysis,  retinitis  albuminurica, 
cerebral  hemorrhage,  then  with  convulsions,  premature  labor,  abruptio  placentae. 
Convulsions  do  occur  in  chronic  nephritics,  and  then  it  is  hard,  but  usually  possible, 
to  make  the  differential  diagnosis. 

Acute  nephritis  is  more  easily  developed  in  a  pregnant  woman  because  the  kid- 
neys are  carrying  an  increased  burden,  and,  too,  are  often  diseased  through  the 
pregnancy  changes  (the  kidney  of  pregnancy,  Ley  den),  and  when  it  does  occur, 
convulsions  almost  always  result.  An  apparently  healthy  gravida,  suddenly, 
after  exposure  to  cold,  after  a  flagrant  error  of  diet  (a  Christmas  dinner,  for  example), 
or  folloAving  an  angina,  develops  an  acute  nephritis  with  convulsions.  These  cases 
are  the  ones  which  occur  without  much  warning,  and  may  surprise  the  most  pains- 
taking accoucheur,  and  clinically  they  cannot  be  differentiated  from  true  eclampsia. 

Causation. — Eclampsia  occurs  once  in  about  600  pregnancies,  but  this  varies 
in  different  statistics  and  in  different  localities.  The  cause  of  this  variation  is 
unknown.  Primiparee  are  oftener  (3  to  1)  affected  than  multiparse,  but  in  the  latter 
the  prognosis  is  usually  worse.  It  generally  appears  in  the  last  three  months  of 
pregnancy,  but  may  occur  as  early  as  the  tenth  week  (author's  case).  Fatal  cases 
are  reported  in  the  third,  fourth,  and  fifth  months.  In  about  20  per  cent,  of  the 
cases  the  convulsions  begin  during  pregnancy;  in  60  per  cent,  during  labor,  and  in 
20  per  cent,  after  delivery.  Schroder  had  62,  190,  and  64  cases  respectively.  Pre- 
disposing causes  are  primiparity,  especially  in  advanced  years,  excessive  nervous 
irritability,  previous  disease  of  the  kidneys  or  liver  (scarlatina  or  other  infectious 
disease),  heredity  (Elliott  reports  a  case  where  a  mother  and  four  daughters  died  of 
eclampsia),  twin  pregnancy,  contracted  pelvis,  infantilism. 

In  spite  of  the  enormous  amount  of  study  that  has  been  put  upon  it,  the  real 
cause  of  the  disease  is  unknown.  The  theory  that  has  most  plausibility  is  that  of  a 
toxemia — some  poison  circulating  in  the  blood  which  produces  necrosis  of  the  liver, 
and,  directly  or  indirectly,  degenerative  changes  of  the  kidneys  and  also  convulsions, 
by  dir(;ct  toxic  action  on  the  anterior  cere]:)ral  cortex. 

Where  do  these  toxins  originate?  Many  theories  have  been  advanced.  Halbertsma  be- 
lieved that  the  uterus,  by  compressing  the  ureters,  produced  thus  a  urinemia.  This  is  disproved 
for  the  majority  of  eclamptics  by  postmortem  examination,  as  it  occurs  in  less  than  10  per  cent,  of 
the  cases.  Delore  suggested  that  bacteria  might  be  the  cause  of  the  toxemia.  Various  bacteria 
were  found  in  the  blood  anrl  the  placenta  by  Doleris,  IJlanc,  and  Favre.  Gerdes  found  a  bacillus 
which  Ilofmeister  proved  to  be  the  common  proteus,  and  Gley  found  the  Staphylococcus  aureus 
and  albus.  The  frequency  of  sepsis  after  eclampsia,  the  febrile;  nature  of  the  disease,  the  fact  that 
it  may  follow  an  attack  of  tonsillitis,  that  it  occurs  oftener  in  cold  and  damp  weather,  would  argue 
for  an  extraneous  microbic  origin.     Stroganov  states  that  eclampsia  is  an  acute  infectious  disease 


THE    TOXEMIAS    OK    PREGNANCY  3o7 

introiliiccil  iIiioukIi  iIk'  luiijis.  Many  cases  ol'  previously  healthy  women,  who,  after  a  few  days  of 
prodromal  syiiipt(jins,  develoj)  (•rlaiiii)sia,  tend  to  make  .such  a  hypothesis  very  pnjhable.  How- 
ever, up  to  the  present  no  one  has  been  abl(!  to  isolate  a  f^erm  that  could  be  considen'd  causative. 
Albert  and  Mi'iller  believe  that  the  infection  is  in  the  genitals,  and  the  toxins  produced  there,  as 
from  an  endometritis,  are  absorbed  and  cause  the  con\ulsions. 

iiouchard,  in  1SN7,  broke  new  (ground  when,  in  his  "  Leeons  sur  les  Aiito-intoxications,"  he 
advanced  the  theory  that  eclampsia  results  from  the  accumulation  of  retained  waste,  which  the 
emunctories  failed  td  f^et  rid  of.  His  l)U|)il,  JJiviere,  Ijelieved  that  an  overproduction  of  toxins 
occurred  during  pref^nancy;  that  this  was  favored  by  hyjx'remia  of  the-  kidneys  and  liver,  and  that 
these  poisons  damajied  the  kidneys.  He  sought  to  prove  these  theories  by  delermininK  the  toxicity 
of  the  blood  and  urine  in  the  eclamptic  and  non-eclamptic  gravida.  (Jther  authors,  Vollhard, 
S('huniach(>r,  and  Stewart,  disproved  these  theories. 

Then  the  liver  was  accused.  I'inard  and  liouffo  de  Saint-Blaise,  arKuerl  that  erlamp.sia  was 
a  hepatotoxemia  due  to  liver  iiisulliciency.  Ahlfeld  and  Scliinorl  have  found,  in  cases  of  typical 
eehimpsia,  pathologic  conditions  which  strongly  resemble  those  of  acute  yellow  atrophy  of  the 
liver. 

Lange  believed  that  the  thyroid  ghxnd  has  much  to  do  with  eclampsia,  and  by  administering 
iodothyrin  he  cured  the  albuminuria  of  tlu;  kidney  of  pregnancy.  Nicholson  and  others  have  ob- 
tained fa\'orable  results  with  thyroid  extract,  but  the  theory  has  not  awakened  general  interest. 
That  eclampsia  may  be  due  to  the  disturbance  of  balance  between  two  organs  with  internal  secre- 
tions which  should  neutralize  each  oth(>r  is  an  attractive  but  absolutely  unproved  hj'pothesis. 
The  parathyroids  (Vassale)  have  been  suggested,  the  ovaries  (Pinard),  the  corpus  luteum,  and 
the  mamnue  (Sellheim),  but  not  yet  the  hyi)ophysis  cerebri.  The  theory  of  Veit,  the  deportation 
and  solution  of  syncytium,  without  the  production  of  sufficient  antisyncytioto.xin,  remains  still  a 
theory. 

Numerous  investigators  have  tried  to  find  a  toxin  in  the  placenta,  but  Frankl,  in  summing  up 
their  efforts  and  his  own,  decides  that  there  are  no  toxins  in  the  placenta,  but  that  there  may  be 
ferments,  and  says  that  this  line  of  study  will  more  likely  lead  to  useful  results.  (See  also  Holland.) 
Eclampsia  has  been  held  a  form  of  anaphylaxis  due  to  the  introduction  of  a  foreign  protein. 

It  has  long  been  observed  that  the  blood  of  eclamptics  contains  an  excess  of  fibrin  (Dienst). 
This  is  probably  not  the  cause  of  the  disease,  but  is  one  of  the  effects  of  the  common  cause.  The 
same  may  be  said  of  the  high  arterial  tension  usually  found  early  in  the  disease. 

Th(>  idea  that  the  child  and  placenta  may  be  the  origin  of  the  toxins  is  not  new.  Ahlfeld 
mentioned  it  in  1894,  and  Fehling  and  Collman  support  this  view.  The  author  has  delivered 
diseased  chiklren  from  eclamptic  mothers,  and  entertains  no  doubt  but  that  the  fetus  can  sicken 
independently  of  the  mother  and  secondarily  infect  her,  or  after  delivery  continue  ill  and  die.  It 
is  more  than  probable  that  certain  cases  of  eclampsia  without  albuminuria  and  other  evidences  of 
renal  disease,  and  cases  of  nephritis  or  toxemia  developing  without  warning  in  previously"  healthy 
women,  may  be  found  to  be  due  to  a  diseased  ovum.  Bouffe  de  Saint-Blaise  in  1S8S  saw  a  case  of 
eclampsia  in  a  molar  pregnancy.  Hitschman  saw  another  in  a  girl  pregnant  four  and  one-half 
months  with  a  hydatid  mole.  These  may  be  confirmatory  of  the  above,  or  they  maj^  mean  that  a 
live  fetus  is  not  necessary  for  the  production  of  the  convulsions.  Eclampsia  may  occur  with  a 
macerated  fetus,  though  usually  the  child  dies  as  the  result  of  the  toxemia,  and  then  the  condition 
of  the  mother  improves.  Poisons  excreted  by  the  fetus  reach  the  general  circulation  without 
passing  through  the  liver,  and  perhaps  these  unoxidized  excreta  irritate  the  kidneys,  which  are  not 
able  to  throw  them  off  in  this  state.  Changes  identical  with  those  found  in  the  eclamptic  mother 
have  been  found  in  the  fetus  also  dead  of  convulsions  (Bar,  Knapp,  Dienst,  and  DeLee).  Zweifel 
has  found  sarcolactic  acid  in  the  urine  of  17  eclamptics,  in  the  blood,  and  in  the  fetal  blood.  It  was 
absent  from  the  urine  of  a  case  of  pure  uremia,  but  present  in  the  blood  of  all  children  born  dead 
and  in  all  the  placentae  examined.  These  experiments  are  in  line  with  the  newer  theories  of  acid 
intoxication.  Zweifel  has  not  proved  that  the  lactacidemia  is  the  cause  of  eclampsia — only  that 
the  lactic  acid  is  present  in  the  urine  of  eclamptics.  This  finding  occurs  also  in  cases  of  aspliyxia, 
dyspnea,  exhaustion  from  severe  physical  effort,  some  febrile  conditions,  and  poisoning  b}'  mor- 
phin,  curare,  strychnin,  veratrin,  cocain,  phosphorus,  etc. 

Since  Rayer  and  Lever  (1843)  proved  the  presence  of  albumin  in  the  urine  of  eclamptics,  and 
later  students  found  the  indications  of  a  nephritis  almost  invariably  in  the  urine,  the  idea  gained 
ground  that  eclampsia  was  allied  to  uremia.  Carl  Braun  said  the  convulsions  were  due  to  acute 
renal  insufficiency.  While  at  autopsy,  or  in  the  urine,  one  will  rarely  miss  evidences  of  nephritis 
(Ingerslev  and  Charpentier  have  found  2.50  cases  in  the  literature  without  them),  still  the  weight 
of  clinical  and  postmortem  evidence  is  against  the  view  that  kidney  disease  is  the  cause  of 
eclampsia.     It  is  more  likely  a  result  of  the  action  of  another  cause,  and  is  secondary,  not  primary. 

Studies  of  the  maternal  metabolism  show  that  there  is  an  alteration  in  nitrogenous  catab- 
olism.  It  has  long  been  known  that  there  is  a  decrease  of  the  total  urea  output,  but  recent  studies 
by  Whitney  and  Williams  show  that  the  amount  of  ammonia  nitrogen  equals  or  even  exceeds  the 
urea  nitrogen  in  the  urine.  It  is  possible  that  study  of  the  metabolism  will  lead  us  to  a  solution  of 
the  problem,  but  nothing  of  great  valu(>  has  yet  been  discovered. 

Ammonium  carbonate  (Spiegelberg),  carbamic  acid  (Ludwig  and  Savor),  or  leukomains 
(Massen)  circulating  in  the  blood  are  mere  theories.  It  would  lead  us  too  far  to  go  deeper  into 
this  mass  of  hypotheses. 

The  theory  that  eclampsia  is  due  to  an  intoxication,  is  a  toxemia,  is  most 
generally  accepted,  while  it  is  admitted  that  the  source  and  the  nature  of  the  poisons 
are  unknown.     If  we  icnew  whether  the  toxins  came  from  the  liver,  the  fetus,  the 


358      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

placenta,  the  intestines,  the  general  metabolism,  disturbed  glandular  balance,  from 
bacterial  activity  or  from  any  other  source,  it  would  help  our  treatment  immensely, 
but  as  yet  we  are  groping  blindly,  empiricallj^ 

The  Cause  of  the  Convulsion. — Here  again  there  is  much  room  for  speculation. 
Without  doubt  the  nervous  system  of  the  pregnant  woman  is  in  a  state  of  hyper- 
excitability.  This  may  easily  be  determined  by  testing  the  exaggerated  reflexes. 
Perhaps  this  is  another  result  of  the  toxemia  of  pregnancy.  Older  writers  classed 
eclampsia  as  a  neurosis  (Dubois),  and,  in  fact,  it  is  more  common  in  neurotic  women. . 
Dlilirssen  explains  the  convulsions  as  being  due  to  a  spasm  of  the  blood-vessels  of 
the  brain,  the  liver,  or  the  kidneys,  from  an  irritation  proceeding  from  the  uterus. 


Focal 
necrosis 


Edema     ^    .i\  j^    *>     /''•*.• --v. 'J-"o  i*,i  V..^,  .-•',.  '  -V  'l3v^'W"V':s''i'-'".' o  ••'.•'    ,,    .?     Subserous 

^^ ^       :f   r^        '     '•','  1***5 t!°v..<'fi,      ■J','*t'  '  "^"?^t;S'sV*^i>W-%'>  *'•        8       hemor- 

Fig.  340. — Eclamptic's  Liver. 

Spasm  of  the  vessels  of  the  l^rain  causing  acute  anemia  and  edema  may  cause  the 
fits,  and  analogy  is  drawn  from  cases  of  epilepsy.  One  need  not  go  far  for  ah  ex- 
planation of  the  convulsions  if  the  toxemic  theory  is  proved, — the  toxins  irritate  the 
nerve-centers,  as  do  other  specific  poisons,  strj^chnin,  tetanus,  etc., — but  the  toxin 
of  eclampsia  has  a  special  affinity  for  the  cortex  of  the  forepart  of  the  brai»,  as  is 
shown  by  the  constancy  of  convulsions  and  coma  and  the  mental  symptoms. 
Individual  convulsions  in  a  case  of  eclampsia  may  })e  elicited  by  any  external  irri- 
tant, for  example,  jarring  of  the  bed,  slamming  of  doors,  bright  lights,  external  or 
internal  examination,  the  induction  of  labor,  a  hypodermic  injection,  an  enema, 
catheterization,  delivery  of  fetus,  etc. 

Pathologic  Anatomy. — Brain. — Flattpning  and  modorato  odoma  of  the  convolutions, 
somftirncs  with  anemia,  .soinctiincs  with  fon^ostion.  Small  or  larjic  hemorrhages  or  areas  of 
Gcrebrai  s^of toning  with  tlirombosis  occurred  in  58  of  65  autopsies  (Schmorl).     Apoplexy  is  not 


THE   TOXEMIAS    OF    PREGNAN'CY 


359 


••'••  1 


> 


'/ 


"V-  -*^  .      >.;•.,<-'  ■/•■.'*•;'.•  •,.-•• 
..i-^  -^' J.: •.•-'-■'•■■.•  .i'i- •••«  J 


Fig.  341. — Thrombus  in  Ecla.mptic  Liver. 


uiicomrnon,  cspci-ially  iiiti)  tlic  \ciitrirlc's.     In  uriu.siiul  ca.scs  otiicr  cuuscs  for  the  convulsions  are 
foiiiul,  ;i.s  tubercle,  t unions,  ineninf^itis,  i)lios[)lioru.s-i)oi.soninir,  etc. 

Lii'cr. — Here  tlie  most  typical  cliaiiges  are  found;  indeed,  one  can  almost  make  the  diagnosis 
from  the  liver  at  autop.sy  ( i"'iK- 
'.i-ii)).  Tiiere  is  albuminoid  de- 
Kenerutioii  with  hemorrlia>j;ic 
and  anemic  necroses.  These 
focal  necroses  occur  near  the 
small  i)ortal  v(>ssels,  which  are 
often  thrombotic  (Fifi-  •^41), 
and  may  be  seen  by  the  naked 
eye.  In  addition  there  is  fatty 
defeneration  of  the  ix'riphery 
of  tlie  lobules,  which  may  be  so 
marked  as  to  make  the  slide  re- 
semble one  from  a  case  of  acute 
yellow  atrophy  of  the  liver,  a 
fact  pointed  out  by  Jiirp;ens, 
Stumpf,  Ahlfeld,  and  others. 
There  may  b(>  a  general  autoly- 
sis of  th(!  liver  or  onl>-  cloudy 
swelling.  lle}>atitis  and  peri- 
hepatitis liaMuorrhagica  ;u'e  also 
occasionally  found.  These 
changes  show  how  profoundly 
the  liver  is  affected  by  the  cir- 
culating poisons  if  the  liver  dis- 
ease is  not  the  i)rim;u'y  trouble 
and  the  general  eclamptic  sj'n- 
drome  the  result  of  acute  he- 
patic insufficiency.  (>See Ewing.) 
Kidneys. — Almost  always 
some  signs  of  disturbance  are 
present.  In  289  cases  observed 
from  1S92  to  1900  in  the  Berlin 
Charite  there  were  symptoms 
referable  to  the  kidneys  in  every 

one,  and  changes  were  found  in  all  that  went  to  autopsj'.     Schmorl,  in  73  autopsies,  found  only 
1  with  normal  kidneys.     A  very  severe  congestion  exists  in  some  cases — often  the  signs  of  a  more 

or  less  acute  nephritis.     Cloudy 
~         "  /'        "  •    "k  t  "      swelling  and  fatt}' degeneration 

*      '         **        »*  •  *'  of  the  epithelium  are  the  rule. 

Thrombosis  of  the  glomeruli 
and  smaller  veins  and  arteries 
are  common.  The  kidney  of 
pregnancy,  with  an  acute 
inflammation, — t  h  e  so-called 
pregnancy  nephritis, — occurs 
in  a  majoritj'  of  cases,  and  this 
is  hard  to  distinguish  from 
acute  parenchymatous  nephri- 
tis. Degenerative  changes  are 
seldom  missed,  a  fact  which  is 
usually  easily  discovered  in  the 
urine.  Further,  we  find  all 
forms  of  subacute  and  chronic 
Bright 's  disease.  Swelling  of 
the  kidney  so  that  it  stretches 
its  capsule  is  rare,  as  is  shown 
at  operations  of  decapsulation 
(Edebohls).  Dilatation  of  the 
ureters  is  found  occasionally, 
particularly  the  right,  but  has 
no  significance.  While  renal 
changes  are  almost  invariably 
found,  most  authors  are  con- 
\-inced  that  they  are  secondary 
either  to  the  general  toxemia  or 
to  the  disease  of  the  liver. 

Circulatory  System. — The 
ventricles   are   usually   con- 
tracted, the  auricles  full  of  dark  blood  which  does  not  clot  readily,  contrary  to   the  condition  of 
hyperinosis  which  existed  during  life.     The  heart  muscle  is  fatty,  with  tiny  hemorrhages,  necroses, 
and  thrombi ;  it  tears  easily,  and  these  changes  may  be  a  cause  of  death.     Fattj-  heart  is  found  espe- 


i 


|V 


•r.,  -, A  ••.  <*■  T^  v  ■.♦•,  V-*  ':■  w  ■ 


,cio^ 


Fio.  342. — Kidney  ix  Eclamp.si 


360      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

cially  in  those  cases  which  had  been  given  large  doses  of  chloroform  and  chloral,  a  fact  which  warns 
to  care  in  the  administration  of  these  drugs.     There  may  be  subpericardial  hemorrhages. 

Thromboses  and  emboli  in  fine  vessels  ai-e  very  common  in  the  lungs,  liver,  kidneys,  brain, 
and  skin;  they  consist  of  liver-cells,  endothelium,  and  syncytium.  The  last  has  no  significance, 
being  found  in  normal  puerperae.  During  life  the  blood  contains  an  excess  of  fibrin  and  coagulates 
very  quicklj^,  so  that  often  it  is  impossible  to  perform  venesection  properly.  Microscopic  findings 
of  the  blood  in  eclampsia  are  not  constant.  The  reds  are  sometimes  increased  (in  one  instance  to 
9,000,000),  which  is  due  to  tlie  concentration  of  the  blood,  and  there  is  marked  leukocytosis  (40,000), 
especially  noted  in  the  multinuclears. 

The  Lungs. — Almost  always  congestion  and  edema  are  found,  and  very  often  hemorrhages, 
which  are  usually  under  the  pleura?.  Bronchopneumonia  is  not  rarely  found,  due  to  admission  of 
food-particles,  blood,  slime,  etc.,  into  the  air-passages — aspiration  pneumonia.  Septic  pneumonia, 
and,  oftener  in  general  hospitals,  croupous  pneumonia,  may  be  the  cause  of  death.  Gangrene  of 
the  lung  is  sometimes  the  cause  of  death.  Small  arterial  and  venous  thromboses  and  emboli  of 
fat,  liver-cells,  decidual  cells,  and  cells  that  look  like  hypertrophied  nuclei  of  lymphoid  cells  of  the 
bone-marrow,  that  is,  syncytium,  are  constant  findings.  These  are  not  characteristic,  occurring 
in  other  conditions. 

The  Fetus. — Bar  and  others  have  found  changes  in  the  child  which  correspond  very  closely 
mth  those  in  the  mother,  especially  when  the  child  died  of  convulsions. 

Diagnosis. — Convulsions  and  coma  during  pregnancy  may  come  from  brain 
tumors,  tubercle,  apoplexy,  meningitis,  pneumonia,  epilepsy,  hysteria,  phosphorus, 
strychnin  and  other  poisonings,  uremia,  and  true  eclampsia.  Characteristic  for 
true  eclampsia  are  repeated  convulsions  with  coma,  or  at  least  lethargy,  between 
them,  early  fever,  and  marked  albuminuria,  with  other  findings  of  renal  involvement. 
The  history  of  the  case  will  almost  always  exclude  poisoning,  but  medicolegally  a 
differential  diagnosis  ma}^  occasionally  be  necessary,  and  this  may  not  always  be 
possible,  even  at  autopsy,  because,  for  example,  the  liver  in  cases  of  phosphorus 
death  resembles  acute  yellow  atrophy.  Epilepsy  is  eliminated  by  the  history  of 
previous  convulsions,  but  the  first  attack  of  a  permanent  neurosis  may  occur  during 
labor,  or,  as  occurred  in  a  case  of  the  author,  epilepsy  may  be  inaugurated  by  an 
attack  of  eclampsia,  a  fact  which  was  also  noted  by  Fere.  The  contracted  pupils 
and  diminished  or  absent  reflexes  are  good  points  in  favor  of  epilepsy.  Epileptic 
attacks  seldom  occur  during  pregnancy  and  labor,  and  are  usually  single,  but  the 
status  epilepticus  may  cause  trouble  in  making  the  differential  diagnosis.  Here  the 
slight  or  absent  urinary  findings,  the  late  presence  of  fever,  diminished  reflexes, 
and  the  history  must  help. 

Hysteria  will,  cause  no  trouble  to  an  observer  who  has  seen  both  conditions. 
An  atypical  convulsive  seizure,  lasting  a  long  time,  with  grotesque  motions  and 
spastic  contractions  of  muscle  groups,  retained  consciousness,  and  mobile  pupil, 
without  cyanosis  or  stertorous  respiration  or  fever,  or  urinary  findings,  serve  to 
make  the  differentiation  easy. 

Organic  disease  of  the  brain  must  be  diagnosed  by  the  usual  medical  methods, 
but  mistakes  are  very  liable  to  occur  in  cases  of  meningitis,  tubercle,  and  apoplexy. 
Spinal  puncture  may  be  required.  The  Wassermann  reaction  may  not  be  used  in 
differentiation  because  it  has  been  found  in  8  cases  of  true  eclamjosia  by  Semon. 
The  treatment  must  be  carried  out  on  obstetric  lines. 

From  uremia  it  is  impossible  to  separate  true  eclampsia  unless  the  preexistence 
of  nephritis  is  known,  but  often  the  general  picture  of  the  case  impresses  the  ob- 
server as  one  of  renal  insufficiency,  and,  again,  another  case  gives  almost  indubitable 
signs  that  the  liver  is  at  fault.  Delirium,  jactitation,  jaundice,  and  petechise  point 
to  hepatic  involvement.     Treatment  in  all  cases  is  the  same. 

Prognosis. — Over  20  per  cent,  of  women  afflicted  with  eclampsia  die,  and  this 
has  been  hardl}^  affected  by  changes  of  treatment  in  the  last  one  hundred  years. 
Wyder  collected  large  statistics,  and  showed  a  general  mortahty  of  20  per  cent,  and 
a  mortality  of  10  per  cent,  of  cases  which  developed  in  the  maternities.  The 
prognosis  varies  in  different  countries,  in  different  years,  and  to  a  certain  extent 
with  different  operators.  Statistics  vary  from  5.31  per  cent.  (Stroganov)  to  45.7 
per  cent.    (Biittner)   for  the  mother,  and  from  30  to  42  per  cent,  for  the  child. 


THE    TOXEMIAS    OF    PREGNANCY  3G1 

(See  Peterson.)  \\'licii  attacked  1)\'  tiue  eclampsia  multiparae  probably  are  no 
more  eii(hiii<i;ere(l  than  priinipara',  hut  since;  renal  disease  is  nion;  eoinnion  in  them, 
the  i)rognosis  is  usually  worse  when  e(jnvulsions  (K-eur.  Eclampsia  oc(;urring  during 
pregnancy  has  the  highest  mortality,  during  labor  less,  and  during  the  puerperium 
the  least,  })ut  the  experience  of  the  inthvidual  observers  may  be  otherwise,  as  in  the 
author's  cases  tlu;  worst  have  been  those  wlu^re  the  attacks  began  postpartum. 

For  the  child  the  chances  are  not  good,  nearly  one-half  of  the  children  dying, 
a  result  that  is  due  to — (1)  Prematurity;  (2)  toxemia;  (}i)  asphj'xiation  by  the 
repeated  convulsions  (jf  the  mother,  with  prolonged  cyanosis;  (4)  drugs  (morphin, 
chloral)  administereil  to  the  mother;  (5)  injuries  sustained  during  birth,  especially 
forced  delivery.     The  child  may  die  of  eclampsia  after  delivery. 

One  nmst,  therefore,  in  individual  cases  give  a  V(;ry  guarded  prognosis,  even  in 
the  apparently  favorable  ones,  because  death  may  occur  in  coma  after  one  or  two 
convulsions.  Death  comes  from  exhaustion,  heart  failure,  toxemia  (the  system 
being  overwli(4nied  by  the  poison,  such  cases  being  evidenced  by  deep  coma,  w'ith 
few  or  no  convulsions),  embolism,  thrombosis  of  the  pulmonary  artery,  fat  embolism 
of  the  lungs,  hemorrhage  into  the  brain,  pulmonary  edema,  oedema  laryngis,  and 
asphyxiation.  Further,  the  patient  is  endangered  by  the  results  and  accidents 
of  severe  operations  undertaken  to  deliver  her,  as  ruptura  uteri,  postpartum  hemor- 
rhage from  cervix  tear,  and  from  sepsis.  Infection  is  a  common  cause  of  death, 
and  eclamptics  show  a  decided  susceptibility  to  it. 

In  individual  cases  the  pulse  is  the  best  index.  If  it  remains  full  and  hard, 
below  120,  there  is  no  immediate  clanger,  but  if  faster,  weak,  compressible, 
or  even  running,  the  prognosis  is  bad.  High  fever  is  not  necessarily  a  bad  prog- 
nostic sign  unless  it  runs  above  104°  F.  and  is  going  higher.  Sjmiptoms  of  edema 
of  the  lungs,  rattling  in  the  chest,  bloody  froth  from  the  mouth  and  nose,  %\ith 
cyanosis,  are  usually  precursors  of  death,  but  may  respond  to  treatment.  Pro- 
longed and  violent  fits  or  frequently  repeated  attacks  with  short  intervals,  or  both, 
give  a  bad  outlook,  but  recovery  has  occurred  after  81  attacks,  though  this  is 
unusual.  When  the  number  exceeds  20,  the  prognosis  gradually  becomes  worse. 
If  the  severity  of  the  symptoms  abates  after  delivery,  the  woman  usually  gets  w'ell. 
Rarely  is  there  a  recurrence  of  the  fits  after  hours  or  days,  and  if  there  is,  recovery 
is  the  rule.  Such  cases  are  likely  to  show  a  large  number  of  attacks,  for  example: 
Jardine,  207;  Engelman,  200.  It  is  doubtful  if  these  were  true  eclampsia.  Deep 
cyanosis  between  attacks  is  an  unfavorable  symptom,  as  also  is  extreme  jactitation. 
Anuria  and  intense  albuminuria  are  of  bad  omen,  and  more  hope  is  justified  as  soon 
as  the  kidneys  show  signs  of  recovery.  Apoplexy  is  almost  alwaj^s  fatal,  but  some- 
times part  of  the  bod^y  will  be  paretic  or  paralyzed  from  a  focal  edema  which  dis- 
appears during  convalescence. 

After  delivery  the  puerpera  is  not  out  of  danger.  Aspiration  pneumonia  is 
not  rare,  the  result  of  slime,  blood,  food,  etc.,  being  draw^n  into  the  lungs  b}-  the  deep 
stertorous  respiration.  The  tongue  may  be  so  severely  bitten  during  the  fits  that 
it  may  become  so  swollen  as  to  demand  intubation  or  tracheotomy  to  prevent 
suffocation.  Pneumonia,  too,  ma}^  result  from  the  infected  bitten  tongue.  Sepsis 
is  common,  and  usually  runs  a  severe  course,  since  the  kidneys  and  liver  are  already 
diseased. 

After  delivery  the  albumin  quickly  diminishes  in  amount,  and  may  have  been 
reduced  to  a  trace  by  the  time  the  puerpera  leaves  her  bed,  disappearing  entirely 
in  from  three  to  twelve  weeks.  A  longer  persistence  of  the  urinary-  fuidings  indi- 
cates permanent  damage  to  the  kidney  parench>ana,  and  one  should  be  guarded  in 
prognosis.  In  subsequent  pregnancies  albuminuria  and  casts  may  recur,  even 
convulsions  (Diihrssen,  1.5  per  cent.),  but  we  must  decide  that  a  chronic  though 
latent  nephritis  has  existed  in  the  mean  time.  >\Iany  authors  believe  that  one  attack 
of  eclampsia  confers  immunity,  but  such  is  not  the  case.     Even  the  kidney  of  preg- 


362      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

nancy  may  recur.  It  has  been  held  that  the  kidney  of  pregnancy  never  left 
permanent  changes  in  the  organs.  This  statement  can  be  neither  questioned  nor 
proved,  because  it  is  never  possible  to  demonstrate  absolutely  that  the  woman  did 
not  carry  into  her  pregnancy  a  latent  nephritis,  dating,  perhaps,  from  a  scarlatina 
or  infection  in  infancy. 

Treatment. — Prevention. — One  can  speak  of  rational  prophylaxis  only  when  the 
cause  of  disease  is  known.  Since  we  do  not  know  the  cause  of  eclampsia,  our  treat- 
ment is  all  empiric.  Even  so,  more  can  be  accomplished  by  prevention  than  by 
treatment,  because  after  the  convulsions  have  set  in  the  nervous  balance  is  over- 
thrown. We  cannot  prevent  the  action  of  the  primary  cause  of  the  eclampsia, 
but  by  carefully  watching  the  pregnant  woman  we  may  discover  the  first  manifesta- 
tions of  the  action  of  such  noxious  influences,  and  by  appropriate  measures  either 
ward  them  off  entirely  or  interrupt  the  pregnancy  before  the  disease  reaches  a  climax. 
It  is  the  pregnancy  that  favors  the  development  of  eclampsia.  If  we  cannot  pre- 
vent and  cure  eclampsia,  we  can  remove  the  pregnancy.  If  the  earliest  signs  of  the 
impending  catastrophe  can  be  detected,  emptying  the  uterus  will  almost  invariably 
prevent  a  fatal  issue. 

The  prevention,  in  a  general  way,  is  equivalent  to  the  conduct  of  the  hygiene 
of  pregnancy.  Every  pregnant  woman  should  be  considered  a  possible  candidate 
for  eclampsia,  and  all  our  efforts  should  be  directed  to  save  her.  Greater  watch- 
fulness is  imperative  if  the  family  history  presages  trouble,  for  example,  if  the  mother 
had  eclampsia,  if  the  parents  were  neurasthenic,  insane,  or  alcoholic,  these  indicating 
a  hereditary  instability  of  the  nervous  system  which  may  lead  to  disorders  of 
metabolism,  especially  during  the  crucial  test  of  pregnancy.  The  personal  history 
is  important;  for  example,  if  the  patient  had  eclampsia  or  declared  renal  disease 
before;  if  she  has  had  diseases  which  may  have  damaged  kidneys  or  liver,  especially 
the  acute  infections;  if  she  is  of  a  "bilious  type,"  one  is  on  the  lookout. 

If,  in  spite  of  the  hygienic  rules  laid  down  for  the  patient,  the  symptoms  of 
toxemia  appear,  or  if  the  urine — which  should  be  examined  as  a  routine  duty 
every  two  weeks  in  the  latter  months  of  pregnancy^shows  evidences  of  deficient 
renal  activity,  the  patient  is  put  on  a  strict  prophylactic  regimen.  Albuminuria  is 
the  most  important  finding,  and,  in  the  author's  experience,  is  never  marked  without 
toxemic  symptoms.  Diminished  daily  amount  of  urine  and  decrease  of  total  solids 
are  next  in  importance.  Casts,  unless  granular  and  cellular,  are  not  unusual  in  the 
urine,  but  they  may  not  be  numerous  without  exciting  suspicion;  white  and  red 
blood-corpuscles  with  renal  epithelium  show  the  acuteness  of  the  process.  The 
percentage  of  urea  is  not  a  reliable  index  of  the  nearness  of  the  attack,  but  it  is  a 
valuable  adjunct  to  the  diagnosis,  since  when  a  woman  passes  less  than  half  the 
amount  of  urea  considered  normal  and  has  albuminuria,  we  can  suspect  derange- 
ment of  the  liver  and  kidneys.  If  the  urea  steadily  diminishes  while  the  albumin 
increases,  the  danger  signs  are  unequivocal.  In  suspected  cases  weekly  and  even 
daily  examinations  of  the  urine  are  made.  As  stated  in  the  chapter  on  the 
Hygiene  of  Pregnancy,  all  gravidas  are  requested  to  notify  the  physician  if  any 
untoward  symptoms  arise,  and  the  accoucheur  should  give  these  women  a  large 
amount  of  personal  attention,  because  the  symptoms  will  show  that  trouble  is 
brewing  long  before  the  urine  discloses  the  fact. 

When  the  first  signs  or  symptoms  of  toxemia  occur,  treatment  must  be  at  once 
instituted.  It  will  proceed  along  three  lines:  (1)  The  diet  should  be  so  ordered 
that  just  enough  nitrogenous  matter  is  given  to  sustain  life,  in  the  form  easiest 
assimilated,  and  that  will  leave  the  least  amount  of  waste  and  by-products,  which 
throw  extra  work  on  the  liver  and  kidneys.  (2)  The  emunctories  should  be 
stimulated  to  throw  off  the  surcharge  of  poisons  already  in  the  blood.  (3)  Should 
the  above  treatment  not  have  the  nc^cdful  effect;  should  the  evidences  of  renal  in- 
sufficiencj'  increase;  or  should  the  signs  of  a  real  nephritis  appear,  the  induction  of 
premature  labor  is  not  only  justifiable,  but  imperatively  indicated. 


tup:  toxemias  of  pregnancy  363 

(Ij  In  a}^{i;ravated  cases  of  toxomia,  and  wliin  the  kidney  is  involved  in  even  a  moderate 
deforce,  it  i.s  well  at  once  to  put  the  ixiticid  tu  hcil  and  allow  nothinfj;  but  water  to  drink.  After  three 
days,  when  iniprox'cincnt  i.s  apfjurcnt,  an  aljsolutc  milk  diet  is  (jrdered.  Tlif  French  are  tiic  most 
ardent  supporters  of  tiiis  treatment,  and  in  my  hands  it  has  given  exeellent  results.  As  the  con- 
dition inii)roves  starches  are  added  to  the  diet,  tlien  the  proteid  vegetables,  with  the  vegetable  oils 
and  butter.  If  the  improvement  is  j)rogre.ssive,  full  vegetarian  diet  with  the  milder  fruits  and  one 
egg  a  day  may  be  allowed.  Later  a  little  fish,  chicken,  or  turkey  is  added,  l)ut  never  a  full  meat 
diet.  Spices,  tea,  coffee,  alcoholics,  beef,  veal,  mutton,  and  i)ork  are  strictly  fcjrbidden.  Water  is 
given  in  large  amounts  imless  the  heart  is  already  overloaded,  liuttcrniilk,  matzfjon,  and  kumiss 
are  recommended.  My  experience  with  a  salt-free  diet  has  been  disappoint  ing.  The  edema  was 
somewhat  lessened  by  it,  Init  the;  condition  of  the  patients  was  not  materially  improved. 

(2)  One  may  increa.se  excretion  by  the  bowels,  the  kidneys,  the  skin,  and  the  lungs.  A 
brisk  saline  i)urge  is  given  at  the  start,  and  the  bcnvels  are  kept  open  by  salines,  alternating  with 
vegetable  cathartics,  sincie  continuous  administration  (jf  the  former  leads  to  anemia  and  headaches. 
Water  is  administenul  morning  and  night  on  an  empty  stomach.  It  is  both  laxative  and  diuretic. 
Diuresis  is  favored  by  the  ingestion  of  liquids,  especially  hot  water  in  large  amounts.  This,  in 
combination  with  the  milk  diet,  does  not  fail  to  produce  polyuria.  Buttermilk  is  also  given,  but 
the  vegetable  diuretics  and  diuretin  are  not  reconunended. 

The  skin  is  to  be;  kept  fr(>c  from  chill  by  woolen  undergarments,  which  should  be  worn  even 
in  summer.  If  the  symptoms  of  toxemia  are  urgent,  hot  wet  packs  twice  daily  are  ordered.  A 
word  of  warning  here:  patients  with  weak  hearts  may  die  in  such  a  sweat,  for  which  reason  careful 
watching,  handy  stinudants,  and  oxygen  are  demanded.  Some  authors  condemn  sweating  in  these 
cases  and  in  eclampsia,  claiming  that  it  is  too  depressing,  that  it  concentrates  the  poison  in  the 
blood,  and,  on  the  other  hand,  the  amount  of  toxin  removed  is  inconsiderable.  The  author  makes 
very  little  use  of  sweats.  Jaborandi  is  heartily  condemned,  even  when  the  patient  is  conscious,  as  it 
is  dangerous  and  unnecessary.  Of  drugs,  the  author  uses  few.  Hexamethylenamin,  .5  grains  four 
times  daily,  in  two  cases  seemed  to  do  good,  but  the  author  wishes  more  experience  before  recom- 
mending it.     It  was  given  on  the  bacterial  theory  of  toxemia. 

A  valuable  means  for  starting  the  skin  and  kidneys  is  the  subdermal  injection  of  0.7  per  cent, 
salt  solution.  It  is  used  only  in  the  advanced  cases,  when  eclampsia  is  threatening  and  ciuick 
action  is  needed.  Fresh  air  in  abundance  aids  excretion  by  the  lungs,  and  the  patient  is 
instructed  to  fill  and  empty  the  lungs  by  very  deep  breaths  in  fresh  air  ten  times  each  morning  and 
evening. 

When  treatment  faithfully  carried  out  on  the  lines  here  laid  down  has  failed  to 
produce  sufficient  amelioration  of  the  symptoms,  if  the  evidences  of  renal  insuffi- 
ciency persist  or  grow  worse,  and  especially  if  a  tendency  to  sleep,  twitchings,  or 
other  symptoms  of  eclampsia  threaten,  the  pregnancy  should  be  terminated. 

The  symptoms  that,  in  my  opinion,  most  surely  indicate  the  near  approach 
of  convulsions  are:  Headache,  occipital  or  frontal;  seeing  colored  lights  or  "span- 
gles"; amaurosis  or  changes  in  the  retina  seen  ^^dth  the  ophthalmoscope;  twitch- 
ing of  the  muscles;  somnolence  or  insomnia;  nausea  and  vomiting;  pain  in  the 
epigastrium;  subicterus;  general  edema  of, the  body;  high  arterial  tension  and 
marked  albuminuria.  Rarely  one  or  the  other  sj^ixiptom  will  stand  out  very  prom- 
inently, or  several  may  be  absent.  Marked  leukoc>"tosis  is  also  significant,  and  in 
doubtful  cases  the  permeability  of  the  kidneys  could  be  tested  with  the  phenol- 
sulphophthalein  and  other  tests,*  though  thus  far  the  results  are  not  of  any  great 
value. 

How  long  one  should  wait  to  see  the  effects  of  treatment  depends  on  the  indi- 
vidual case  and  on  the  attendant's  experience,  but  the  final  proof  of  our  deep  ignor- 
ance of  the  nature  of  these  affections  is  brought  hj  the  fact  that  sometimes,  when. 
these  patients  go  untreated,  eclampsia  does  not  occur,  and  when  treatment  has 
produced  apparent  cure,  the  convulsions  occasionally  manifest  themselves,  as  in 
one  case,  where  the  patient  had  been  in  bed  under  medical  treatment  for  six  weeks, 
was  successfully  delivered,  but  three  days  postpartum  convulsions  developed 
and  death  ensued.  Eclampsia  is  not  ahvaj's  a  preventable  disease,  as  Davis  and 
Edgar  claim,  a  view  which  is  supported  In'  Williams.  As  yet  we  have  no  certain 
index  of  impending  eclampsia — all  we  can  say  is  that  the  gravida  presents  the  S}ii- 
drome  of  a  disease  in  which  convulsions  are  the  usual  termination,  and  that  it  is 
wisest  to  terminate  the  pregnane}^,  the  ultimate  cause  of  the  disturbance. 

Methods. — That  method  of  inducing  premature  labor  .should  be  selected  which  will  empty 
the  uterus  quickest  and  with  least  traumatism.  The  symptoms  rarely  are  so  threatening  as  to 
demand  excessive  haste.  In  multipara?  the  simple  rupture  of  the  membranes  is  usually  sufficient, 
pains  coming  on,  as  a  rule,  mthin  twenty-four  hours.     In  primipara;  it  is  better  to  prepare  the 

*  Jour.  Amer.  Med.  Assoc,  Symposium  of  the  June,  1912,  Meeting. 


364      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

cervix  by  packing  it  and  the  lower  uterine  segment  with  gauze  for  from  twelve  to  twenty  hours. 
Pains  are  elicited,  the  tissues  softened,  and  the  chances  of  injury  to  the  cervix  and  danger  to  the 
fetus  diminished.  Alter  removal  of  the  gauze  the  membranes  are  punctured,  the  liquor  amnii  is 
allowed  to  drain  off,  and  then  a  colpeuryntcr  is  inserted,  which  evokes  strong  pains  and  completes 
the  dilatation,  so  that  when  the  bag  is  expelled  the  child  soon  follows.  (See  Induction  of  Labor.) 
After  labor  has  been  inaugurated  it  should  be  terminated  as  soon  as  the  conditions  will  permit,  as 
experience  has  shown  that  eclampsia  is  less  likely  to  occur  postpartum  after  a  quick  delivery. 
The  pains  seem  to  elicit  convulsions  in  some  cases,  and  if  eclampsia  is  very  imminent,  it  may  be 
best  to  select  an  operation  which  empties  the  uterus  in  one  sitting.  Accouchement  force  (forced 
deUvery  after  rapidly  dilating  the  cervix  by  steel  dilators,  bags,  or  the  hands,  in  one  sitting)  is  to 
be  condemned,  since  it  is  dangerous  to  the  mother  and  fetus.  Deep  lacerations  are  the  rule,  and 
sometimes  they  extend  into  the  peritoneal  cavity.  Vaginal  cesarean  section  is  a  better  operation 
in  urgent  cases,  but  sometimes  it  presents  insurmountable  difficulties;  fot  example,  the  cervix  will 
not  come  clown  by  traction  so  that  it  may  be  incised,  but  tears  if  the  attempt  is  forced;  the  broad 
ligaments  may  be  edematous  and  fix  the  uterus  high  in  the  abdomen;  hemorrhage  may  be  so 
profuse  that  the  field  becomes  dangerous  to  work  in;  even  deep  anterior  and  posterior  incisions 
may  fail  to  produce  sufficient  room  to  deliver  the  child  unmutilated,  because  of  rigidity  of  the  un- 
prepared parts.  If  it  were  possible  to  recognize  beforehand  all  these  difficulties  and  complications, 
the  best  method  of  deli\'ery  would  be  abdominal  cesarean  section.  This  operation  will  rarely  be 
called  for,  because  usually  the  simpler  methods  suffice,  and,  further,  the  abdominal  delivery  has 
shown  a  very  high  mortality.  The  kidneys  are  much  concerned  in  all  operations  which  open  the 
peritoneal  ca\aty,  and  are  likely  to  be  severely  affected.  Sepsis  is  much  more  common.  However, 
in  eclampsia  occasionally  a  case  will  occur  where  the  urgency  of  the  symptoms  is  great,  the  cervix 
closed,  laigh,  hard,  the  patient  a  primipara  with  rigid  vagina  and  perineum,  and  the  abdominal 
deHvery  will  offer  the  easiest  and  safest  solution  of  all  the  difficulties.  Of  course,  a  contracted 
pelvis,  placenta  prsevia,  or  other  complication  may  alter  the  method  of  procedure. 

The  question  of  anesthesia  deserves  careful  thought.  Formerly  it  was  taught  that  every 
manipulation  should  be  done  under  anesthesia,  because  it  was  feared  that  the  irritation  would 
bring  on  a  convulsion — a  point  emphasized  by  R.  Barnes.  Experience  has  shown  that  anesthetics 
are  particularly  dangerous  in  such  conditions  because  of  their  destructive  action  on  the  kidney,  the 
liver,  and  the  blood.  Ether  is  less  dangerous  than  chloroform,  but  even  this  is  used  only  for  opera- 
tive delivery.  The  danger  of  provoking  convulsions  actually  exists,  but  it  is  estimated  to  be  less 
than  the  damage  done  to  liver,  kidneys,  and  blood  by  the  poisonous  narcotics. 

Treatment  of  Eclampsia.  —  When  the  pregnant,  parturient,  or  puerperal 
woman  has  had  the  first  convulsion,  the  case  at  once  assumes  a  most  serious 
aspect.  The  nervous  balance  has  been  upset,  and  one  convulsion  is  likely  to 
lead  to  another.  The  mortality  of  eclampsia  is  still  from  20  to  45  per  cent,  for 
the  mother  and  30  to  60  per  cent,  for  the  child.  Such  high  mortalities  rarely  ac- 
company surgical  complications,  hence  the  patient  deserves  as  much,  if  not  more, 
consideration  than  does  the  surgical  patient.  She  should  have  at  least  two  physi- 
cians and  one  or  more  good  obstetric  nurses.  If  a  good  maternity  hospital  is  near 
by,  she  should  be  quickly  transported  thither;  if  not,  the  facilities  of  the  maternity 
should  be  closely  imitated  at  home. 

There  are  three  general  plans  of  treatment — two  extremes  and  one  occupying 
a  middle  position.  Diihrssen's  dictum  is — after  the  first  convulsion  put  the  patient 
into  a  deep  sleep  and  deliver  at  once.  The  other  extreme  is,  put  the  patient  to  bed, 
give  narcotics,  stimulate  the  emunctories,  etc.,  and  await  the  natural  termination 
of  pregnancy  and  labor.  Those  accoucheurs  occupying  the  middle  position  use 
the  medical  treatment  more  or  less,  and  hasten  the  labor  only  if  the  patient's  con- 
dition is  evidently  going  from  bad  to  worse. 

Experience  is  accumulating  to  prove  that  the  rapid  emptying  of  the  uterus  in 
deep  narcosis  after  the  fir.st  convulsion  gives  the  best  results.  Carl  Braun  empha- 
sized the  fact  that  the  convulsions  ceased  or  became  less  severe  after  delivery. 
Diihrssen  showed  that  in  93.75  per  cent,  such  a  result  was  found,  and  Olshausen 
showed  85  per  cent.  Seitz  and  Reuben  Peterson  prove  it  conclusively  in  very  large 
statistics.  In  the  author's  experience  of  72  cases  the  patients  did  better  after 
early  delivery  so  far  as  the  convulsions  were  concerned,  but  the  proportion  of  actual 
recoveries  was  only  slightly  increased.  Statistics  from  large  material,  however, 
show  a  decided  improvement.  Peterson,  collecting  615  cases  of  early  delivery  (as 
soon  as  possible  after  the  first  convulsion),  finds  a  mortality  of  15.9  per  cent.,  and 
compares  this  with  28.9  per  cent.,  the;  mortality  in  the  same  maternities  under  so- 
called  conservative  treatment.  Another  table  shows  4  per  cent,  and  31  per  cent. 
respectively.     Another  strong  argument  for  early  delivery  is  the  larger  number  of 


THE   TOXEMIAS    OF    PREGNANCY  305 

children  saved  thereby,  estimated  l)y  \aiious  authors  as  two  and  three  times  as 
many. 

Methods. — Tlic  iiictliod  of  effecting  the  delivery  depends  on,  first,  tlie  jjeriod  of  jirejinancy; 
second,  the  environment  of  tlie  patient;  third,  th(!  .stut(!  of  tlie  eervix;  fourth,  the  Kkill  of  the 
operator;  fiftli,  extraneous  coniplications,  for  example,  eontraeted  pelvis,  placenta  prajvia,  etc. 
Bc^fore  th(!  seventh  month  all  children  die,  and  it  is,  therefore,  neeessarj^  to  procure  only  enough 
dilatation  of  the  cervix  to  perform  craniot(jmy  and  extraction.  After  viability  one  nnist  try  to 
save  the  haljy  also. 

If  the  ])atient  is  in  a  maternity  in  the  hands  of  a  capable  obstetric  surgeon,  immediate  de- 
livery is  pract ised,  overcoming  the  resistance  of  the  cervix  and  perineum.  In  a  private  home,  with- 
out skilled  assistance,  the  accoucheiu'  had  better  rely  (jn  medicinal  and  less  active  measures — 
[juncture  of  the  membranes,  the  use  of  the  colpeurynter,  and,  when  only  a  little  of  the  cervix  is 
eft,  manual  dilatation. 

If  the  cer\'ix  is  fully  dilated,  delivery  is  accomplished  at  once  by  forceps  if  the  head  is  en- 
gaged; by  version  and  inunediate  extraction  if  the  head  is  above  the  brim.  The  pains  in 
eclampsia  are  usualh'  stronti,  and  r:ij)idly  efface  and  dilate  the  cervix.  Indeed,  one  is  sometimes 
siH'prised  to  find  the  child  delivered  vmder  the  coverlet. 

If  the  cer\'ix  is  effaced,  shortened,  ttiken  up,  so  that  only  the  thin  edge  remains,  this  may  be 
dilated  with  the  finjiers,  or  with  any  of  the  metallic  dilators  on  the  market,  or  by  means  of  hydro- 
static bags,  or  the  thin  partition  maybe  incised  (Diihrssen's  incisions).  Manual  dilatation  in 
these  instances  is  the  method  of  choice.  After  this,  forceps  or  version  and  extraction  of  the  cliild, 
depending  on  engagenK^it. 

If  the  cervix  is  tightly  closed,  not  effaced,  the  cervical  canal  long,  the  greatest  difficulties  are 
met.  Without  doubt  the  vaginal  cesarean  section,  where  it  can  be  performed,  is  the  best  method 
of  delivery  imder  these  conditions.  Abdominal  cesarean  section,  recommended  by  Halbertsma 
in  1SS9,  still  shows  a  high  mortality,  and  while  it  saves  most  babies,  is  too  grave  an  operation  to 
be  recommended  except  for  the  worst  cases.  The  author  is  convinced  that  it  has  a  place  in  the 
treatment  of  eclampsia,  and  believes  that  its  field  will  grow  larger  in  time. 

Unless  eith(>r  of  these  methods  of  delivery  is  practised,  the  first  local  mterference  to  be  made 
is  the  rupture  of  the  bag  of  waters.  In  many  cases  this  causes  the  convulsions  to  abate,  but  we 
usually  go  ahead  with  other  means  of  effecting  delivery. 

Manual  dilatation  of  the  closed  cervix  is  an  operation  requiring  from  one  to  three  hours; 
it  is  always  attended  by  laceration  of  the  parts,  which  tears  are  very  often  deep,  and  not  seldom 
fatal,  either  from  hemorrhage  or  from  extension  through  the  uterus  into  the  peritoneal  cavity,  or 
from  infection,  and  is,  therefore,  condemned.  The  same  statement  applies  to  the  use  of  Bossi's 
and  other  metal  dilators  when  the  cervix  is  uneffaced. 

Incisions  into  a  closed  cervix  may  not  be  made  imless  the  typical  vaginal  cesarean  section  be 
performed. 

Dilatation  by  bags,  the  colpeurynter  of  Carl  Braun,  the  inelastic  balloon  of  Champetier 
de  Ribcs,  or  its  modification  by  Voorhees,  can,  in  favorable  cases  (soft,  dilatable  cervix),  be 
accomplished  in  one  sitting  under  anesthesia,  lasting  one  to  two  hours,  but  if  the  cervix  is  rigid,  an 
attempt  to  force  it  open  in  this  time  would  fail  if  it  did  not  rupture  the  uterus.  In  such  cases 
the  patient  must  be  put  to  bed  and  the  action  of  labor-pains  awaited.  Only  uterine  action  will 
soften,  efface,  and  safely  dilate  a  hard  cervix.  Unfortunately,  rigid  cervix  is  a  frccjuent  complica- 
tion of  eclampsia,  since  this  condition  is  common  in  primipane  and  in  those  of  advanced  age. 

Often  after  the  bags  have  procured  partial  opening  of  the  womb  delivery  maj'  be  effected  by 
vaginal  cesarean  section.  A  rigid  pelvic  floor  must  not  be  overcome  by  brute  force,  since  uncon- 
trollable lacerations  may  result,  and,  too,  the  baby's  head  must  not  be  used  as  the  forcing  wedge. 
Perineotomy  should  be  done,  the  cut  being  a  bold  one,  through  the  anterior  or  puborectal  portion 
of  the  levator  ani.     (For  further  particulars  see  p.  30.5.) 

During  the  delivery  of  eclamptics  extraordinary  precautions  against  sepsis  must  be  observed, 
because  they  arc  particularly  liable  to  infection,  the  kidncj's  and  liver  being  thrown  out  of  immuniz- 
ing action.  In  spite  of  the  most  rigid  precautions  the  author  has  seen  fatal  infection  arise.  One 
source  of  trouble  is  feces  streaming  from  the  anus,  the  result  of  the  administration  of  cathartics 
and  enemata  before  delivery.  This  danger  is  so  great  that  the  author  witlilaolds  such  practice 
luitil  after  the  uterus  is  emptied.  If  the  field  of  operation  is  constantly  soiled  by  discharges  from 
the  rectum,  the  anus  should  be  closed  by  a  circular  suture,  ichich  is  to  he  removed  Just  before  the  child 
is  delivered. 

What  was  said  about  anesthetics  in  discussing  prevention  applies  here.  Ether  is  recom- 
mended, but  as  little  is  gi\-en  as  po.ssible.  Neither  chloroform  nor  ether  should  be  given  during 
the  attacks,  since  they  do  no  good,  poison  the  patient,  and  overload  the  room  with  noxious  vapors. 
Fatty  heart  is  a  frequent  finding  at  autop.sy  in  those  cases  where  chloroform  had  been  freeh'  ad- 
ministered. In  the  .sixties  chloroform  was  given  continuously  for  hours — once  .seventeen  hours, 
by  Simpson.  Morphin  and  scopolamin  have  been  used,  but  with  indifferent  success.  Recently 
McPherson  recommended  them. 

Hemorrhage  during  delivery,  if  moderate,  is  not  to  be  checked  too  soon,  since  bleeding  is  one 
of  the  adjuvant  means  of  cure. 

Should  the  perineum  be  torn  during  spontaneous  delivery,  it  may  be  wiser  not  to  give  an 
anesthetic  for  its  repair,  but  to  leave  it  for  future  operation.  If  the  tear  occurs  in  operative 
deliver}',  especially  if  a  complete  one,  it  should  be  sutured — at  least  the  sphincter  should  be  imited. 

Adjuvant  Treatment. — Protection  against  injury.  Since  the  convulsions  some- 
times show  frightful  vehemence,  the  patient  must  be  quickly  undressed  and  put  to 


366 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


bed,  surrounded  AAdth  pillows,  and  watched  by  a  trained  attendant,  preferably  a 
physician.  False  teeth  should  be  removed.  To  prevent  the  biting  of  the  tongue 
a  simple  device  illustrated  in  Fig.  343  may  be  used.  A  large  wooden  clothespin 
is  wrapped  in  a  thin  handkerchief  and  hung  near  the  head  of  the  bed.  As  the 
attendant  sees  the  attack  approach  it  is  placed  between  the  teeth,  so  that  the 
elasticity  of  the  prongs  takes  up  the  champing  of  the  jaws.  If  the  tongue  is  swollen 
from  injury,  it  may  be  necessary,  to  prevent  asphyxiation,  to  intubate,  using  soft- 
rubber  tubing,  or  to  do  tracheotomy.  Restraint  of  the  movements  should  not  be 
made — all  that  may  be  done  is  to  keep  the  woman  from  injuring  herself.  Heart 
failure  may  be  induced  by  forcibly  holding  the  patient  still.  For  extreme  and  ex- 
hausting jactitation  morphin  may  be  given,  or,  but  rarely,  an  anesthetic  may  be 
used.  Mucus  in  the  throat  and  mouth  is  to  be  removed  frequently,  but  with  gentle- 
ness, and  it  is  best  for  the  patient  to  lie  on  the  side,  to  allow  the  oral  secretions  free 
escape— an  especially  important  injunction  during  vomiting;  these  precautions 
are  taken  to  prevent  aspiration  pneumonia.  In  the  side  position,  too,  the  swollen 
tongue  falls  forward  and  frees  the  respiration. 

All  irritants  should  be  withheld,  which  means  that  examinations  are  to  be 

omitted,  if  possible,  and  the 
patient  disturbed  only  for  ab- 
solutely necessary  treatment. 
Visitors  should  be  excluded 
from  the  room,  which  should 
be  well  darkened,  and  the  at- 
tendants should  move  about 
quietly,  permit  no  loud  talk- 
ing, jarring  the  bed,  etc.  As  in- 
tetanus,  these  external  irri- 
tants may  excite  a  convulsion. 
Narcotics . —  Formerly 
chloroform  was  used  for  each 
convulsion,  and  even  contin- 
uously. G.  Veit  introduced  the 
morphin  treatment,  and  von 
Winckel  gave  chloral  in  large 
doses  per  rectum.  Experi- 
ence has  not  sustained  these 
methods,  and,  indeed,  they  are 
only  symptomatic,  since  the  at- 
tacks are  but  a  symptom  of  the 
general  intoxication.  While  the 
frequently  repeated  convulsions  are  a  severe  strain  on  the  heart  and  the  cyanosis 
weakens  both  heart  and  general  system,  still  it  is  the  intoxication  which  is  to  be 
feared,  and  one  should  hesitate  before  adding  other  poisons  to  an  already  overloaded 
circulation.  Without  doubt  chloroform  causes  many  deaths,  by  degenerating  the 
liver,  the  blood,  and  the  heart  muscle  (secondary  chloroform  death),  and  morphin  in- 
creases the  coma.  The  children  often  die  from  undoubted  morphin  poisoning.  Lum- 
bar anesthesia  has  been  tried,  but  failed,  and  the  same  result  was  experienced  with 
lumbar  puncture.  The  author  uses  narcotics  and  anesthetics  as  sparingly  as  possible. 
Elimination. — On  the  theory  that  eclampsia  is  a  toxemia,  one  would  try  to 
get  rid  of  the  poisons  through  the  emunctories.  Experience  has  been  disappoint- 
ing, as  one  would  expect,  since  the  toxin  is  probal^ly  colloidal,  and  closely  bound 
to  the  nerve-cells.  Cathartics  should  be  withheld  until  the  uterus  is  empty,  be- 
cause of  the  danger  of  infecting  the  operating  field  with  liquid  feces.  After  delivery 
a  full  dose  of  salts,  jalap,  or  castor  oil  is  given,  but  the  patient  is  not  to  be  strongly 


Fio.  343. — Use  of  Large  Clothespin  to  Prevent  Injury  to  Tongue 

IN  Eclampsia. 

Case  of  eclampsia  at  Mercy  Hospital.     Stage  of  stertorous  respiration. 

Note  swollen  tongue. 


THE   TOXEMIAS   OF    PREGNANCY  367 

purged.  Diapliorotic's,  ospocially  i)ilo('arpin,  are  to  be  condemned.  Hot  baths 
involve  too  niucli  manipulation,  but  hot  wet  packs  and  alcohol  sweats  are  recom- 
mended by  many  autiiors.  They  should  not  be  used  during  labor,  but  afterward 
one  or  two  may  be  given,  though  they  are  depressing  and  have  caused  death.  In 
view  of  this  fact,  and  because  they  have  not  proved  of  any  real  value,  the  author 
has  dispensed  with  them.  Another  objection  raised  against  the  packs  and  sweats 
is  that  they  concentrate  the  poison  in  the  blood  and  thus  the  nerve-centers  get  a 
double  dose,  while  the  amount  of  i)oison  thus  eliminated  through  the  skin  is  minimal. 

IMcdiciual  diun^tics  are  too  slow  in  action,  if  they  are  not  objectionable,  be- 
cause irritating  to  the  kidneys. 

Diaphoresis  and  diuresis  are  best  obtained  by  the  free  exhibition  of  liquids. 
Water  and  lemonade  by  mouth  and  salt  solution  hypodermically  do  more  to  favor 
the  action  of  the  skin  and  of  the  kidneys  than  any  other  means,  but  one  must  oV^- 
serve  care  not  to  overload  either  the  stomach  or  the  heart,  accidents  which  the 
author  has  seen  as  the  result  of  overzealousness.  Licpiids  are  administered  to 
unconscious  patients  by  stomach-tube,  having  due  regard  to  the  amount  given 
and  the  possibility  of  some  of  the  fluid  penetrating  the  bronchial  tubes.  Salt 
solution  is  best  administered  hypodermically,  a  quart  morning  and  evening.  If 
the  patient  is  very  edematous,  one  should  use  less  water.  The  use  of  salt  does  not 
harmonize  with  some  theories  regarding  edema,  but  practical  experience  shows  its 
value.  Puncture  or  incision  of  the  swollen  limbs  or  swollen  vulva  may  be  indicated, 
under  strict  antiseptic  precautions,  of  course.  Advantageously  combined  with 
hypodermoclysis  is  the  withdrawal  of  blood. 

Venesection  is  one  of  the  oldest  remedies  for  eclampsia,  but  with  the  advent 
of  chloroform  it  lost  its  prestige.  Now  it  is  coming  into  favor  again  as  an  adjuvant, 
and  l^ids  fair  to  hold  a  permanent,  but  secondary,  place  in  treatment.  In  cases  in 
which  the  convulsions  recur  frequently  in  spite  of  treatment,  in  w^hich  the  pulse  is 
full  and  strong,  the  face  flushed  or  cyanotic — in  short,  when  the  picture  might  be 
called  sthenic  or  apoplectic,  bleeding  will  do  good.  In  cases  of  the  opposite  tj'pe 
bleeding  is  a  procedure  of  doubtful  utility.  Stimulation  is  here  more  desirable. 
When  the  evidences  of  cardiac  engorgement  are  present  and  pulmonary  edema 
threatens,  even  if  the  pulse  is  weak,  bleeding  wdth  stimulation  may  tide  the  patient 
over. 

By  withdrawing  a  pint  of  blood  one  removes  considerable  poison,  but  bleeding 
also  favors  diuresis  and  diaphoresis.  Venesection  should  be  reserved  until  after 
delivery,  since  a  hemorrhage  at  birth  may  make  further  bleeding  unwdse.  It  may 
be  impossilile  to  get  enough  blood  from  the  vein,  because  it  clots  so  rapidly  and 
firmly  in  the  incision. 

Oxygen  is  another  adjuvant.  It  should  ahvays  be  used  in  the  form  of  pure 
fresh  air,  and  a  great  deal  of  it — a  point  frequently  neglected  while  the  oxygen  tank 
stands  in  the  stuffy  room.  Oxygen  is  given  during  the  convulsion  and  right  after 
it,  to  relieve,  as  quickly  as  possible,  the  cyanosis,  and  it  is  valuable  also  as  a  heart 
support.  Artificial  respiration  may  be  necessarj'^  to  tide  the  patient  over  a  syncope 
following  an  attack,  or  to  improve  the  oxygenation  of  the  blood  between  attacks. 
Part  of  the  coma  is  due  to  hypercarbonization  of  the  blood.  ^>ratrum  viride,  first 
used  by  Dr.  Baker,  of  Eufala,  Alabama,  in  1859,  has  attained  considerable  repute 
in  America  and  Italy  as  a  specific,  but  large  experience  does  not  sustain  it.  Vera- 
tronc,  an  aseptic  preparation,  is  given  in  10-minim  doses  hypodermically  every 
thirty  minutes  until  the  pulse  has  come  do"uni  to  60;  then  no  more  is  given  imtil 
the  pulse  rises  above  90.  In  the  author's  experience  the  drug  has  not  altered  the 
results  either  way,  and  he  seldom  uses  it,  and  then  only  in  the  puerperium. 

Other  remedies,  mentioned  for  the  sake  of  completion,  are  thyroid  extract 
(Lange  and  Nicholson);  parathyroid  extract  (Vassale) ;  alkalis  (Zweifel),  on  the 
theory  of  acidosis;    amyl  nitrite  (Jenks);    lumbar  puncture;    trephining  the  skull; 


368      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

amputation  of  the  mammie  (Sellheim);  injection  of  air  and  oxygen  into  the 
mammne,  as  is  done  for  a  similar  disease  in  cattle  (Gilles) ;  and  renal  decapsula- 
tion (Edebohls).  Both  theory  and  practice  speak  against  the  last  operation. 
Chirie  collected  30  cases  with  a  mortality  of  46  per  cent.,  and  the  clinical  his- 
tories do  not  show  that  the  decapsulation  improved  the  conditions  present  with 
any  regularity.  Littauer  reports  62  cases  with  20  deaths,  which  is  better,  espe- 
cially since  only  the  serious  ones  were  operated.  The  question  of  permanent 
damage  to  the  kidney  from  the  shrinking  of  the  new  connective-tissue  capsule 
requires  sober  consideration.  Dienst  recommends  hirudin,  an  extract  of  leeches, 
given  intravenously  to  reduce  the  fibrin  content  of  the  blood. 

The  after-treatment  is  on  the  general  lines  just  laid  down.  Water  is  given  for 
forty-eight  hours,  then  milk  and  water,  or  rice-water  with  strained  gruels,  meat  and 
broths  being  withheld.  Since  the  kidneys  now  begin  to  act  freely,  often  140  to 
180  ounces  of  urine  a  day  being  passed,  it  is  well  to  watch  the  bladder  for  over- 
filling. Involuntary  bowel  movements  are  the  rule,  and,  therefore,  the  lochial 
pad  should  be  arranged  so  that  the  feces  do  not  dam  up  into  the  vulva.  Warm- 
water  bags  are  to  be  closely  watched,  because  eclamptics  are  especially  liable  to 
burns  and  necroses.     Sometimes  spontaneous  necroses  resemble  burns. 

Since  the  convulsions  may  recur,  even  after  a  week,  the  puerpera  requires  con- 
stant supervision,  and  especially  if  she  shows  any  signs  of  puerperal  insanity,  such 
cases  not  seldom  making  attempts  at  suicide  or  trying  to  kill  the  child. 

The  temperature  of  the  eclamptic  quickly  subsides,  a  rise  after  such  a  fall 
indicating  sepsis,  pneumonia,  etc.  Nursing  should  not  be  allowed  until  the  puerpera 
has  been  fully  conscious  for  several  days  and  the  urine  has  become  nearly  normal, 
and  when  her  strength  permits.  In  a  few  reported  cases  and  one  of  my  own  it  has 
seemed  that  the  milk  of  the  mother  caused  convulsions  in  the  child.  (See  also 
Goodall.) 

Literature 

Ahlfeld:  Lehrbuch  d.  Geburtsh.,  3.  Aufl.,  p.  235. — Albert:  Arch.  f.  Gyn.,  vol.  Ixvi,  p.  483. — Blanc:  Arch,  de  Tocol- 
ogie,  1889  and  1890. — Bouchard:  Legona  sur  les  auto-intoxications,  18S7. — Bouffe  de  Saint-Blaise:  Annales  de 
Gyn.,  1891,  vol.  xxxv,  p.  48,  and  ibid.,  1898,  vol.  i,  pp.  343,  432. — Braun,  Carl:  Berlin,  klin.  Wooh.,  1886,  No. 
49. — Chirie:  L'Obstetrique,  Juin,  1909. — Collman:  Centralbl.  f.  Gyn.,  1897,  No.  13.  —  Cragin  and  Hull: 
"Chloroform,"  Jour.  Amer.  Med.  Assoc,  June,  1910. — Delore:  Arch,  de  Tocologie,  1884,  vol.  ii,  p.  921. — 
Devraigne:  Obstetrique,  May,  1909. — Dienst:  Centralbl.  f.  Gyn.,  December,  1909,  No.  50;  ibid.,  p.  133. — Dirmoser: 
Pernicious  Vomiting  of  Pregnancy,  Vienna,  1901. — Dubois,  P.:  Bull,  de  TAcademie  de  Med.,  1852,  6  Mars. — 
*Diihrssen:  Handb.  der  Geb.,  vol.  ii,  3,  p.  2403. — Ehrenfest:  Surg.,  Gyn.,  and  Obst.,  September,  1911. — Engelman: 
Cent.  f.  Gyn.,  1907,  p.  306. — Engelman  and  Frdnkel:  Zentralbl.  f.  Gyn.,  1909,  No.  18,  pp.  618  and  634. — Ewing: 
"Pathog.  of  the  Toxemias  of  Pregnancy,"  Amer.  Jour.  Med.  Sci.,  June,  1910. — Favre:  Virchow's  Arch.,  vol. 
cxxvii,  p.  133. — Fehling:  Verhandl.  d.  Deutsch.  CJes.  f.  Gyn.,  1901,  p.  261. — Fieux:  "Complete  Report  of  Meet- 
ing of  French  Obstetricians,"  Annales  de  Gyn.,  Toulouse,  December,  1910. — Frankl:  Praktische  Ergebnisse  der 
Geb.  undGyn.,  1909,  vol.  i,  Heft  1,  p.  232;  also  1910,  vol.  ii,  p.  2. — Freund:  Deutsch.  med.  Woch.,  vol.  xxxiii, 
1908,  p.  1625.— G'mie.s.-  Centralbl.  f.  Gyn.,  1892,  No.  20.— Goodall:  "Should  Eclamptics  Nurse  the  New-born?" 
Amer.  Jour.  Obstet.,  January,  1911. — Halberisma:  Miinch.  med.  Woch.,  1887,  No.  35,  etc. — Hitschman: 
Zentralbl.  f.  Gyn.,  1904,  No.  37. — Hofbauer:  "The  Toxicoses  of  Pregnancy,"  Zeitsch.  f.  Geb.  u.  Gyn.,  vol.  Ixi, 
Heft  2,  p.  185.— Ilofmeister:  Centralbl.  f.  Gyn.,  1892,  No.  51. — Holland:  Jour.  Obstet.  and  Gyn.  of  Great  Bri- 
tain, December,  1909.  Gives  literature  on  causation  to  date. — Jaggard:  American  System  of  Obstetrics,  vol. 
i,  p.  421. — Sardine:  Jour.  Obst.  and  Gyn.,  Brit.  Empire,  June,  1906. — Jilrgens,  Slumpf,  Ahlfeld:  Berhn.  klin, 
Woch.,  1886,  p.  875;  Lehrbuch  d.  Geb.,  1903. — Kossman:  Monatssch.  f.  Geb.,  1901,  vol.  xiv,  p.  288. — Lange: 
Zeitschr.  f.  Gob.  u.  Gyn.,  vol.  xi,  H.  1. — Littauer:  Centralbl.  f.  Gyn.,  1911,  No.  33. — Massen:  Zent.  f.  Gyn., 
1895,  p.  nOG.— Mayer:  Centralbl.  f.  G.vn.,  September,  1911,  p.  12m.— McClintock:  Dublin  Jour.  Med.  Sci., 
1873. — Montgomery:  Signs  and  Symptoms  of  Pregnancy,  1857,  p.  93. — Mailer:  Ibid.,  p.  259. — Peterson,  R.: 
Amer.  Jour.  Obstet.,  July,  1911. — Pinard:  Annales  de  Gyn.  et  I'Obst.,  1909,  Juillct,  p.  391. — Pinard  and  Bouffe 
de  Saint-Blaise:  Annales  de  Gyn.,  1891,  vol.  xxxv,  pp.  48  et  seq. — Rebaudi:  Gaz.  degli  Ospedaii  Milan,  September 
21,  1909. — Riviire:  Auto-intoxication  eclamptique,  Paris,  1888. — Schmid:  Zeitschr.  f.  Geb.  u.  Gyn.,  1911,  vol. 
Ixix,  H.  1,  p.  148.  Gives  literature. — Schmorl:  Zentralbl.  f.  Gyn.,  1901;  ibid.,  Verhandl.  d.  Deutsch.  Ges.  f. 
Gyn.,  1901,  p.  303  et  seq. — Schuhmacher:  Hegar's  Beitrage,  vol.  v,  p.  257. — Seitz:  Arch.  f.  Gyn.,  1909,  vol. 
Ixxxvii,  p.  117. — Semon:  Zeitschr.  f.  Geb.  u.  Gyn.,  1910,  vol.  Ixvii,  iii,  p.  773. — Stewart:  Amer.  Jour.  Obstet., 
1901,  p.  HOG.— Stroganov:  Centralbl.  f.  Gyn.,  1901,  p.  1300.— Underhill:  Arch,  of  Internal  Medicine,  1910,  vol. 
v,  p.  61. — Vollhard:  Monatsschr.  f.  Geb.  u.  Gyn.,  vol.  v,  p.  411. — Ward:  "Thyroidism  and  Toxemia,"  Surg. 
Gyn.,  and  Obst.,  December,  1909,  p.  632. — Whitney:  Amer.  Gyn.,  1903,  p.  ISO. — Williams:  Johns  Hopkins  Hospi- 
tal Bulletin,  1906,  vol.  xvii,  p.  Hl.—Wyder:  Verhandl.  d.  Deutsch.  Ges.  f.  Gyn.,  1901,  vol.  ix,  p.  268. — Zweifel: 
Arch.  f.  Gyn.,   1905,  vol.  Ixxvi,  H.  3. 


CHAPTER  XWIII 
THE  KIDNEY  OF  PREGNANCY 

Barnes  said  tluit  pivguaucy  is  tlic  test  of  botlily  suuudiicss,  and  it  is  generally 
admitted  that  the  kidneys  are  the  point  of  weakest  resistance  during  this  period. 
\'()n  Leydeii  dcscriljod  certain  elianges  in  the  kichiej-  to  which  he  gave  the  above 
luune,  l)eli(>ving  that  they  occurretl  in  a  kirge  ])ercentage  of  kithieys  in  normal 
l)i"egnancy.  This  condition  is  supposed  to  exist  when  the  gravida  shows  edema  and 
albuminuria  in  the  latter  half  of  pregnancy.  The  kidney  is  large,  pale,  soft,  dourly, 
with  markings  obliterated,  anemic  or  grayish-j^ellow  in  color,  and  microscopically 
shows  fatty  changes  in  the  glomeruli  and  tubules,  })ut  no  infiltration  of  leukocj'tes 
nor  vascular  changes. 

Slight  albuminuria,  a  moderate  number  of  hyaline  and  granular  casts,  ■\\ith 
white  blood-corpuscles  and  renal  epithelium,  occur,  according  to  Fischer,  in  50 
per  cent,  of  the  pregnancies,  but  in  the  author's  experience  such  findings  are 
always  indicative  of  some  compromise  of  the  function  of  the  kidneys. 

In  the  author's  cases  albuminuria  is  always  regarded  wdth  great  suspicion, 
and  if  casts,  especially  granular  or  cellular,  appear,  the  woman  is  considered  ill 
and  placed  under  treatment.  As  a  rule,  in  these  cases  edema,  lassitude,  headache, 
and  neuralgia  accompany  the  urinary  findings.  The  author  considers  the  "kid- 
ne}^  of  pregnancy"  only  the  first  evidence  of  a  mild  toxemia.  Often  the  symptoms 
become  aggravated — the  albuminuria  increases,  casts,  blood,  and  epithelium  appear, 
the  urine  diminishes  in  amount,  and  the  case  develops  the  characteristic  aspect  of 
preeclamptic  toxemia.  Some  writers  call  these  aggravated  findings  the  ''nephritis 
of  pregnancy,"  claiming  that  this  leads  to  eclampsia  or  to  coma.  Clinically,  it  is 
impossible  to  differentiate  these  cases  of  nephritic  toxemia  from  real  eclampsia, 
though  occasionally  one  may,  from  the  predominance  of  renal  symptoms,  suspect 
that  most  of  the  trouble  lies  with  the  kidney's. 

With  our  present  views  the  "kidney  of  pregnancy"  is  the  result  of  the  intoxica- 
tion of  pregnancy,  and  the  causation  of  eclampsia  would  be  its  causation.  The  kid- 
neys suffer  in  their  effort  to  eliminate  toxins  or  undermetabolized  products  or 
insufficiently  oxidized  proteins  from  the  liver,  or  the  accumulated  excreta  of  the 

f(>tUS. 

Some  of  the  theories  of  the  cause  of  renal  disturbances  are :  Compression  of  the  kidneys  or  the 

renal  vessels  by  the  gravid  uterus  (impossible);  increased  arterial  tension  (does  not  always  exist); 
spasm  of  tlie  nnial  arteries,  causing  anemia  and  degeneration  (merely  hypothetic);  the  hydremia 
of  pregnancy  (not  constant  and  usually  absent  in  later  months);  compression  of  the  ureters  (oc- 
curs in  only  one-fifth  of  the  cases,  and  is  then  usualh'  unilateral,  while  the  changes  are  bilateral); 
increased  intra-abdominal  ])ressure  (this  is  not  proved  to  exist  in  pregnancy,  though  it  is  generally 
believed  that  the  blood  from  the  extremities  has  greater  difficulty  in  reaching  the  heart — large 
abdominal  tumors  seldom  cause  albuminuria);  overwork  of  the  kidneys  (plausible);  bacteriuria 
(very  jirobably  the  cause  of  some  cases,  the  author  having  proved  that  the  urine  of  even  apparently 
healthy  pregnant  women  contains  streptococci — see  Pyelitis). 

For  the  symptoms,  see  Eclampsia.  The  differential  diagnosis  is  to  be  made 
from  chronic  nephritis  with  acute  exacerbation,  but  it  is  seldom  possible.  A  pre^'i- 
ous  history  of  renal  disease,  the  vascular  manifestations  of  the  latter,  and  the  course 
of  the  present  illness  may  show  differences  from  the  simple  kidney  of  pregnancy. 

Nephritis  begins  earher  in  pregnancy.  Retinitis  albuminurica  is  more  com- 
mon in  nephritis.  In  toxemia  the  retina,  although  the  patient  has  eye  symptoms, 
may  show  normal  conditions  or  onlv  edema.  It  is  seldom  possible  to  read  the  diag- 
24  '         369 


370  THE   PATHOLOGY    OF   PEEGNANCY     LABOR,    AND    THE    PUERPERIUM 

nosis  from  the  urinary  findings.  In  nephritis  the  amount  of  albumin  may  be  less, 
with  lower  specific  gravity  and  less  coloring-matter.  Zweifel's  sarcolactic  acid 
test  has  not  been  proved  clinically  useful,  and  the  nitrogen  partition  gives  equivocal 
results.  Since  the  condition  under  consideration  is  the  result  of  a  toxemia,  it  is  not 
surprising  that  pregnancy  is  frequently  interrupted  from  the  same  cause  (13  per 
cent.,  Fellner).     The  kidney  of  pregnancy  may  recur. 

The  treatment  is  the  same  as  for  threatened  eclampsia. 


ACUTE  YELLOW  ATROPHY  OF  THE  LIVER 

Closely  allied  to  h>T)eremesis  and  to  eclampsia  is  acute  yellow  atrophy  of  the 
liver — ^the  icterus  gravis  of  older  writers.  Pregnancy  seems  to  predispose  to  this 
disease,  since  over  half  the  cases  reported  occur  in  pregnant  women.  It  appears 
at  any  period  of  gestation,  during  labor,  or  in  the  puerperium.  Without  doubt 
several  diseases  may  terminate  under  the  clinical  picture  of  acute  yellow  atrophy, 
and  the  author  has  seen  hyperemesis  gravidarum,  eclampsia,  sepsis  acuta,  and 
chloroform  poisoning  do  so,  also  one  case  of  secondary  syphilis  in  a  prostitute. 
Other  authors  report  tyi^hoid,  osteomyelitis,  diphtheria,  erysipelas,  phosphorus, 
alcohol,  and  i3tomain-poisoning  as  precedent  illnesses.  It  is  sometimes  epidemic. 
The  causation  is  unknown,  and  whether  the  degeneration  of  the  liver  is  clue  to  in- 
fection or  to  a  toxicosis  is  still  suh  judice.  Bacteria  (among  others  the  streptococcus, 
Prochaska)  and  Bacterium  coli  (the  author)  have  been  cultivated  from  the  liver, 
but  since  degeneration  and  not  inflammatory  changes  are  predominant,  the  theory 
of  an  intoxication  is  more  plausible. 

Pathology. — At  autopsy  the  liver  is  found  wasted,  perhaps  to  one-half  its 
volume,  soft,  friable,  sometimes  almost  diffluent,  yellowish  streaked,  and  mottled 
with  red.  Rarely  one  finds  an  acute  diffuse  hepatitis  or  the  evidences  of  other 
hepatic  disease,  in  which  case  the  liver  may  even  be  enlarged.  The  liver-cells  have 
undergone  albuminoid  degeneration,  the  nuclei  are  indistinct  or  absent,  and  in  the 
red  portions  the  cells  have  disappeared  entirely,  or  are  found  only  at  the  periphery  of 
the  lobules.  Tiny  hemorrhages  are  sometimes  found,  especially  under  the  capsule. 
The  interlobular  connective  tissue  appears  increased  because  the  liver-cells  have 
dropped  away  from  it  and  there  is  a  slight  wandering  in  of  leukocytes.  These  prob- 
ably have  to  do  with  the  conversion  and  the  carrying  away  of  the  fatty  degenerated 
parenchyma,  though  it  is  probable  that  a  proteolytic  enzyme  is  also  active.  The 
heart,  the  muscles,  and  the  glands  of  the  bronchi  and  of  the  digestive  tract  are  fatty 
degenerated,  and  all  the  tissues  are  bile  stained.  The  kidneys  are  intensely  in- 
volved, in  one  of  the  author's  cases  the  convoluted  tubules  being  completely  de- 
generated, but  the  tubuli  recti  and  the  glomeruli  being  unafTected.  This  case  showed 
no  inflammatory  changes,  but  such  are  reported  by  some  authors.  The  spleen 
is  large  and  soft,  similar  to  that  seen  in  the  acute  infectious  diseases.  ' 

Symptoms. — Much  variation  exists  in  the  descriptions  given  of  this  affection. 
If  the  hepatic  atrophy  is  a  termination  of  hyperemesis  or  of  eclampsia,  the  symp- 
toms of  these  disorders  precede.  If  it  follows  the  use  of  chloroform,  the  symptoms 
are  very  acute — may  be  fatal  in  from  six  hours  to  as  many  days.  In  the  "idio- 
pathic" cases  a  prodromal  stage  with  anorexia,  vomiting,  constipation,  headache, 
perhaps  slight  mental  disturbances,  extreme  weakness,  a  tinge  of  icterus,  and  pain 
in  the  epigastrium  exists,  but  its  significance  is  not  recognized.  After  a  few  days 
to  a  few  weeks  symptoms  of  serious  illness  appear,  rarely  with  a  chill  and  high  fever 
(Vinay),  but  usually  suddenly.  Frequent  vomiting,  first  glairy,  then  bilious  and 
bloody,  anorexia,  thirst,  pain  in  the  epigastrium,  acholic  stools,  with  occasional 
hemorrhage,  intense  headache,  restlessness,  later  extreme  and  incessant  jactitation, 
^^•ith  rolling  the  head  to  and  fro  on  the  pillow,  insomnia,  delirium,  sometimes  con- 
vulsions, and  coma  before  death.     In  secondary  chloroform  poisoning  I  have  seen 


ACUTE    YELLOW    ATROPHY    OF    LIVER  371 

the  disease  end  fatally  in  six  hours  with  all  Ihc  characteristic  symptoms  appearing 
in  rajiid  succession.  Abortion  usually  takes  placr;  just  Ijcfore  df^ath,  but  may 
not  o(;cur.     Otherwise  uterine  hemorrhage  is  infrecjuent. 

li^xamination  of  the  patient  shows  extreme  exaggeration  of  reflexes,  general 
icterus,  sometimes  of  a  lemon,  sometimes  of  an  orange-yellow,  tint;  minute  pe- 
techia; on  the  trunk  and  extremities,  or  an  erythematous  eruption;  a  slight  cyanosis 
of  the  face,  with  puffiness  <jf  tlie  features;  a  dry  brown  tongue,  with  sordes;  a 
characteristic  Init  intlescribubk;  fa-tor  ex  ore — it  reseni])les  the  fruity  odor  of  sepsis, 
but  has  a  slight  iiungency;  the  j^ulse  is  fast,  weak,  and  numbers  120  to  140  beats; 
the  respirations  are  dys}>neic,  stertorous,  and  later  weak  and  superficial;  the  tem- 
perature is  almost  always  elevated, — 102°  to  104°  F., — but  is  rarely  subnormal; 
at  first  contracted,  latcT  dilated,  pupils  are  seen,  together  with  slight  exo))hthalmos; 
toward  the  end,  however,  the  eyes  are  sunken;  there  are  extreme  tenderness  over 
the  liver  and  diminution  of  liver  dulness,  which  is  determinable  by  daily  measure- 
ment; enlargement  of  the  spleen  occurs  (66  per  cent.);  the  urine  is  diminished, 
containing  bile,  albumin,  casts  of  all  kinds,  fatty  renal  epithelium,  blood,  methe- 
moglobin  (Stumpf),  often  leucin  balls  and  tyrosin  crystals,  very  little  urea  (which, 
divided,  shows  a  large  percentage  of  ammonia  nitrogen,  indicating  that  the  liver 
function  is  in  abeyance),  acetone,  diacetic  acid,  indican,  albumose,  and  peptone, 
but  sugar  rarely. 

One  or  more  of  these  symptoms  or  findings  may  ])e  absent,  l:)ut  always,  after 
the  prodromal  stage,  there  are  enough  present  to  make  a  positive  diagnosis.  The 
disease  lasts  a  few  hours  or  days  after  the  real  symptoms  appear,  the  most  rapidly 
fatal  cases  being  those  in  which  the  cerebral  symptoms,  delirium,  and  agitation  are 
worst.  Death  is  due  to  exhaustion  and  intoxication,  the  heart  giving  out  first,  and 
it  occurs  in  deep  coma. 

Diagnosis. — If  a  pregnant  woman,  after  a  w^ek  or  two  of  lassitude,  headache, 
and  symptoms  of  gastric  catarrh,. suddenly  develops  delirium,  jactitation,  jaundice, 
with  epigastric  tenderness  and  diminution  of  liver  dulness,  the  diagnosis  of  acute 
y(41ow  atrophy  is  almost  certain.  If  such  symptoms  appear  after  hyperemesis, 
eclampsia,  and  sepsis,  the  diagnosis  may  still  be  asserted,  and  differentiation  is  not 
necessary,  since  both  may  be  clue  to  the  same  cause,  which  may  be  unknown,  or  at 
least  its  action  not  understood.  The  administration  of  chloroform  should  ])e  con- 
sidered in  the  history  taking.  In  those  cases  which  begin  with  a  chill  and  high 
fever  the  disease  may  be  an  acute  septicemia  with  this  unusual  clinical  picture. 
Confusion  will  arise  only  with  "bilious"  typhoid,  yellow  fever,  and  phosphorus- 
poisoning,  but  a  careful  medical  examination  will  usually  procure  clearness. 

The  prognosis  is  l^ad.  Recoveries  are  reported,  and  while  most  authors  claim 
these  are  mistaken  diagnoses,  the  writer  believes  that  he  has  had  a  case  which  sur- 
vived the  disease.  The  fetus  is  practically  always  lost,  through  either  prematurity 
or  toxemia.  It  is  usually  icteric,  but  in  cases  of  simple  maternal  icterus  the  child  is 
not  jaundiced. 

The  treatment  is  symptomatic.  In  hyperemesis  one  should  terminate  preg- 
nancy as  soon  as  suspicions  are  aroused  that  the  liver  is  beginning  to  suffer.  Indeed, 
in  all  cases  the  pregnancy  should  be  interrupted  as  soon  as  the  diagnosis  is  made, 
unless  the  patient  is  so  sick  that  the  interference  itself  would  precipitate  the  end. 
Vaginal  cesarean  section  would  be  the  best  method. 


CHOREA  GRAVIDARUM 

Another  disease  which  in  all  probability  is  toxemic  or  infectious  in  origin  is 
chorea  gravidarum.  The  causal  connection  between  pregnancy  and  chorea  is  very 
certain,  but  predisposition  is  pro\4ded  by  heredity  (neurasthenia,  insanity,  al- 
coholism, hysteria),  pre\dous  chorea  in  infancy,   nervous  shock,   as  fear,   anger, 


372      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

acute  polyarticular  rheumatism,  endocarditis,  infections  of  various  kinds.  In 
three  cases  observed  b}'  the  author  the  picture  was  one  of  toxemia,  and  in  two  of 
them  treatment  on  this  hypothesis  resulted  happily.  In  milder  cases  a  hysteric 
element  may  be  discerned;  indeed,  some  authors  distinguish  a  hysteric  and  an 
icUopatliic  form. 

Chorea  during  pregnancy  often  becomes  threatening,  the  movements  at  first 
localized,  rapidly  becoming  general,  incessant,  violent,  and  preventing  sleep.  One 
observes  anemia,  exhaustion,  delirium,  perhaps  maniacal,  and  later  torpor,  then 
fever,  coma,  and  death.  Emaciation,  bed-sores,  furunculosis,  cardiac  murmurs, 
and  albuminuria  are  sometimes  found  on  examination.  All  degrees  of  severity  are 
noted.  The  disease  usually  appears  before  the  middle  of  pregnancy,  rarely  in 
labor,  and  still  more  seldom  after ;  it  lasts  from  eight  days  to  months,  disappearing, 
as  a  rule,  with  the  expulsion  of  the  ovum,  whether  spontaneous  or  induced.  Re- 
covery often  occurs  before  term,  delivery  then  being  natural.  The  child  may  be 
choreic.  The  toxemic  forms  are  acuter  and  seldom  go  to  full  term,  abortion  being 
common.  Primiparae  are  most  affected,  especially  if  younger  than  twenty-five 
years,  but  when  chorea  appears  in  a  multipara  or  recurs  in  a  subsequent  pregnancy, 
it  is  usually  more  serious. 

The  prognosis  is  grave,  20  to  30  per  cent,  of  the  women  and  over  half  of  the 
children  dying,  the  latter  from  prematurity.  Permanent  mental  disturbances  may 
follow,  as  after  eclampsia.  Death  occurs  from  exhaustion,  inanition,  injury,  de- 
cubitus, sepsis,  endocarditis,  and  toxemia,  shown  by  delirium  and  coma. 

Treatment. — The  general  rules  for  medical  cases  apply  here,  but  in  view  of  the 
danger  of  the  disease  and  its  probable  cause  (toxemia),  one  should  not  temporize 
too  long,  but  as  soon  as  the  movements  become  marked  the  patient  is  to  be  put  in 
bed  and  placed  on  a  milk-and-water  diet.  Sodium  bromid,  chloral,  even  morphin, 
may  be  administered,  but  the  author  was  able  only  with  hyoscin  to  calm  the  move- 
ments, and  even  this  failed  after  a  few  days.  By  skilful  nursing  the  nutrition  is 
maintained  and  exhaustion  prevented. 

Pregnancy  must  be  terminated  when  it  is  seen  that  the  general  health  has  begun 
to  suffer,  certainly  before  fever  or  delirium  begins.  Curiously,  Wade  saw  recovery 
after  dilatation  of  the  cervix  without  abortion,  as  Copeman  did  in  hyperemesis. 
If  the  uterus  is  emptied  early  enough,  recovery  is  the  rule. 


PRESUMABLE  TOXEMIAS 

Every  physician  meets  conditions  in  pregnancy  which  are  best  explained  by 
calling  them  toxicoses.  Truly  the  expression  means  nothing  definite,  but  the  affec- 
tions present  the  picture  of  intoxications  and  respond  to  appropriate  treatment. 
Asthma  in  a  woman  who  never  had  the  disease  before  may  have  such  a  basis.  Faint- 
ing spells,  acute  collapse,  or  even  sudden  death  may  have  no  other  apparent  cause. 
Such  accidents  strongly  resemble  anaphylactic  phenomena.  Peripheral  neuritis 
may  be  of  septic  origin,  but  well-authenticated  cases  have  been  found  as  a  compli- 
cation of  an  almost  certain  toxemia, — hyperemesis  gravidarum, — as  in  the  case  of 
Soloview,  quoted  by  Vinay.  The  tingling  of  the  hands  and  legs,  with  numbness, 
evon^ancsthesia  and  paresis,  of  which  many  pregnant  women  complain,  are  prob- 
ably due  to  affection  of  the  nerves  by  some  circulating  toxin.  The  nerve-trunks 
are  tender  and  sometimes  determinably  enlarged,  especially  the  ulnar.  Since  the 
symptoms  disappear  quickly  after  delivery,  the  injury  to  the  nerves  is  shght,  but 
grave  forms  of  neuritis  and  polyneuritis  do  occur,  either  on  a  toxemic  or  an  infec- 
tious basis. 

Psychoses  during  pregnancy  are  usually  toxemic.  A  bad  heredity  is  found 
m  nearly  half  of  the  cases,  but  this  does  not  preclude  the  idea  of  a  toxicosis,  because 
we  have  seen  that  such  taint   predisposes  to  other  toxemias,  as  eclampsia  and 


PSYCHOSES    IN    PREGNANCY  373 

liypcrciiicsis.  It  seems  that  distiirlicd  in<taI)olism  is  more  common  in  women  whose 
nervous  systems  are  not  etiual  to  the  strain  of  i)regnancy.  The  author,  in  two 
instances  of  insanity  in  pregnancy,  produced  striking  results  with  eHminative  treat- 
irunit,  though  in  one  mental  disease  developed  after  an  afebrile  puerperiuin  of  eight 
weeks.  Korsakoff's  psychosis  has  been  observed  in  ])regnancy.  \\'hile  usually 
alcoholic  in  origin,  the  syndrome,  polyneuritis  and  delusions,  may  appear  during 
the  early  months  of  gestation,  and  a  toxemia  may  be  involved.  "Williams  and  others 
believe  that  most  cases  of  puerperal  insanity  are  infectious  in  origin.  The  fre- 
quency of  insanity  after  pu(>rperal  fevers  is  strongly  suggestive,  but  very  often  the 
psychosis  follows  an  eclampsia,  a  chorea,  hy])ereniesis,  or  a  normal  ])uerperium,  anrl 
other  theories  must  be  invoked.  One  might  divide  the  cases  into  infectious,  toxic, 
and  idiopathic  (heredity,  inanition,  anemic)  psychoses.  It  is  more  than  possible 
that  some  of  the  diseases  we  call  toxemias  are  in  reality  infections,  the  causal  bac- 
terium still  eluding  our  crude  methods  of  investigation. 

Most  authors  do  not  favor  the  induction  of  abortion  or  prcniiature  lal^or  in  the 
insanity  of  pregnancy,  but  the  writer  believes  that  the  cases  should  be  treated  just 
as  any  other  toxemia,  unless  the  accoucheur,  after  consultation  with  an  alienist,  is 
convinc(xl  that  the  mental  disease  is  simply  contemporaneous  with  gestation,  with- 
out direct  causal  relation.  So  far  as  the  child  is  concerned,  no  indication  for  abor- 
tion will  lie,  because  if  the  psychosis  is  toxemic,  the  condition  is  not  necessarily 
transmitted  to  the  offspring,  and,  further,  we  have  no  right  to  sacrifice  the  child 
on  the  assumption  of  the  possibility  of  its  being  mentally  unfit. 

In  some  neurotic  women  I  have  seen  the  occurrence  of  pregnancy  produce  a 
degree  of  terror  that  certainly  was  close  to  mania.  During  labor  acute  insanity  is 
sometimes  observed  in  women  of  poor  nervous  balance,  neuropaths,  hysterics,  when 
the  pain  is  very  severe.  Without  doubt  the  strain  of  labor  is  too  much  for  many 
nervous  systems,  and  the  author  believes  that  prolonged  painful  lalior,  without  in- 
fection, will  explain  many  cases  of  puerperal  insanity.  Transitory  mental  aberra- 
tion during  the  agony  of  the  second  stage  is  not  seldom  observed,  and  it  may  be 
infanticidal  or  homicidal,  a  point  of  importance  in  medicolegal  cases.  It  is  an 
indication  for  immediate  delivery. 

During  the  puerperium  and  lactation  insanity  is  a  not  infrequent  disease, 
statistics  of  the  asylums  showing  from  10  to  18  per  cent,  of  female  inmates  affected 
at  this  time.  Puerperal  infection,  mastitis,  eclampsia  and  allied  toxemias,  post- 
partum and  other  hemorrhages,  especially  if  grafted  on  a  bad  heredity,  exhausting 
labor,  the  drain  of  lactation,  are  the  most  common  causes.  The  attack  may  be 
developed  by  a  violent  psychic  shock,  such  as  death  of  husband  or  child. 

Melancholia  with  suicidal  intent  was  the  most  common  form  in  the  author's 
cases,  but  mania  with  infanticidal  tendencies  was  also  observed.  Yinay  saj's  that 
the  maniacal  forms  are  most  frequent.  The  prognosis  is  fair,  the  majority  of  the 
cases  recovering  in  from  six  weeks  to  six  months.  The  treatment  is  along  general 
lines. 

Neuritis. — Pain  in  the  nerves,  especially  the  trigeminal,  the  ulnar,  and  the 
sciatic,  is  frequently  noted  in  pregnancy,  and  is  generally  treated  as  a  neuralgia, 
but  often  prickling  sensations,  numl)ness,  and  slight  paralysis  of  the  member  or 
memb(>rs  show  that  the  nerve  is  more  deeply  involved — that  a  neuritis  exists.  Poly- 
neuritis with  marked  paralyses,  even  atrophy,  has  been  observed,  and  has  been 
ascribed  to  toxemia.  The  degeneration  of  special  nerves  in  hj^jeremesis  gra\4darum 
has  been  mentioned.  Not  rarely  pregnant  women  complain  of  numbness  and 
pricking  of  the  fingers,  with  lack  of  power  in  the  hands,  and  examination  shows  the 
members  to  be  puffy,  slightly  cyanosed,  with  diminished  tactile  sensibility,  and 
occasionally  tenderness  of  the  ulnar  nerve  is  discovered.  The  nerves  of  the  special 
senses  may  be  involved — neuritis  optica,  auditoria,  etc.  (q.  v.),  and  the  pregnancy 
may  have  to  be  terminated  to  prevent  permanent  blindness  or  deafness.     After 


374      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

delivery  the  symptoms  rapidly  subside,  having  been  probably  toxemic.  Treat- 
ment is  along  these  lines. 

Puerperal  neuritis  is  of  the  same  nature,  though  Bar  calls  it  septic.  Mono- 
plegias after  delivery  are  probably  septic.  They  are  usually  radial  or  cubital, 
Mobius  believing  that  these  nerves  are  points  of  predilection  in  puerperal  infections. 
Sciatic  neuritis  is  particularly  intense  when  a  puerpera  is  affected.  Occasionally 
paralysis  and  atrophy  result.  While  some  of  the  cases  are  acute  and  heal  rapidly, 
many  pursue  a  course  of  months,  and  recovery  may  be  incomplete.  When  the  con- 
nective tissue  of  the  pelvis  is  inflamed,  the  nerves  of  the  sacral  plexus  not  seldom 
are  also  involved,  with  peripheral  muscular  and  sensory  disturbances.  Recovery 
occurs  after  the  inflammatory  process  has  subsided,  but  scar  formation  may  render 
it  incomplete. 

Injury  to  the  nerves  in  the  pelvis  by  the  forceps  may  result  in  peripheral  neu- 
ritis or  paralysis,  but  the  prognosis  is  good.  The  differential  diagnosis  is  on  general 
lines — here  need  only  be  mentioned  the  rupture  of  the  symphysis  pubis,  where  the 
pseudoparaplegia,  with  abduction  of  the  thighs,  at  first  glance,  might  cause  con- 
fusion. The  findings  over  the  pubis  and  the  results  of  the  neurologic  examination 
will  always  clear  the  chagnosis.  Treatment  of  neuritis  is  given  in  text-books  on 
internal  medicine.  For  toxemic  polyneuritis  it  may  be  necessary  to  induce  labor, 
especially  if  vital  nerves — phrenic,  pneumogastric,  or  the  nerves  of  the  special 
senses — begin  to  show  the  least  involvement. 


BLOOD  DISEASES 

Older  writers  spoke  of  the  condition  of  the  blood  during  pregnancy  as  being  one  of  chlor- 
anemia.  Later  studies  show  that  in  healthy  women,  rather,  there  is  an  increase  of  the  reds,  of  the 
hemoglobin,  of  the  fibrin,  and  of  the  white  blood-corpuscles.  Anemia  in  the  early  months,  how- 
ever, is  not  uncommon,  especially  if  the  woman  was  chlorotic  as  a  girl.  It  is  probable  that  the 
fetus  obtains  its  iron  from  the  maternal  red  blood-corpuscles,  and  this  may  explain  the  anemia  of 
the  early  months,  the  blood-forming  organs  not  being  equal  to  their  added  tasks.  The  author 
frequently  gives  iron,  arsenic,  and  mercury  in  combination  during  pregnancy,  with  success  in 
anemic  states.  Chlorosis  is  a  not  infrequent  cause  of  abortion  which  tonic  treatment  may  pre- 
vent. Chlorotic  women  stand  hemorrhage  very  poorly,  a  loss  which  may  be  insignificant  for 
another  being  fatal  to  them,  and,  besides,  they  show  a  tendency  to  bleed — a  point  of  great  im- 
portance in  the  treatment  of  the  third  stage.  Chlorosis,  which  is  often  a  sign  of  general  infantil- 
ism, may  cause  atonia  uteri  during  the  second  and  third  stages  of  labor,  and  one  may  find  a 
generally  contracted  pelvis  too. 

Pernicious  anemia  seems  to  be  favored  by  frequent  child-bearing,  especially  if  the  woman 
is  otherwise  weak  or  anemic.  Hemorrhage  favors  the  disease,  and  it  may  follow  an  infection; 
indeed,  a  careful  diagnosis  is  necessary  to  shut  out  tuberculosis,  cancer,  helminthiasis,  chronic 
gastritis,  intestinal  infections,  and  other  conditions  which  cause  secondary  anemia.  A  toxemia 
would  cause  the  disease,  but,  although  this  theory  has  been  advanced,  no  proof  is  shown.  The 
same  causes  are  said  to  excite  leukemia  wliich  may  occur  during  pregnancy,  but  it  is  doubtful 
if  there  is  any  special  relation  between  the  two.  If  there  were,  one  should  meet  the  disease  oftener. 
The  prognosis  is  bad  in  both  these  affections,  and  the  pregnancy  should  be  terminated  as  soon  as 
the  diagnosis  is  made,  though  often  neither  child  nor  mother  is  much  benefited  by  the  interference. 

Labor  may  occur  natui'ally  in  these  conditions  without  any  particular  tendency  to  hemor- 
rhage, but  sudden  exhaustion,  with  coma  and  cedcma  pulmonum,  has  been  frequently  noted  to 
follow  a  few  hours  after  delivery.     Leukemia  does  not  pass  over  to  the  fetus. 

Hemophilia  is  rare  during  the  reproductive  period.  Contrary  to  most  writers,  the  author 
believes  that  fatal  cases  of  hemophilia  can  occur  during  delivery.  Hemophiliacs  may  have  profuse 
menses,  and  may  bleed  to  death  from  defloration;  they  abort  frequently,  and  may  have  post- 
partum hemorrhage  or  late  bleedings  in  the  puerperium.  Hemophilia,  or  at  least  a  hemorrhagic 
diathesis,  can  occur  in  a  woman  who  has  no  family  history  of  it,  and  in  whom  the  bleeding  tendency 
has  not  been  in  evidence  in  previous  deliveries,  abortions,  or  menstruations.  The  author  is  con- 
vinced that  a  temporary  hemorrhagic  diathesis  can  occur  during  pregnancy,  its  basis  being  a  la- 
tent_ hemophilia,  syphilis,  malaria,  intoxication  }>y  chemical  or  hemolytic  poisons,  a  toxemia,  or  a 
sepsis.  It  is  a  generally'  admitted  fact  that  toxemia  disposes  to  hemorrhage.  The  hemorrhagic 
types  of  eclampsia,  hyperemesis,  etc.,  are  particularly  fatal.  The  blood  in  the  cases  observed  by 
the  writer  was  lake-colored,  like  port  wine,  the  clots  small,  soft,  and  black.  Suggillations,  pe- 
techia;, and  bloody  infiltration  around  the  vulva,  vagina,  and  cervix  and  the  hypodermic  punctures 
betrayed  the  fact  of  a  dissolution  of  the  blood. 

In  one  case  of  hajmatoma  vulva;  (p.  743)  the  woman  had  a  gingivitis  with  hemorrhages  and 
other  toxemic  symptoms  which  gave  almost  the  clinical  picture  of  scurvy.  It  is  more  than  possible 
that  a  toxemia  or  infection  lies  at  the  bottom  of  these  diseases.  This  subject  is  an  inviting  field 
for  investigation. 


BLOOD    DISEASES    IN    PREGNANCY  375 

So  fur  as  treatment  is  coneerned,  if  the  ccjiulitioii  is  reconnizcd  duririK  prefi;nancy,  the  attempt 
should  b(!  made,  by  j^eneral  tonic  remedies,  to  upbuild  the  [latient's  strength.  Iron,  mereury, 
and  arsenic  have  given  the  author  good  results.  Calcium  chlorid  and  gelatin  are  sui)f)o.sed  to 
increase  the  clotting  power  of  the  blood,  ancl  may  Ik;  administered  for  a  few  days  l)ef(jre,  during, 
and  after  labor.  The  author  could  not  etJiivince  himself  that  any  effect  was  obtained,  a  view  also 
held  by  Robertson.  The  use  of  a  heterogeneous  serum,  as  that  of  the  horse,  has  been  arivocated 
in  ca.ses  of  olwtinate  licniorriiage,  as  aLso  has  been  human  sfjrum,  and  the  results  with  the  latter 
certainly  encourage  trial.  Tlu;  object  is  to  supply  the  missing  thrombin,  thrombogen,  and 
thrombokinase. 

The  author  has  had  two  cases  of  polyglobulism,  a  syndrome  with  enlarged  spleen,  intense 
cyanosis,  hypcrcrythrocytosis.  The  spleens  in  both  |)atients  reached  the  brim  of  the  pelvis;  one 
woman  had  8,()()0,()()0  reds  and  ()(),00()  whites,  clubbed  fingers,  rheumatic  pains,  and  general  a.s- 
thenia.  One  was  sterile  iiitor  having  had  two  children  before  the  disease  appeared;  one  had  two 
still-born  macerated  children,  tlien,  under  iron,  arsenic,  and  mercury  treatment,  a  live  child  with- 
out trouble,  followed  by  sterility.  The  pregnancy  seemed  to  aggravate  the  general  conditions  very 
much. 

SKIN  DISEASES  IN  PREGNANCY 

A  close  relation  exists  l^etweeii  the  skin  and  the  changes  in  the  general  metab- 
olism due  to  pregnancy.  Virchow  and  Neusser  beUeved  that  there  is  some  relation 
between  the  ovaries  and  the  skin.  Of  the  milder  manifestations  of  the  disturbed 
nutrition  of  the  integument  may  be  mentioned  the  pigmentation,  hyperidrosis, 
edema,  falling  of  the  hair,  cracking  of  the  nails,  erythema,  acne,  etc.  While  most 
skin  diseases  are  aggravated  or  even  developed,  some  are  cured  by  the  advent  of 
pregnancy.  Pregnant  women  may  have  all  the  dermatoses  that  other  women  have, 
and,  since  the  reaction  is  usually  more  severe,  it  is  probable  that  many  of  the  affec- 
tions hitherto  designated  as  gestational  are  really  merely  coincident.  The  latest 
and  most  complete  exposition  of  the  subject  is  given  by  Scheuer. 

Pruritus  is  an  affection,  perhaps  neurotic,  perhaps  toxemic,  usually  localized 
on  the  vulva,  sometimes  general,  which  begins  in  the  middle  or  end  of  pregnancy,  and 
may  rarely  reach  such  an  intensity  as  to  demand  the  emptying  of  the  uterus.  Dia- 
betes should  always  be  looked  for.  Neurasthenic  and  hysteric  women  more  often 
have  the  itching.  Genital  pruritus  is  often  a  symptom  of  varicose  veins,  edema, 
vulvitis,  vaginitis,  cervicitis,  with  leukorrheal  discharge,  and  in  these  cases  the  skin 
of  the  vulva  is  thickened,  red,  and  shiny.  Mycosis  vulvae  is  not  infrequent  in 
multiparse.  Lack  of  cleanliness  is  another  cause  of  itching.  Eczema  and  other 
dermatoses  must,  of  course,  be  sought.  The  pruritus  is  usuall}^  worse  at  night  and 
in  simimer  because  of  the  warmth,  and  the  patients  lose  sleep.  After  delivery  re- 
covery promptly  ensues.  Subsequent  pregnancy  usually  shows  recurrence.  In  one 
case  the  author  found  evidences  of  renal  inefficiency,  and  the  woman  had  a  prurigi- 
noid  eruption  on  the  arms,  legs,  back,  shoulders,  and  chest.  Besnier  called  this 
form  of  pruritus  "prurigo  gestationis."  He  describes  an  itchy  eruption  of  tiny  pap- 
ules closely  grouped,  especially  on  the  backs  of  hands  and  feet,  appearing  usuallj' 
after  the  third  month,  recurring  in  successive  pregnancies,  and  disappearing  after 
delivery.  Usually  the  skin  is  normal  in  appearance  except  for  scratch-marks.  The 
treatment  is  general  and  local.  If  diabetic,  the  usual  treatment;  if  toxemic  or 
neurotic,  appropriate  remedies  will  be  employed.  Sodium  ]:)romid  in  20-grain  doses 
often  produces  sleep.  A  bland  diet,  without  condiments,  spices,  and  alcoholics, 
and  one  with  little  protein, is  prescribed — in  short,  general  hygienic  conduct.  Baths 
may  be  tried,  but  the  author  has  had  little  success  with  them.  Very  light  clothing, 
with  linen  next  to  the  skin,  is  good.  For  local  use  on  the  skin  the  author  has  had 
success  with  this  lotion: 

I^.     Carbolic  acid O.o  per  cent. 

Zinc  oxifl. 

Finely  levigated  calamin,  of  each lo.O 

Lime-water to  make  100.0         " 

For  pruritus  vulvse  the  author  has  used  with  varying  success  the  follo'u-ing 
applications:  Chloral  hydrate,  5  to  20  gm.  per  liter;  bichlorid  of  mercury,  1  :  1000; 


376      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

carbolic  acid,  2  per  cent,  solution;  essence  of  peppermint,  4  gm.  per  liter;  an  oint- 
ment consisting  of  ichthyol,  2  per  cent.;  menthol,  0.5  per  cent.;  ointment  of  rose- 
water,  a  sufficient  quantity;  or,  carbolic  acid,  0.5  per  cent.;  menthol,  1  per  cent.; 
zinc-oxid  ointment  and  ointment  of  rose-water,  of  each,  a  sufficient  quantity. 

The  washes  and  ointments  are  to  be  applied  cold,  after  cleansing  the  parts 
thoroughly  with  tar-soap  and  water,  using  much  soap.  In  cases  of  mycosis  vulvae 
the  white  patches  are  to  be  painted  with  10  per  cent,  silver  nitrate,  and  the  patient 
given  a  dusting-powder  of  boric  acid.  This  smarts  a  good  deal,  but  is  helpful. 
For  irritating  discharges  the  best  results  have  been  obtained  with  daily  potassium 
permanganate  douches,  1  :  3000,  followed  by  one  of  essence  of  peppermint,  a  tea- 
spoonful  to  a  quart  of  cool  water. 

Excessive  pigmentation  cannot  be  combated  during  gestation.  If  the  mask  of 
pregnancy  does  not  disappear  within  six  months  after  delivery,  the  parts  may  be 
rubbed  with  pure  lemon-juice  morning  and  evening,  which,  failing  to  remove  the 
stains,  a  treatment  with  bichloricl  of  mercury  may  be  recommended,  under  the  care 
of  a  good  dermatologist. 

Excessive  hirsuties,  very  rare  in  pregnancy,  usually  disappears  of  itself. 
Brickner  describes  a  disease  which  he  calls  fibroma  molluscum  gravidarum. 
The  forehead,  chest,  shoulders,  arms,  and  hands,  in  the  order  named,  present  pedun- 
culate, pinkish,  warty  excrescences,  in  size  from  a  pin-head  to  a  bean,  which  drop 
off  before  or  surely  after  labor.  A  tendency  to  warts  is  known  to  exist  in  preg- 
nancy, but  no  one  has  described  this  disease.  The  writer  has  seen  five  cases  of  it, 
but  in  none  was  the  eruption  so  generalized  as  in  Brickner's.  Treatment  is  symp- 
tomatic. 

Edema. — More  than  half  of  all  pregnant  women  show  some  edema  of  the  feet, 
the  hands,  or  the  face.  Often  this  is  an  elastic  puffiness  which  does  not  pit.  The 
cause  of  this  is  not  known.  A  real  anasarca,  with  exudation  of  serum  in  the  tissues, 
is  usually  due  to  toxemia,  renal  or  hepatic,  and  is  produced  by  the  alteration  of  the 
constitution  of  the  blood  or  capillaries  or  both.  It  is  present  in  the  morning  in 
the  feet,  hands,  and  eyelids,  sometimes  disappearing  by  night. 

Edema  which  grows  worse  during  the  day  is  usually  clue  to  mechanical  causes 
— varicose  veins,  tight  garters,  cardiac  disease,  and  obstruction  to  the  abdomi- 
nal circulation  (twin  pregnancy,  pendulous  belly,  abdominal  constriction).  The 
accoucheur  is  warned  not  to  conclude  lightly  that  an  edema  is  mechanical  or  of  no 
significance  because  the  urinary  findings  are  negative.  A  nephritis  may  exist 
without  albuminuria,  and  eclampsia  may  occur  with  no  other  warning  than  the 
anasarca. 

The  treatment  is  plain  when  the  cause  is  discovered.  General  obstetric  hy- 
giene usually  suffices.  (See  p.  225,  The  Conduct  of  Pregnancy.)  It  has  been  sug- 
gested that  the  amount  of  salt  in  the  food  be  curtailed,  but  the  author  has  not  seen 
constant  improvement  under  this  regimen.  Rest  in  bed  with  milk-and-water  diet 
is  one  of  the  best  means  we  have.  Excessive  edema  is  always  pathologic,  and  usu- 
ally preeclamptic,  and,  therefore,  treatment  directed  against  the  toxemia  is  indi- 
cated. Puncture  of  the  swollen  tissues  should  not  be  done  unless  the  patient  is  in 
lal^or  and  soon  to  be  delivered,  because  of  the  danger  of  infection  from  the  prolonged 
drainage  and,  of  course,  extreme  antisepsis  will  be  oljserved. 

Special  skin  diseases,  described  by  writers  as  due  to  pregnancy,  are  very  rare. 
Herpes  gestationis  is  a  form  of  herpes  which  appears  during  pregnancy,  especially  on 
the  arms,  legs,  face,  and  chest,  in  the  order  named,  passes  through  the  usual  states 
of  grouped  vesicles,  small  bull®,  pustules,  and  crusts — is  of  chronic  nature,  and 
liable  to  recurrence  in  subseciuent  pregnancies.  Very  probably  other  affections, 
for  example,  erythema  multiforme  and  dermatitis  herpetiformis,  have  been  called 
herpes  gestationis. 

Impetigo  herpetiformis  (Hebra),  on  the  other  hand,  is  a  serious  disease  (mor- 


THE    KIDNEY   OF    PREGNANCY  377 

t 

tality,  80  per  cent.),  sufficiently  characteristic  to  be  called  a  gestational  affection, 
though  it  is  rare  in  America.  The  following  is  a  dcscripticjn  of  tlu,'  author's  typical 
case  treated  in  conjunction  with  Dr.  Josef  Zei.sler; 

A  quintipiira,  uKod  tliirty-scvon,  had  the  disease  in  her  third  pn-Knancy  and  miscarried,  but 

not  in  the  fourth,  a  iioriiud  i)n'friKUicy.  Since  four  weeks  siie  has  been  bedridden  heeause  of  gen- 
eral weakness,  vomit iiiji,  diarrhea,  insonuiia,  pain  in  the  le^s,  and  an  eruption  whieli  lic^an  on  the 
insid(>  of  tiie  thif^hs  and  lias  slowly  spread  all  over  tlie  legs,  trunk,  and  arms.  ( Injujts  of  [justules, 
pin-head  to  lentil  in  size,  appear,  coalesce,  form  crusts  which  fall  off  and  litter  the  bed,  leaving 
reddened  skin.  T\w  lesion  extends  progressively  in  all  directions.  The  center  of  the  large  areas 
is  healed,  l)ut  largi;  patches  of  epidermis  an;  elevated  in  places,  resembling  pemf)higtis.  In  the 
genital  region  the  crusts  and  excoriated  skin  producetl  a  red,  fetid,  oozing,  bleeding  surface.  The 
mouth  was  early  aifectcd,  showing  gray  plaques. 

The  general  condition  of  the  woman  is  poor,  but  she  has  no  fever, — contrary  to  Kaposi, — a 
pulse  of  about  100,  and  there  is  slight  iet(>rus.  At  eight  months  the  woman  aborted,  whereupon  the 
eruption  rapidly  disappeared  and  the  woman  (juickly  recovered.  The  child  showed  no  eruption. 
Bacteriologic  examination  of  tlie  pustules  and  of  the  blood  was  negative.  Polyuria  was  present, 
with  a  trace  of  albumin,  diminished  urea,  no  sugar,  no  jjeptones  or  indican,  and  no  casts. 

The  cause  of  impetigo  herpetiformis  is  unknown — an  infection  or  a  toxemia  ap- 
pears probable.  Wolff-Eisner  believe  it  is  of  an  anaphylactic  nature,  the  foreign 
protein  coming  from  the  uterus.  Mayer  believes  it  is  a  toxemia,  and  that  the 
system  does  not  react  with  sufficient  antitoxin.  He  therefore  injected  20  c.c.  of 
the  blood-serum  of  a  healthy  gravida  to  supply  the  antitoxin.  Result,  cure  in  three 
cases.  Treatment  is  palliative,  but  the  author,  having  observed  the  rapid  subsi- 
dence of  the  disease  following  the  expulsion  of  the  fetus,  if  rapid  amelioration  did  not 
follow  Mayer's  treatment,  would  induce  labor. 

During  the  puerperium  the  author  has  observed  the  following  skin  diseases: 
Sudamina;  acne;  furunculosis;  erythema  multiforme;  pityriasis  versicolor;  drug 
eruptions;  urticaria  from  too  free  use  of  cresylic  acid  preparations;  eczema  from 
bichlorid,  which  in  one  case  became  a"  generalized  eruption  with  high  fever,  and  was 
erroneously  called  by  the  attending  physician  an  erysipelas.  Septic  eruptions  will 
be  discussed  under  Puerperal  Infections. 

^  Literature 

Bevan:  "Chloroform  Deaths,"  Jour.  Amer.  Med.  Assoc,  1909. — Brickner:  Amer.  Jour.  Obstet.,  1900. — Biiiiff:  Trans- 
actions of  the  Edinburgh  Obst.  Soc,  1S94,  189.5. — Charpentier:  Traite  d'Obstet. — DebreuUil:  La  pratique  dermat., 
1901,  vol.  ii,  p.  918. — De  Lee:  "Fatal  Hemorrhagic  Diathesis,"  Amer.  Jour.  Obstet.,  1901,  vol.  xliv,  Xo.  6. — 
Duhring:  Amer.  Jour.  Med.  Sci.,  vol.  Ixxxviii,  p.  391. — Fellner:  Die  Beziehungen  innorer  Krankh.  zu  Schwan- 
gersch.,  etc.,  190.3,  p.  183. — Frankl-Hochwart  and  C.  v.  Noorden:  Erkrank.  des  weibl.  Genital,  in  Bez.  z. 
inneren  Medizin,  2  volumes,  1912. — Hebra:  Wien.  med.  Woch.,  1872,  No.  48. — Linser:  Arch.  f.  Derm.  u.  Syph., 
1911. — Mayer:  Centralbl.  f.  Gyn.,  1911,  No.  9,  p.  3.51. — Miiller,  P.:  Die  Krankheiten  des  weiblichen  Korpers, 
p.  40.5. — Polyglobulism:  Jour.  Amer.  Med.  Assoc,  November  23,  1907,  p.  1776.  Gives  full  literature. — Robert- 
non:  Jour.  Amer.  Med.  Assoc,  vol.  1,  No.  20. — Scheurer:  Hautkrank.  sexuellen  Ursprungs,  Vienna,  1911. — Vinay: 
Maladies  dc  la  Grossesse,  p.  249;  ibid.,  1894,  p.  584;  ibid.,  p.  485. 


CHAPTER  XXIX 
LOCAL  DISEASES  INCIDENT  TO  PREGNANCY 

Varicosities. — Varices  of  the  legs  or  of  the  vulva  or  hemorrhoids  are  found  in  a 
majority  of  pregnant  women.  While  marked  varicosities  are  present  in  only  20 
per  cent,  of  gravidae,  a  few  dilated  veins  are  an  almost  constant  accompaniment  of 
gestation.  The  veins  of  the  ankles,  legs,  thighs,  vulva,  vagina,  rectum,  and  broad 
ligaments  are  affected,  in  frequency  and  degree,  according  to  the  order  given,  but 
one  or  the  other  form  may  be  alone  present  or  predominant.  Fine  venous  networks 
or  large  paquets  of  tortuous  veins,  resembling  bunches  of  angle-worms,  are  observed. 
The  vulvar  lips  may  be  enlarged  and  spongy  (Fig.  132).  They  resemble  varicoceles 
and  cause  much  the  same  distress.  Edema  often  attends  varicosities.  The  patient 
complains  of  pain,  fatigue,  burning,  itching,  and  a  feeling  of  tension  in  the  affected 
parts.  In  some  cases  the  veins  are  so  dilated  and  the  legs  so  edematous  and  painful 
that  the  patient  can  hardly  walk.  After  the  delivery  of  the  child  the  varicosities 
collapse,  and  they  almost  always  disappear  in  three  weeks.  The  causes  of  varicose 
veins  are  not  kno\vn,  but  pregnancy  surely  has  much  to  do  with  developing  them. 
Women  who  are  much  on  their  feet  and  have  to  work  hard,  multiparas  with  pendu- 
lous belly,  women  with  heart  disease,  are  most  afflicted,  and  a  special  disposition 
can  also  be  observed.  This  may  be  congenital.  Frequent  pregnancies  and  tight 
abdominal  bands  and  garters  also  favor  them.  Varicosities  are  not  due  to  pressure 
of  the  gravid  uterus  on  the  veins  of  the  pelvis,  because  this  is  impossible,  nor  to 
increased  intra-abdominal  tension,  because  this  seldom  exists  to  such  a  degree. 
That  there  is  some  obstruction  to  the  return  circulation  from  the  legs  is  highly 
probable,  but  there  must  be  some  change  in  the  vessel-wall  or  of  the  blood  which 
predisposes  to  venectasis  during  pregnancy.  Toxemia  again  has  been  suggested, 
also  a  vasodilating  ferment  from  the  corpus  luteum.  It  may  be  the  same  condition 
which  causes  the  pelvic  vessels  to  enlarge  and  dilate  with  the  progress  of  pregnancy. 
That  some  such  relation  exists  is  proved  by  the  fact  that  in  some  women  the,  veins 
enlarge  as  soon  as  conception  occurs,  and  that  they  collapse  if  the  fetus  dies  in  utero. 
With  other  abdominal  tumors  varicose  veins  of  the  legs  are  rarely  observed,  and 
this  point  may  be  used  in  the  differential  diagnosis.  A  woman  was  sent  to  the 
author  from  a  neighboring  city  for  her  accouchement.  She  was  suffering  from 
carcinoma  of  the  ovaries  with  immense  abdominal  distention.  There  were  no 
varicosities,  but  the  patient  said  she  had  had  such  in  all  her  six  pregnancies. 

Varicosities,  beyond  the  pain  they  produce,  are  dangerous  because  they  may 
ulcerate,  become  infected  (phlebitis  and  periphlebitis),  may  thrombose,  sometimes 
give  rise  to  emboli,  and  may  burst,  allowing  fatal  hemorrhage.  Vaginal,  vulvar, 
and  broad-ligament  varices  may  rupture  also  into  the  connective  tissue,  causing 
hematomata,  which  may  be  fatal  from  internal  hemorrhage,  or,  becoming  infected, 
from  sepsis.  During  labor  vaginal  and  vulvar  varicosities  not  seldom  are  torn,  re- 
quiring quick  diagnosis  and  immediate  suture  or  firm  tamponade,  because  the  bleed- 
ing is  profuse.  Differential  diagnosis  from  placenta  prajvia,  abruptio  placentae, 
and  atony  of  the  uterus  must  be  made,  which  is  done  by  inspection  and  finding 
the  bleeding  vessel.  A  hematoma  occurring  during  labor  may  obstruct  the  de- 
livery of  the  fetus.  Treatment  consists  in  opening  and  packing  the  cavity  until 
the  cervix  is  dilated,  then  removal  of  the  packing,  delivery,  followed  by  repacking 
the  cavity  of  the  hematoma  and  the  uterovaginal  tract.     Occasionally  a  varix  of 

378 


LOCAL    DISEASES   INCIDENT   TO    PREGNANCY  379 

the  broad  ligament  will  burst  into  the  peritoneal  cavity,  producing  the  symptoms  of 
ectopic  gestation,  and  one  may  thus  rupture  during  labor,  the  patient  dying  of  intra- 
peritoneal hemorrhage  without  a  drop  showing  externally  to  apprise  the  accoucheur 
of  the  cause  of  the  fatal  anemia. 

Clotting,  occurring  in  bnjad-ligament  varices,  may  lead  to  emljoli,  which  may 
break  off  during  labor,  and  this  warns  to  gentleness  in  handling  the  uterus  during 
the  third  stage  or  during  the  puerperium. 

Treatment. — A  hemorrhage  from  a  varicosity  is  easily  controlled  by  pressure 
or  suture.  The  patient  must  be  instructed  to  avoid  injuring  and  infecting  the 
superficial  veins  by  scratciiing  them  or  knocking  against  things;  to  avoid  coitus  if 
the  varices  are  vulvar  or  vaginal,  and  she  should  be  taught  how  to  stop  hemorrhage 
while  waiting  for  help  if  one  of  them  should  bleed.  Phlebitis  and  periphlebitis 
are  treated  by  rest  in  bed,  moderate  elevation  of  the  leg,  and  wet  boric-acid  dress- 
ings. Rest  must  be  enjoined  for  three  weeks,  or  until  it  is  judged  that  the  throm- 
bosis is  complete  and  the  thrombus  firmly  organized — this  to  avoid  the  danger  of 
embolism.  Suppurating  thrombi  of  the  legs  are  to  be  drained.  Little  can  be  done 
to  improve  the  bad  cases  of  varicosities  during  pregnancy.  A  rubber  stocking  or 
flannel  bandage  may  be  worn,  and  the  feet  held  elevated  whenever  possible.  JNIore 
comfort  is  gotten  from  the  application  of  adhesive  strips  placed  spirally  around  the 
limbs  while  the  woman  is  recumbent.  They  divide  and  support  the  column  of 
blood. 

Hemorrhoids  occasionally  are  very  obstinate  and  aimoying  to  the  pregnant 
woman,  who  perhaps  is  not  affected  with  them  under  other  conditions.  Hemor- 
rhages, fissures,  with  exuberant  granulations,  or  extrusion  and  gangrene,  may  occur. 
Operation  is  not  to  be  made  during  gestation,  but  the  usual  treatment  may  be  pur- 
sued. During  labor  the  hemorrhoids  come  out,  swell  up,  and  may  bleed.  They 
predispose  to  lacerations  of  the  perineum.  An  attempt  should  be  made  to  replace 
and  retain  them  with  a  pad.  Some  accoucheurs  use  this  opportunity  to  remove  the 
masses,  but  probably  it  is  best  to  wait  until  the  puerperium  is  over.  Postpartum, 
hemorrhoids  often  cause  a  great  deal  of  distress.  If  the  piles  are  internal,  they  may 
be  replaced,  under  ether  if  necessary;  if  external,  no  such  attempt  may  be  made, 
but  the  hips  should  be  elevated  and  cold  applied  to  the  parts.  If  there  is  a  hemor- 
rhage into  one  or  the  other  pile,  it  may  be  incised  under  local  anesthesia  and  the 
clot  turned  out. 

The  author  uses  these  prescriptions,  in  order: 

(1)  I^.     Acidi  tannici 2.0  per  cent. 

Ext.  hamamelis 12.0         " 

Menthol 0.5 

Ext.  opii  aq 0.5         " 

Ung.  aquse  rosie q.s.  ad  100.0         " 

Fiat  unguent. 

(2)  I^.     Ichthyol.  ammoniat 25.0  per  cent. 

Glycerini 75.0         " 

(3)  I^.     Ichthyol., 

Ext.  hamamehs aa  5.0  per  cent. 

Menthol 0.5 

01.  thcobroma? q.s.  ad  100.0         " 

Fiat  suppositoria. 

Relaxation  of  the  Pelvic  Joints. — The  ancients  believed  that  the  pelvic  bones 
separated  during  delivery  and  labor  thus  was  rendered  possible.  Later  this  view 
was  dropped,  and  cases  where  such  separation  occurred  were  called  abnormal.  In 
cows  the  sacro-iliac  joints  soften,  and  in  guinea-pigs  all  the  joints,  especially  the 
pubis,  soften  and  enlarge,  allowing  wide  latitude  of  motion.  In  the  human  there 
is  no  doubt  but  that  the  joints  soften,  thicken,  and  thus  enlarge  the  cavity  of  the 
pelvis.     The  bones  Ijecome  more  movable  on  each  other  and  thus  permit  the  pelvis 


380      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

to  accommodate  itself  to  the  mechanism  of  labor.  Matthews  Duncan  proved  this. 
The  mobility  in  the  joints  renders  the  Walcher  position  effective  in  enlarging  the 
inlet,  and,  by  placing  the  parturient  in  the  exaggerated  lithotomy  position,  through 
the  same  conditions,  some  enlargement  of  the  bony  outlet  is  produced.  That  a 
small  pelvic  cavity  enlarges  during  pregnancy  the  author  is  convinced,  and  that 
the  tilting  (or  "nutation")  of  the  sacrum  favors  the  passage  of  the  fetus  is  another 
clinically  demonstrated  fact. 

When  the  softening  of  the  pubic  and  other  joints  l^ecomes  marked,  symptoms 
resembling  arthritis  are  produced,  as  follows:  Pain  in  and  about  the  pelvis,  referred 
to  the  site  of  the  joints,  and  especially  to  the  particular  one  involved;  difficulty  in 
locomotion;  easy  tiring,  with  a  general  sense  of  weakness;  inability  to  rise  from  a 
sitting  posture  without  raising  the  trunk  on  the  hands  or  outside  assistance;  relief 
by  walking,  but  soon  followed  by  pain  in  the  pelvis,  necessitating  rest ;  the  condition 
is  worse  in  the  morning,  better  in  the  day,  and  worse  again  in  the  evening;  pain 
reflected  up  and  clown  the  nerve-trunks  of  the  pelvis,  simulating  neuralgia,  or  even 
pains  in  the  hypogastrium,  simulating  abdominal  disorders.  When  the  patient  is 
bedridden,  the  case  is  decidedly  pathologic.  On  examination  no  cause  for  the  symp- 
toms can  be  found  until  the  condition  of  the  pelvic  joints  is  discovered.  The  ten- 
derness of  the  pubic  cartilage  is  the  most  prominent  finding.  The  sides  of  the  joint 
are  painless,  but  pressure  directly  over  the  middle  evokes  lively  expressions  of 
suffering.  Then  the  groove  may  be  found  over  the  pubis  or  with  the  finger  in  the 
vagina.  By  rocking  the  pelvis  one  can  feel  the  bones  ride  on  each  other,  especially 
plainly  if  the  woman  is  examined  while  erect  and  stands  first  on  one  foot  and  then 
on  the  other.  Deep  pressure  over  the  sacro-iliac  joints  elicits  pain,  but  not  over 
the  coccyx.  The  gait  is  peculiar,  waddling — "like  a  duck,"  as  one  woman  expressed 
it.  A  distinct  rising  and  falling  of  the  crests  of  the  ilia  can  be  seen,  which  is  not  all 
due  to  the  tilting  of  the  pelvis.  The  distress  in  walking  may  sometimes  be  a  real 
pain,  referred  to  the  affected  joint  or  joints.  The  affection  occurs  in  the  latter  half 
of  pregnancy,  in  multiparse  more  than  in  primiparse,  is  often  combined  with  varicose 
veins,  the  joints  under  these  conditions  seeming  to  partake  of  the  general  imbibition 
of  the  tissues  of  the  pelvis;  it  often  recurs  in  successive  pregnancies. 

During  labor,  if  the  sacro-iliac  synchondrosis  is  loose,  the  ilium  may  be  dis- 
located on  the  sacrum,  a  condition  which  was  noted  by  Madame  Lachapelle.  A 
case  of  this  kind  is  reported  by  Bates,  of  Denver.  The  joint  may  rupture  during 
operative  or  even  natural  delivery.  After  delivery  the  solidity  of  the  pelvis  is  rapidly 
restored,  unless  the  synchondroses  were  injured,  in  which  case  the  patient  may  be 
bedridden  for  weeks  or  months.  Milder  cases  of  injury  to  the  sacro-iliac  joints  are 
undoubtedly  commoner  than  is  generally  believed.  Such  injury  explains  many  of 
the  prolonged  backaches  and  neurasthenic  states  following  parturition.  An  ortho- 
pedist should  be  drawn  in  consultation  in  such  cases. 

How  closely  this  condition  is  related  to  osteomalacia  has  not  yet  been  dis- 
covered. It  bears  some  resemblance.  The  diagnosis  is  easy  if  the  disease  is  borne 
in  mind.  Neuritis  and  paraplegia  seldom  need  consideration,  but  are  easily  elimi- 
nated. The  prognosis  is  good,  but  the  possibility  of  rupture  of  the  symphysis 
should  be  remembered.  (See  Chapter  on  Ruptura  Symphysis.)  During  preg- 
nancy curative  treatment  is  impossible.  External  applications,  rest  in  the  hori- 
zontal position,  and  general  hygiene  arc  prescribed.  A  tight  girdle  (Osgood's 
brace)  or  adhesive  straps  may  be  tried. 

Literature 

DeLee:  "Relaxation  of  P(;lvic  Joints,"  Jour.  Ainfr.  Mud.  Assoc,  January  4,  1902. — Duncan,  Matthews:  Researches 
in  Obstetrics,  18G8,  p.   140. 


CHAPTER  XXX 
EXTRA-UTERINE  PREGNANCY 

A  BETTKR  term  is  ectopic  pr('ji;n;in('y,  or  eccyesis,  which  means  a  gestation  which 
occurs  outside  of  the  cavity  of  tlie  uterus.  Extra-uterine  gestation  is  the  term  more 
commonly  used,  but  this  would  exclude  from  the  study  those  cases  where  preg- 
nancy develops  in  the  interstitial  portion  of  the  tube. 

An  ovum  may  be  fertilized  and  remain  at  any  point  of  its  passage  from  the 
ovary  to  the  uterus  (Fig.  344).  The  most  common  sites  of  its  nesting  are  the  tube, 
its  mecUan  or  isthmial,  its  ampullary,  its  uterine  or  interstitial,  portions,  in  the  order 
named,  and,  lastly,  the  ovary.  Primary  abdominal  pregnancy  has  been  reported 
on  the  posterior  fold  of  the  broad  ligament  and  on  the  omentum  (Hirst  and  Knipe, 
Hammacher,  and  Galabin),  but  it  is  of  such  exceeding  rarity  that  it  need  only  be 
mentioned.  Hecker  considered  it  very  common,  but  these  were  secondary  ab- 
dominal pregnancies.  Pregnancy  has  developed  in  a  sinus,  possibly  with  a  piece  of 
Fallopian  tube,  following  vaginal  hysterectomy,  and  also  in  the  stump  of  a  tube 


Tubal  with 

rupture  into 

Ampullar         broad  ligament  Interstitial 


Tubal  with 

rupture  into 

peritoneal  cavity 


Ovarian 


Fig.  344. — Diagram  of  Locations  of  Ectopic  Ova. 


after  partial  salpingectomy.  Pregnancy  may  occur  in  a  closed  accessory  horn  of 
the  uterus  and  on  the  fimbria  ovarica  of  the  Fallopian  tube.  In  the  latter  instance 
one  speaks  of  a  tubo-ovarian  form.  As  the  ovum  distends  its  container  other  struc- 
tures are  encroached  upon,  adhesions  form  between  them,  and  the  primary  topog- 
raphy of  the  gestation  is  modified.  When  the  tubal  wall  bursts,  the  fetus  escap- 
ing into  the  free  abdominal  cavity  or  into  a  mass  of  preformed  adhesions,  we  speak 
of  tubo-abdominal  pregnancy;  if  the  rupture  occurs  in  the  lower  portion  of  the 
tube,  between  the  folds  of  the  broad  ligament,  an  intraligamentous  sac  is  formed; 
if  the  sac  which  is  formed  in  an  interstitial  pregnancy  bursts  into  the  uterus  (rare), 
we  speak  of  tubo-uterine;  if  the  ovarial  pregnancy  goes  toward  term,  it  ahiiost 
always  becomes  ovario-abdominal — these  are  all  secondary  forms,  and  clinically,  as 
well  as  anatomically,  hard  to  distinguish  from  each  other. 

Causation. — The  first  mention  of  extra-uterine  pregnancy  is  by  Abulcasis  in 
the  tenth  century,  and  Riolan,  in  1626,  refers  to  several  cases.     Since  then  the  sub- 
SSI 


382      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

ject  was  frequently  noted,  and  recently,  since  operative  interference  has  become 
common,  an  enormous  literature  has  accumulated  (Werth). 

Extra-uterine  pregnancy  is  quite  frequent,  and  occurs  also  in  the  lower  animals 
— the  ape,  cow,  sheep,  bitch,  and  hare.  Many  cases  of  rupture  of  the  sac,  or  tubal 
abortion,  and  spontaneous  recovery  undoubtedly  occur,  and  pass  under  the  diag- 
nosis of  appendicitis  or  abdominal  colic.  "Prostitutes'  colic"  is  surely  often  of 
this  nature.  It  is  more  frequent  in  city  than  in  country  practice;  oftener  after 
the  thirtieth  year — frequently  after  a  long  period  of  relative  sterility;  and  in  women 
who  have  had  an  antecedent  pelvic  disease.  Repetitions  of  the  accident  in  the 
same  tube  and  in  the  other  tube  have  been  reported,  and  intra-uterine  and  extra- 
uterine gestation  may  coexist. 

The  actual  causes  are  unknown,  but  the  following  have  been  advanced,  with 
more  or  less  plausibility,  in  the  order  named:  (1)  Salpingitis;  (2)  pelvic  adhesions; 
(3)  infantile  tubes  with  lack  of  cilia;  (4)  external  wandering  of  the  ovum;  (5) 
diverticula  and  accessory  tubes;  (6)  decidual  reaction  of  the  tubes;  (7)  disease  of 
the  corpus  luteum  (Frankel  and  Opitz). 

Salpingitis  may  act  either  by  the  loss  of  the  cilia,  which  should  favor  the  mo- 
tion of  the  ovum  to  the  uterus,  or  by  gluing  the  folds  of  the  mucosa  tubse  together 
and  forming  blind  pouches  in  which  the  ovum  is  caught,  or  by  occluding  the  tube 
through  the  kinks  or  swelling.  Gonorrhea  is  a  frequent  antecedent,  but  puerperal 
mfections  and  other  inflammations  are  also  found.  Pelvic  adhesions  may  bind 
the  tubes  and  ovaries  clown  and  compress  the  lumen  of  the  tube,  or  prevent  the 
escape  of  the  ovum  from  the  neighborhood  of  the  ovary.  Infantile  tubes  are  much 
convoluted  (Freund),  and  perhaps  have  little  propelling  power.  In  cases  of  ex- 
ternal wandering  of  the  ovum  it  may  have  grown  so  large  that  it  is  unable  to  pass 
the  lumen  of  the  tube,  and  durii^  the  long  journey  the  trophoblast  has  had  time 
to  develop,  so  that  it  can  attach  itself  anywhere,  or  perhaps  the  slow  motion  im- 
parted to  the  ovum  by  the  weakened  or  undeveloped  or  adherent  tube  gives  it  time 
to  become  fixed.     Much  of  the  above  is  purely  theoretic. 


PATHOLOGY 

Tubal  Pregnancy. — This  is  by  far  the  most  common  form.  Whether  the  ovum 
rests  in  the  ampulla,  the  median,  isthmic,  or  the  interstitial  portion  of  the  tube,  the 
course  is  the  same,  the  trophoblast  producing  cytolysis  of  the  cells  of  the  tubal 
mucosa,  and  the  ovum  then  burrowing  into  the  wall  of  the  tube,  in  a  way  distinctly 
analogous  to  that  of  pregnancy  in  the  normal  uterus.  A  decidua  may  or  may  not 
he  formed,  but  usually  one  finds  islands  of  decidual  reaction  in  and  near  the  im- 
plantation of  the  ovum,  and  even  in  the  other  tube.  As  the  ovum  grows  it  bulges 
the  Avail  of  the  tube  inward,  occluding  its  lumen,  the  cells  of  the  opposing  surfaces 
necrose,  and  the  capsularis,  if  there  is  one,  fuses  with  the  opposite  side  of  the  tube. 
The  villi  erode  their  way  into  the  blood-vessels  and  between  the  muscular  fibers. 
Conditions  in  the  wall  of  the  tube  are  so  different  from  those  in  the  thick  decidua 
of  the  uterus  that  the  dangers  of  tubal  pregnancy  are  easily  grasped.  In  the  uterus 
the  ovum  develops  in  the  thick  decidua  and  in  a  mucous  membrane  capable  of  strong 
decidual  reaction,  which  membrane  might  really  be  considered  a  protective  wall 
against  the  advancing  army  of  villi.  The  blood-vessels  are  small,  and  the  muscle  of 
the  uterus  is  physically  adapted  to  stretching  and  hypertrophy.  On  the  other 
hand,  in  the  tube  there  is  little  or  no  decidua,  and  the  advancing  villi  rapidly  eat 
their  way  into  the  muscle-fibers  and  into  the  blood-vessels.  These  latter  are  large, 
and  the  muscle  of  the  tube  is  not  so  capable  of  hypertrophy  and  stretching.  Indeed, 
in  the  tube  the  ovum  acts  like  a  rapidly  growing  destructive  neoplasm. 

The  ovum  may  be  arrested  between  two  folds  of  the  redundant  tubal  mucous 
memljrane,  or  it  may  attach  itself  to  the  top  of  a  fold  (Werth) .     Minute  differences 


EXTRA-UTERINE  PREGNANCY  383 

in  the  early  development  of  llic  ovum  rcsuH  here,  hut  they  are  of  no  elinieal  im- 
portance. In  either  case  the  fi;rovviiif>;  ovum  (lislends  the  tube  to  the  point  of  rup- 
ture. Some  hypertrophy  of  the  tube  occurs  in  all  cases,  and  in  rare  ones  the  tube 
grows  until  term  without  rupture,  these  being  the  instances  where  it  has  been  sup- 
posed that  muscle-fibers  could  develop  in  an  adventitious  sac. 

Usually  the  hypertrophy  of  the  muscle  of  the  tube  is  insufficient  to  accommo- 
date the  egg,  antl  the  fibers  at  the  placental  site  being  separated  and  destnjyed  by 
the  erosive  action  of  the  villi,  a  weak  spot  here  results.  Any  traumatism,  as  strain- 
ing at  stool,  a  jar,  coitus,  a  bimanual  examination,  causes  a  slight  hemorrhage 
at  this  site,  with  a  rupture,  or  the  tube  bursts  from  overdistention  of  the  thinned 
necrosed  wall,  and  the  villi  lie  free  in  the  peritoneum.  Bleeding  naturally  results  from 
each  of  these  occurrences.  If  the  site  of  the  rupture  was  on  the  free  portion  of  the 
tube,  the  hemorrhage  takes  place  into  the  peritoneal  cavity,  a  hematocele  forming 
in  the  pelvis.  When  the  tube  bursts  into  the  broad  ligament,  a  hematoma  develops 
there.  Rupture  of  the  tube  is  the  usual  termination  of  isthmic  and  of  interstitial 
pregnancy,  and  it  almost  always  occurs  in  the  second  and  third  months. 

When  the  ovum  is  in  the  ampulla,  the  gestation  sac,  in  developing,  may  point 
in  the  direction  of  the  fimbriated  end  of  the  tube,  and  a  process  known  as  tubal 
abortion  is  the  usual  termination. 

The  course  of  tul^al  abortion  resembles  that  of  uterine  abortion  very  closely — a 
hemorrhage  occurs  in  the  decidua  serotina,  loosening  the  ovum  from  its  bed.     The 


Fig.  345. — Tubal  Abortion  in  Progress,  when  a  Rup-  Fig.  3-16. — Tubal  Hematoma  from  Tubal  Ges- 

ture OF  THE  Tube  from  Necrosis  Caused  such  a  tation. 

Hemorrhage  that  Operation  became  Imperative. 

blood  and  the  ovum  now  fill  the  overdistended  tube.  The  bag  of  waters  may  rup- 
ture and  the  fetus  escape  among  the  clots  in  the  lumen  of  the  tube.  Blood  oozes 
through  the  fimbriated  end  of  the  tube  and  clots  around  it,  slowly  forming  a  hemato- 
cele in  the  lower  pelvis.  The  ovum  and  clots  are  gradual!}'  extruded  through  the 
open  end  of  the  tube  into  the  peritoneal  cavity,  and  they  are  all  finally  absorbed, 
unless  the  hemorrhage  has  been  so  great  as  to  demand  surgical  interference  (Fig. 
345) .  If  the  extrusion  does  not  take  place  or  is  not  awaited,  the  hemorrhages  into 
the  tube  destroy  the  ovum  and  it  becomes  converted  into  a  mola  carnosa,  very  like 
those  often  found  in  the  uterus  (Figs.  346  and  347).  In  these  earl}-  moles  it  is  rare 
to  find  the  little  fetus — it  has  been  destroyed  or  even  absorbed.  Unless  one  finds 
the  fetus  or  demonstrates  villi,  the  diagnosis  of  ectopic  gestation  may  not  be 
made.  In  molar  formation  also  a  slight  amount  of  blood  may  ooze  into  the  pelvis 
and  bind  the  tube  to  neighboring  structures. 

Hematocele. — Very  soon  after  the  blood  touches  the  peritoneal  surface  it  clots, 
and  the  peritoneal  surface  also  throws  out  a  layer  of  fibrin.  Adhesions  are  thus 
quickly  formed  between  the  tube  and  the  neighboring  organs,  and  the  blood  is  en- 
capsulated. This  is  a  hematocele,  and  the  sac  is  composed  of  the  fibrin  mentioned, 
the  neighboring  organs,  mainly  intestines,  bound  together  by  adhesions.  When  a 
new  bleeding  occurs  from  the  end  of  the  tube,  the  newly  formed  sac  is  overdistended 
and  may  rupture,  the  process  of  adhesive  reaction  being  continued  a  shorter  or 
longer  distance,  in  the  direction  of  least  resistance.     Another  hemorrhage  causes  a 


384      THE  PATHOLOGY  OF  PREGNANCY;  LABOR,  AND  THE  PUERPERIUM 

repetition  of  the  process,  and  the  woman  may  die  from  the  repeated  losses  of  blood. 
This  slow  hematocele  formation  is  the  rule  in  tubal  abortion  and  tubal  mole,  but  it 
may  occur  with  a  slow  rupture  of  the  tube  as  well. 

When  the  tul^e  l^ursts,  it  usually  does  so  suddenly,  and  a  profuse  intraperitoneal 
hemorrhage  results.  If  the  woman  does  not  die  from  shock  and  the  anemia,  this 
mass  of  blood,  too,  is  walled  off  and  a  large  hematocele  forms.  This  condition  is 
found  in  isthmic  and  in  interstitial  pregnancies.  Rupture  of  the  tube  may  occur 
in  any  part  of  its  periphery.  Sometimes  the  perforation  is  minute,  the  villi  seem- 
ing to  have  actually  eaten  a  hole  through  the  wall. 

Hematoma. — When  the  rupture  of  the  tube  takes  place  into  the  broad  liga- 
ment, the  two  folds  are  torn  asunder  by  the  blood,  and  one  finds  a  mass   lateral  to 


Fig.  347. — Cross-section  of  Early  Mole,  Enlarged. 

the  uterus,  extending  variably  to  the  wall  of  the  pelvis,  under  the  round  ligament, 
even  up  into  the  iliac  fossa. 

The  fetus  does  not  always  die.  Sometimes  the  rupture  occurs  at  a  point  in  the 
periphery  of  the  ovum  which  does  not  affect  the  placental  site,  and  then  the  embryo 
escapes  into  the  peritoneal  cavity  or  between  the  folds  of  the  broad  ligament  and 
continues  its  development.  These  are  secondary  abdominal  pregnancies.  Secon- 
dary abdominal  pregnancy  may  also  result  when  the  tube,  not  rupturing,  but  im- 
mensely thinned,  forms  one  layer  of  a  sac,  which  in  the  main  is  composed  of  lamel- 
lated  fibrin  and  adherent  intestines  and  omentum.  Such  sacs  may  be  readily  pedun- 
culated at  operation.  If  the  fibers  of  the  tube  grow  and  are  very  slowly  distracted, 
the  pregnancy  may  also  develop  into,  and  l)etween  the  folds  of,  the  broad  ligament, 
without  the  violent  symptoms  of  rupture.  Still,  in  all  forms  there  may  be  late 
rupture  of  the  sac. 

Interstitial  pregnancy  (Fig.  348)  has  the  same  terminations  as  tubal,  that  is, 


EXTIIA-UTERINE    PREGNANCY 


385 


rupture,  mole,  and  abortion,  the  latter  occiin-inji;  into  the  uterus  (rare).  The  corner 
of  the  uterus  is  developed,  distortiiiji;  the  rest  of  the  orsau.  Rupture  is  of  late  oc- 
currenc'O,  because  tlie  uterine  wall  is  capaijle  of  in(jre  iiypertroi)hy  than  the  tubal, 
and  the  ovum  may  cUe,  or  it  may  develop  to  maturity  in  the  broad  ligament.  The 
gestation  sac  may  grow  into  the  uterus  and  then  continue  as  a  normal  pregnancy. 
(See  iViigular  Pregnancy.)  Such  a  (liagn(jsis  is  exposed  to  much  Cjuestion,  Ijut  cases 
notinfre(|uentlyoc('ur  where  this  explanation  of  the  phenomenon  seems  very  proi;al)le. 
^•Vmpullary  gestation  pursues  the  same  course  as  the  others,  but  abortion  is  the 
usual  termination,  because  the  open  end  of  the  tube  is  near  by.  The  ovum  may 
be  inserted  on  the  fiml^ria  ovarica,  and  in  such  an  event  the  pregnancy  is  almost 
entirely  abtlominal,  and  the  sac  is  made  up  of  lamellated  filjrin  and  adherent  in- 


Placenta 


Tube 


Fig.  348. — Ixterstitial  Pregnancy  (Simon,  Berlin,  1885). 


testines,  uterus,  ovary,  and  omentum.     The  placenta  spreads  out  over  the  tube, 
ovary,  pelvic  wall,  and  back  of  the  uterus.     It  may  be  attached  to  the  omentmii. 

Ovarian  Pregnancy. — This  is  one  of  the  rarest  forms,  but  its  occurrence  is 
proved,  there  being  over  30  cases  on  record.  Norris,  Young,  and  Shea  give  a  resmne 
of  20  or  more  authentic  cases,  with  the  literature.  It  is  not  easy  to  decide  that  a 
given  case  is  truly  ovarian  in  origin,  because  the  sac  quickly  makes  adhesions  to  the 
tube  or  uterus,  or  a  pregnancy  on  the  fimbria  ovarica  may  tear  loose  from  its  at- 
tachment or  grow  over  onto  the  ovary,  and  one  cannot  decide  if  the  location  of 
placental  tissue  on  the  latter  is  primary  or  secondary.  To  establish  the  anatomic 
certainty  of  an  ovarian  pregnancy  all  that  is  necessary  is  to  prove  that  "the  tube, 
including  the  fimbria  ovarica  (excluding  also  gestation  in  an  accessory  tube),  is 
absolutely  free  from  any  part  in  the  formation  of  the  fetal  sac"  (Werth).  Werth 
evidently  considers  primary  abdominal  pregnancy  so  rare  that  it  need  not  be  con- 
sidered. 


386  THE    PATHOLOGY   OF   PREGNANCY,    LABOR,    AND    THE   PUERPERIUM 

Ovarian  pregnancy  pursues  the  same  course  as  tubal.  The  impregnation  of  the 
ovum  by  the  spermatozoid  takes  place  before  the  former  leaves  the  ovary,  and  if 
the  ovum  was  deeply  located  in  the  ovary,  the  sac  is  evenly  covered  by  ovarian 
stroma;  if  it  was  superficial,  the  fetal  sac  grows  out  into  the  peritoneal  cavity.  In 
both  cases  the  pregnancy  is  pedunculated  and  easily  removed,  though  it  does  con- 
tract adhesions  with  the  surrounding  structures.  If  the  ovum  was  near  the  hilum, 
the  gestation-sac  may  become  intraligamentous,  spreading  the  utero-ovarian  liga- 
ment apart,  and  showing  the  tube  stretched  over  its  exterior,  as  occurs  on  a  cystic 
tumor  of  the  ovary  in  a  similar  location.  Rupture  of  the  sac,  with  hematocele,  is 
the  usual  termination,  with  or  without  death  of  the  fetus,  but  molar  formation  is 
also  observed.  One  may  not  say  a  hematoma  found  in  the  ovary  is  always  the  result 
of  a  pregnancy,  unless  chorionic  villi  or  parts  of  a  fetus  be  demonstrated  in  it. 
Rupture  of  a  Graafian  follicle  is  sometimes  attended  by  free,  even  threatening, 
hemorrhage,  and  hemorrhagic  ovarian  cysts  or  twisted  ovarian  tumors  may  cause 
pelvic  hemorrhage.  A  differential  diagnosis  of  such  accidents  from  ectopic  gesta- 
tion cannot  be  positively  made  before  operation. 

Later  Course. — If  a  tubal  pregnancy  terminates  by  abortion,  the  extruded 
mass  of  clots  with  the  embryo  are  rapidly  absorbed.  Tubal  moles  also  disappear 
in  the  same  way,  but  more  slowly,  and  subsequent  permeability  of  the  tube  is 
established.  If,  in  rupture,  the  placenta  became  detached,  torn,  or  disorganized 
by  blood-clots,  the  fetus  dies,  and,  unless  advanced  beyond  the  eighth  week,  the 
little  body  is  absorbed.  The  blood-masses  slowly  shrink,  harden,  and  are  dissolved 
by  leukocytic  and  ferment  action,  disappearing  in  a  longer  or  shorter  time,  depend- 
ing on  their  size. 

If  the  child  escapes  alive,  it  may  continue  its  development  among  the  intestines 
or  in  the  broad  ligament,  i.  e.,  secondary  abdominal  pregnancy.  In  either  case  it 
may  have  escaped  inside  an  intact  amniotic  sac  or  naked.  A  new  sac  now  forms, 
made  up  of  fibrin,  adherent  intestines,  omentum,  uterus,  broad  ligament,  etc.,  de- 
pending on  the  location  in  which  the  fetus  happens  to  be.  In  the  structure  of  the 
sac  no  traces  of  the  original  container,  tube  or  ovary,  will  be  found,  except  at  one 
place,  the  site  of  the  rupture. 

If  rupture  of  the  container  does  not  take  place,  but  the  tube  or  the  ovary  dis- 
tends, accommodating  the  growing  ovum,  a  large  pelveo-abdominal  sac  is  formed 
which  becomes  adherent  to  all  the  surfaces  it  touches — pelvic  wall,  uterus,  bladder, 
rectum,  intestine,  omentum,  liver,  spleen,  stomach.  This  sac  in  structure  shows  the 
tissue  of  the  original  site  of  implantation  of  the  ovum,  such  as  tube,  ovary,  together 
with  lamellated  fibrin,  muscular  fibers  from  neighboring  organs,  especially  the  broad 
ligament  and  the  peritoneum,  to  which  it  at  first  adhered.  The  sac  varies  in  thick- 
ness from  1  mm.  to  several  centimeters,  depending  on  the  amount  of  fibrin. 

The  placenta  is  spread  out  over  the  tissues  adjacent  to  its  first  point  of  develop- 
ment, is  usually  thin,  but  otherwise  like  a  uterine  placenta.  The  blood-vessels  in 
the  neighborhood  of  the  placenta  are  enormously  dilated,  and  many  new  ones  are 
formed — this  especially  when  the  omentum  is  used  to  help  nourish  the  placenta. 
In  one  of  the  writer's  cases  the  newly  formed  blood-vessels  in  the  omentum  were  as 
large  as  crows'  quills,  had  very  thin  walls,  tore  easily,  and  were  innumerably  dis- 
tributed over  the  sac. 

In  one  or  the  other  of  these  fashions  the  secondary  abdominal  pregnancy 
may  go  to  term.  Spurious  labor  now  sets  in,  the  child  dies  as  the  result  of  hemor- 
rhage into,  or  dislocation  of,  the  placenta,  or  may  not  die  until  later,  and  nature  tries 
to  get  rid  of  the  foreign  body.  The  contractions  of  the  uterus  expel  the  decidua, 
and  usually  the  attendant  hemorrhage  is  slight.  At  any  period  of  pregnancy  the 
sac  may  rupture,  or  the  child  may  die  and  the  changes  about  to  be  described  may 
be  inaugurated.  Spurious  labor  with  expulsion  of  the  uterine  decidua  may  follow 
the  death  of  the  child  at  any  time.     There  is  always  a  degree  of  peritonitis  in  ectopic 


EXTRA-UTERINE    PREGNANCY  387 

gestation  with  hcinoniiagc,  and  tliis,  according  to  Dudgeon  and  Sargent,  is  due  to 
the  Staphylococcus  albus,  and  is  a  conservative  process.  Jaundice  is  also  frequent 
from  absorption  of  more  Ijlood-pigment  than  the  liver  can  take  care  of. 

After  the  death  of  the  fetus  it  first  becomes  macerated,  as  in  intra-uterine  preg- 
nancy, then  the  licjuor  ainnii  is  absorlxnl,  the  sac  lays  itself  onto  the  l)(j<ly,  a  zone  of 
granulations  fills  the  interspaces,  and  the  soft  parts  of  the  fetus  are  absorbed,  i.  e., 
it  is  skeletonized.  By  way  of  the  blood,  or  by  passing  through  the  intervening 
wall  from  contiguous  structures,  especially  the  bowel,  infection  may  gain  entry  to 
the  mass,  and  it  suppurates,  the  pus  finding  its  way  out  through  the  bladder,  the 
rectum,  or,  least  often,  the  vagina  or  abdominal  wall.  OEdema  Ijullosum  can  be 
seen  in  the  bladder  when  the  perforation  into  this  organ  begins.  Through  the  fistula 
are  passed,  first,  the  broken-down  fluid  placenta,  then  the  soft  parts  of  the  fetus, 
and  finally  the  separate  bones,  by  a  process  of  suppuration  which  may  last  months 
or  years,  and  which  the  patient  may  not  survive.  Sometimes,  even  after  months, 
the  woman  dies  from  hemorrhage  due  to  rupture  of  the  sac,  sometimes  from  peri- 
tonitis, but  rarely,  since  firm  adhesions  have  walled  off  the  danger-zone. 

Another  termination  after  death  of  the  fetus  is  mummification,  the  child  drjnng 
up,  and  in  this  state  it  may  be  found  years  after.  Absorption  of  the  water  of  the 
fetus  takes  place,  and  it  is  surprising  how  well  its  tissues  are  preserved.  Calcium 
salts  are  deposited  in  the  sac  around  the  fetus,  and  if  these  are  abundant,  the  child 
is  incased  by  a  shell  or  even  partly  calcified  itself — lithokelyphos,  or  lithopedioii 
("stone  child").  Wagner  had  a  case  where  a  mummified  fetus  was  carried  for 
twenty-nine  years,  and  Yirchow  one  for  twenty-eight  years.  Smith  describes  a 
calcified  fetus  which  was  removed  from  a  woman  ninety-four  years  old  sixty 
years  after  conception.  There  are  many  cases  on  record.  Suppuration  may  occur 
at  any  time  even  after  calcification  is  marked. 

Changes  in  the  Uterus. — In  response  to  the  stimulus  of  pregnancy  (what  it  is, 
we  do  not  know),  the  uterus  hypertrophies  as  if  it  were  carrying  the  ovum  itself. 
It  enlarges  to  the  size  of  a  three  months'  pregnancy,  its  walls  are  thick,  and  it  ex- 
hibits intermittent  contractions.  A  decidua  develops  in  it,  and  this  may  be  as 
much  as  1  cm.  in  thickness,  presenting  all  the  characters  of  an  intra-uterine  preg- 
nancy decidua,  except  that  it  contains  no  chorionic  villi.  At  the  time  of  spurious  labor 
or  spurious  abortion  the  decidua  is  cast  off,  either  in  one  piece,  as  a  cast  of  the  uterine 
cavity,  or  in  large  shreds  or  plaques,  sometimes  accompanied  by  fetor. 

Combined  extra-  and  intra-uterine  pregnancy  is  not  very  rare,  Weibel,  in  1905, 
having  collected  over  119  cases.  Double  tubal  gestation  has  been  observed,  also 
two  gestation-sacs  in  one  tube.  Twins,  and  even  triplets,  have  been  found  in  one 
sac.  Fcetus  papyraceus  may  also  occur  in  combined  gestations,  as  well  as  in  twin 
ectopic  gestation. 

Extra-  and  intra-uterine  pregnancy  offers  a  very  serious  prognosis.  Abortion 
of  the  uterine  ovum  precedes  or  follows  the  rupture  of  the  ectopic  sac,  but  death 
from  internal  hemorrhage  may  occur  before  abortion  takes  place.  Rarely  the  woman 
goes  to  term,  and  then  labor  is  usually  spontaneous,  but  death  frequentlj'  follows 
from  internal  hemorrhage  or  sepsis  starting  from  the  abdominal  mass.  The  extra- 
uterine fetus  rarely  obstructs  the  passage  of  the  intra-uterine.  If  the  ectopic  preg- 
nancy is  successfully  removed,  the  patient  may  go  to  term  with  the  other  one 
normally. 

Repeated  extra-uterine  pregnancies,  after  months  or  years,  are  not  seldom  ob- 
served, and  the  recurrence  may  be  situated  in  the  same  tube  originally  affected  or 
in  the  other. 

CLINICAL  COURSE 

Rarely  do  the  first  months  of  an  ectopic  gestation  pass  without  sjTnptoms  which 
direct  attention  to  the  pelvis  as  the  seat  of  trouble.     Once  in  a  while  a  woman,  pre- 


388      THE  PATHOLOGY  OF  PEEGNANCY,  LABOR,  AND  THE  PUERPERIUM 

viousl}'  perfectly  well,  has  sudden  symptoms  of  internal  hemorrhage  and  may  die 
from  the  same  even  before  a  diagnosis  can  be  made.  Medicolegally,  the  question 
of  foul  play  may  have  to  be  settled  in  such  instances. 

Usually  the  patient  misses  a  period  and  has  the  ordinary  concomitant  symptoms 
of  eai'ly  pregnancy,  but  soon  complains  of  pains  in  the  lower  abdomen,  especially 
on  the  affected  side — cramp-like,  due  to  uterine  and  tubal  contractions.  There 
may  be  mild  pelveoperitonitic  symptoms.  After  a  few  weeks  irregular  bloody 
vaginal  discharges  appear,  which  the  attending  physician  believes  indicate  a  threat- 
ening abortion.  On  the  occasion  of  a  jar,  a  strain,  coitus,  or  an  examination  a 
sudden  severe  pain  is  felt  on  one  side,  the  patient  feels  faint  or  dizzy,  and  may  vomit 
or  be  nauseated.  Symptoms  of  shock  may  appear,  and  the  shock  may  be  due  to 
the  sudden  distention  of  the  tube,  to  irritation  of  the  peritoneum  by  blood,  or  to  the 
great  loss  of  blood.  The  pains  continuing,  a  piece  or  all  of  the  uterine  decidua  is 
discharged.  A  careless  attendant  will  now  conclude  that  the  abortion  has  taken 
place.  These  symptoms  may  indicate  that  a  hemorrhage  has  occurred  in  the  tube, 
or  through  it  into  the  belly,  or  that  a  rupture  of  the  tube  has  taken  place.  Rarely 
is  the  first  hemorrhage  so  severe  that  the  patient  dies — clotting  occurs  at  the  site 
of  rupture  and  the  blood  is  absorbed,  the  acute  symptoms  subsiding  in  two  or  three 
days,  the  whole  process  terminating  in  three  to  six  weeks.  Again,  because  the  clot 
is  disturbed  or  the  blood-pressure  raised,  the  hemorrhage  recommences  in  a  few 
hours  or  days,^ — almost  never  after  weeks, — and  the  patient  may  die  from  a  slower 
anemia  or  from  a  second  or  third  severe  hemorrhage.  Tubal  mole  seems  to  cause 
repeated  hemorrhages,  the  hematocele  sac  breaking  at  different  points,  fresh  ad- 
hesions forming,  and  new  additions  to  the  sac  being  made.  If  the  case  is  not  treated, 
nature  often  works  a  cure,  the  sac  being  bound  off  by  firm  adhesions  and  the  clots 
being  slowly  absorbed.  Nowadays,-  however,  most  cases  are  operated  on.  In 
rare  cases  the  pain  may  be  referred  to  another  part  of  the  abdomen — the  gall- 
bladder, for  instance,  and  sometimes  intestinal  symptoms,  like  an  enteritis, 
predominate.     Pyosalpinx  may  complicate  ectopic  gestation. 

The  symptoms  of  rupture  of  the  sac  are  pain  on  the  affected  side,  sometimes 
excruciating  and  sudden,  soon  spreading  all  over  the  lower  abdomen;  nausea,  some- 
times vomiting,  sometimes  diarrhea,  plus  evidences  of  hemorrhage  and  shock. 
That  shock  plays  a  real  part  in  the  symptoms  is  certain,  because  the  author  has 
found  severe  prostration  without  enough  blood-loss  to  explain  it.  The  striking 
pallor  with  slight  cyanosis  about  the  lips,  pearly  conjunctivae,  yawning  and  sighing, 
fast,  small  pulse,  and  extreme  weakness  reveal  the  fact  of  blood-loss.  Rarely  the 
pulse  is  slow — even  46,  but  feeble. 

Internal  examination,  if  the  blood  is  still  fluid,  will  usually  reveal  only  a  large 
uterus;  later,  when  the  blood  has  clotted  and  the  hematocele  is  forming,  one  can 
outline  the  mass  in  the  culdesac.  Under  particularly  favorable  circumstances  the 
finger  may  feel  a  soft  bulging  downward  of  the  culdesac  earlier.  When  the 
rupture  has  taken  place  into  the  broad  ligament,  a  hematoma  forming  here,  the 
pain  is  most  intense,  and  shock  overbalances  the  anemia,  because  of  the  tearing 
asunder  of  the  folds  of  the  peritoneum.  Internal  examination  will  always  disclose 
a  firm  mass  on  one  side  of  the  uterus. 

If  the  rupture  or  the  tubal  abortion  occurs  more  gradually,  the  symptoms  are 
proportionately  less  stormy,  and  the  true  condition  may  not  be  discovered. 

If,  after  the  escape  of  the  ovum  into  the  peritoneal  cavity  or  into  the  broad 
ligament,  it  continues  to  develop,  symptoms  of  peritoneal  irritation  arise — pain, 
soreness,  nausea,  vomiting,  diarrhea  and  constipation  (sometimes  hemorrhages 
from  the  bowel),  bladder  disturbance,  loss  of  strength,  and  invalidism.  The  signs 
and  symptoms  of  pregnancy  continue,  fetal  movements  are  more  pronounced,  are 
painful,  and  may  distress  the  patient,  and  the  signs  of  tumor  in  the  belly  grow  with 
the  weeks.     This  tumor  may  be  asymmetric  or  median.     If  the  fetus  dies,  the  symp- 


EXTRA.-UTERINE    PREGNANCY  389 

toins  of  prconancy  disappear,  while  those  usually  made  by  a  macerating  neoplasm 
become  noticeable,  evidently  duo  to  a  toxemia.  Subfebrile  temperatures,  rapid 
pulse,  anorexia,  coated  tongue,  loss  of  weight,  and  invalidism  are  almost  always  in 
evidence.  Subicterus,  even  marked  jaundice,  is  often  a  striking  symjjtom.  Icterus 
with  fever  denotes  beginning  decomposition  of  the  sa(;  and  c:ontents.  Now  the 
patient  gets  really  sick,  since  an  abdominal  abscess  is  forming,  and  she  may  die  of 
sepsis,  of  peritonitis,  or  of  exhaustion  and  hectic,  from  prolonged  suppuration,  the 
product  of  con{'e])tion  being  gradually  expelled  through  a  fistula  int(j  the  bladder, 
the  rectum,  vagina,  or  belly-wall. 

If  the  sac  goes  on  to  lithopedion  formation,  involution  of  the  uterus  occurs,  the 
irritation  of  the  peritoneum  subsides,  and  the  patient  may  forget  that  she  was  preg- 
nant, and  may  even  have  children  normally.  Cases  are  on  record  where  an  extra- 
uterine^ tumor,  offering  an  obstacle  to  delivery,  was  found  to  be  a  calcified  fetus. 

Rupture  of  the  sac  and  suppuration  may  occur  at  any  time  during  pregnancy, 
a  point  of  practical  importance  in  treatment.  The  symptoms  and  anatomic  course 
of  a  pregnancy  in  a  rudimentary  horn  of  the  uterus  are  so  similar  to  those  of  ectopic 
gestation  that  these  subjects  should  be  considered  together. 


DIAGNOSIS 

Before  rupture  of  the  tube  or  a  hemorrhage  into  it  the  diagnosis  of  ectopic 
gestation  has  hardly  ever  been  made,  because  the  tube  is  as  soft  as  an  intestinal  loop. 
Kanavel  reports  a  case  of  a  woman  who  had  ectopic  gestation  once  before,  diag- 
nosing a  recurrence  after  going  over  her  period  one  week,  and  operation  proved  she 
was  right.  Miller,  of  Pittsburgh,  discovered  a  mass  in  a  tube  which  he  had  palpated 
a  f(nv  weeks  previouslj',  when  it  was  empty,  and  proved  the  ectopic  pregnancy  by 
operation.  Almost  all  the  cases,  however,  where  such  a  diagnosis  has  been  reported 
were  tubal  abortions  in  progress  or  tubal  moles.  Tubal  mole  is  often  diagnosed. 
In  the  early  part  of  pregnancy  the  diagTiosis  must  decide  if  an  extra-uterine  tumor 
is  an  ovum  or  not,  and  during  the  latter  half  one  must  decide  if  the  ovum  is  extra- 
uterine or  intra-uterine.  No  pelvic  condition  gives  rise  to  more  diagnostic  errors. 
The  author  has  seen  such  mistakes  made  by  every  gynecologist  and  surgeon  in  the 
city,  including  himself.  In  the  majority  of  cases  the  patient  will  give  a  history  of 
previous  pelvic  inflammation,  either  gonorrheal  or  puerperal,  and  often  a  period  of 
sterility  elapses  l)efore  the  aberrant  conception. 

Direct  Diagnosis — First  Trimester.— When  a  woman  in  the  reproductive  period, 
after  some  irregularity  of  the  menses,  such  as  going  over  the  proper  time  a  few  days 
or  having  only  a  small  amount,  or  even  a  more  profuse  flow,  complains  of  cramping 
pains  in  the  lower  abdomen,  mostly  unilateral,  with  irregular  uterine  hemorrhage, 
the  suspicion  of  ectopic  pregnancy  is  aroused.  If,  suddenly,  an  excruciating  pelvic 
pain  occurs,  with  dizziness,  faintness,  or  collapse,  the  diagnosis  is  almost  certain, 
and  is  confirmed  by  finding  an  extra-uterine  tumor  or  the  discharge  of  a  uterine 
decidua.  The  direct  diagnosis  of  fluid  blood  in  the  peritoneal  cavity  is  seldom  easy. 
A  sense  of  soft  resistance  is  found  in  the  posterior  vaginal  fornix,  but  the  uterus  is 
not  dis]:)laced;  indeed,  in  one  case  the  author  found  it  raised  up  in  the  sea  of  blood. 
Puncture  of  the  fornix  wdth  a  long  sharp  needle  may  reveal  the  blood,  but  it  usually 
is  not  necessary  for  the  diagnosis.  Percussion  of  the  flanks  in  not  one  of  the  author's 
cases  gave  dulness,  even  though  a  quart  or  more  of  blood  was  removed  at  operation. 
After  twenty-four  to  forty-eight  hours  the  l)lood-clots  Ijecome  readily  palpable  and 
now  displace  the  uterus — that  is,  a  hematocele  forms.  When  the  discharge  of 
blood  is  slower,  a  peritubal  hematocele  forms,  which  increases  from  day  to  day,  and 
one  can  trace  the  advance  of  the  process  with  the  finger  by  successive  examinations. 
The  hematocele  may  be  retro-uterine,  before  the  uterus,  at  the  side,  before  or  be- 
hind, and  the  organs  are  displaced  in  typical  directions.     A  broad-ligament  hema- 


390  THE    PATHOLOGY    OF    PREGNANCY,    LABOR,    AND    THE    PUERPERIUM 

toma  can  more  easily  be  diagnosed  from  the  stormy  beginning  and  the  firm,  tender 
tumor  at  the  side  of  the  uterus,  displacing  it  to  the  side  and  upward. 

Warning!  In  all  cases  where  the  history  of  the  patient  gives  only  a  hint  of  the 
possibihty  of  an  extra-uterine  gestation,  the  examination  must  be  conducted  with 
the  utmost  gentleness  to  avoid  rupturing  the  sac.  The  author  witnessed  an  almost 
fatal  intraperitoneal  hemorrhage  on  the  examination  table. 

Direct  Diagnosis — After  First  Trimester. — When  a  pregnant  woman  complains 
of  irregular  bloody  discharges  from  the  uterus,  excessively  painful  fetal  movements 
very  low  in  the  pelvis,  abdominal  pains  and  distress,  with  intestinal  symptoms  and 
invalidism,  one  may  strongly  suspect  an  ectopic  fetus.  The  demonstration  of  the 
enlarged  empty  uterus  alongside  the  fetal  sac  confirms  the  suspicion. 

The  direct  diagnosis  of  the  life  of  the  ovum  can  usually  be  made,  and  is  based 
on — (1)  The  absence  or  mildness  of  the  symptoms  of  rupture  of  the  tube  during  the 
second  and  third  months;  (2)  the  continuation  of  the  symptoms  of  pregnancy — 
nausea,  mammary  signs,  fetal  movements,  fetal  heart,  etc.;  (3)  the  presence  of  a 
loud  uterine  souffie  (in  ectopic  gestation,  contrary  to  normal,  this  sign  is  of  value  for 
determining  the  location  of  the  placenta) ;  (4)  the  absence  of  symptoms  of  toxemia 
and  of  suppuration;  (5)  the  continuation  of  the  growth  and  of  the  softening  of  the 
uterus  and  of  the  vagina;    (6)  the  gradually  increasing  size  of  the  abdominal  tumor. 

Differential  Diagnosis. — Only  the  most  common  difficulties  in  diagnosis  can 
be  considered,  and  these  will  be  given  in  the  order  of  frequency : 

Abortion  Ectopic  Pregnancy 

1.  Onset    quiet,    with    gradually    intensifying       1.  Onset    stormy,    with    irregular  and  colicky 

and  regular  pains  in  the  lower  abdomen,  pains,    sometimes   few    and    excruciating, 

resembhng  labor.  localized  on  one  side. 

2.  External  hemorrhage  profuse  or  moderate,       2.  External  hemorrhage  slight  or  absent  and 

with  clots.  dark,  fluid. 

3.  Symptoms  of  hemorrhage  proportionate  to      3.  Symptoms  of  hemorrhage  and  shock  much 

visible  blood-loss.  greater  than  visible  blood-ldss. 

4.  Discharge  of  parts  of  ovum.  4.  Only   a  uterine   decidua,   if   anything;    no 

viUi. 

5.  Demonstration  of  ovum  in  uterus  or  empty      5.  Finding  of  a  mass  alongside  the  uterus. 

uterus  and  empty  pelvis. 

Before  every  curetage  for  a.bortion  it  is  wise  to  make  a  careful  bimanual  ex- 
amination to  rule  out  extra-uterine  pregnancy,  and  should  collapse  come  on  after 
such  an  operation,  strong  suspicion  of  rupture  of  an  ectopic  sac  must  be  entertained. 
Perforation  of  the  uterus  and  rupture  of  a  pus-sac,  or  other  abdominal  hollow  organ, 
give  the  same  symptoms,  and  it  may  be  necessary  to  open  the  belly  to  find  out  the 
true  conditions. 

If  infection  of  a  hematocele  or  of  a  hematoma  sets  in,  the  condition  cannot  be 
difi"erentiated  from  a  pyosalpinx,  a  pelvic  cellulitis,  or  perimetritis,  unless  operation 
shows  the  hemorrhagic  nature  of  the  pelvic  tumor.  Jaundice  is  an  important  sign, 
since  it  usually  accompanies  a  degenerating  blood-clot.  Treatment  is  on  general 
principles  of  pelvic  infections. 

In  the  early  months  confusion  is  often  caused  by  a  long  cervix  softened  at  its 
upper  part,  which  allows  the  fundus  to  bend  backward  or  to  the  side.  The  cervix  is 
hard,  is  held  to  be  the  uterus,  and  the  fundus  is  thought  to  be  the  ectopic  sac. 
By  straightening  out  the  uterus  the  diagnosis  may  be  made  certain,  but  before 
attempting  to  do  so  the  presence  of  an  eccyesis  must  be  ruled  out.  Or  the  preg- 
nancy is  situated  in  one  horn  of  the  uterus  and  distends  this  side,  the  rest  remain- 
ing hard.  This  is  an  "angular  pregnancy,"  "grossesse  angulaire,"  and  is  not  sel- 
dom the  cause  of  error  (Fig.  349). 

Intra-uterine  Angular  Pregnancy  Extra-uterine  Pregnancy 

1.  Histor\' is  that  of  normal  pregnancy,  thougli,       1.   History  of  colicky  pains  and  peritoneal  irri- 
not    seldom    gro.ssesse    angulaire    causes  tation  for  several  weeks;    then  a  stormy 

occasional  slight  hemorrhages  and  pains.  event  (rupture),  with  severe  pain,  shock, 

etc. 


EXTRA-UTERINE    PREGNANX'Y 


391 


2.  No  expulsion  of  incinhniiic,  unless  abortion. 

3.  No  anemia. 

4.  Demonstration  of  tube  and  round  linament 

on  outside;  of  the  tumor.      (See  Fij^.  :i\\).) 
").  Can  feel  the  wall  of  t  he  uterus  [)ass  over  onto 
tumor,  especially  durinfi;  a  contraction. 

6.  The  tumor  is  soft,  feels  like  a  pregnancy,  is 

high  up  in  the  side  of  the  pelvis,  and  mov- 
able as  a  jiart  of  the  uterus. 

7.  The  angular  portion  of  the  uterus  contracts. 

5.  Gradually  the  tyjjieal  shape  of  the  uterus 

returns. 


2.  Expulsion  of  deeidua. 

li.   Mor(!  or  less  anemia. 

4.  Tube  and  round  ligamon.  not  palpable, 
or  medial  to  the  tumor. 

F).  The  mass  is  separated  fnjm  the  uterus  by  a 
groove.  This  is  especially  deep  in  prog- 
nancy  in  an  accessory  horn. 

G.  The  tumor  is  harder,  lies  at  the  side  of  the 
uterus  or  in  the  culdesac,  and  is  not  mov- 
able (careful!). 

7.  No  contractions  of  the  sac. 

8.  The  tumor  becomes  more  and  more  a.sym- 
metric  at  successive  examinations. 

Angular  pregnancy  cannot  be  differentiated  from  interstitial  pregnancy  except 
by  the  clinical  course.  It  is  well,  therefore,  to  place  the  patient  in  a  hospital  for 
observation. 


Fig.  349. — Axgul.4.h  Pregnancy  at  Four  Months  Simul.\ting  Ectopic  Gestation  (Mrs.  S.,  twins  at  term). 


Pregnancy  in  a  retroverted  uterus 
real  condition  has  been  an  ovisac  or  a 
attempts  to  replace  the  supposed  uterus 

Retroflexio  Uteri  Gravidi 

1.  History  typical  of  pregnancy. 

2.  Urinary  difficulties  usual  and  marked  after 

ten  weeks. 

3.  Pain  and  hemorrhage  rare  and  slight. 

4.  The  finger  feels  the  angle  at  the  cervix,  and 

nothing  where  the  fimdus  .should  be  (Fig. 
357). 

5.  The   retroflexed   fundus   is   round,    smooth, 

more  or  less  movable  (careful!),  feels  like 
a  pregnancy,  and  sometimes  contracts. 

6.  Late  in  pregnancy,  condition  is  rare,  and  in 

cases    of   partial   retroflexion    cannot    feel 
an  adjacent,  but  empty,  uterus. 


has  often  been  thought  to  exist  when  the 
hematocele  in  the  Douglas  culdesac,  and 
have  resulted  disastrously. 

Ectopic  Ge.st.\tiox 

1.  History    strongly    suggestive    of    abnormal 

gestation. 

2.  Seldom  bladder  sj-mptoms  until  after  fifth 

month. 

3.  The  opposite  is  the  rule. 

4.  The  finger  feels  an  angle,  but  the  abdominal 

hand   finds  the  fundus,   and  occasionally 
the  Fallopian  tubes,  in  front  of  the  mass. 

5.  The  mass  in  the  culdesac  is  irregular,  not 

movable,  putty-like,  does  not  feel  like  a 
pregnant  uterus,  and  never  contracts. 

6.  Late  in   pregnancy   may  find   an   adjacent 

ma.ss  which  represents  the  enlarged  empty 
uterus  (Figs.  350  and  351). 


392 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


Pregnancy  in  the  uterus,  complicated  by  ovarian  or  other  cystic  pelvic  tumors, 
may  give  rise  to  a  diagnosis  of  ectopic  gestation,  especially  since  the  accoucheur 
fears  the  danger  of  overlooking  the  latter  and  wishes  to  operate  on  this  account. 
The  mistake  is  pardonable  because  usually,  in  either  case,  the  abdomen  would  have 
to  be  opened.  Adnexa  tumors,  pyosalpinx,  hydrosalpinx,  and  ovarian  cyst  may 
be  mistaken  for  ectopic  sacs.  The  main  point  in  the  diagnosis  is  the  finding  of  the 
unchanged  uterus  alongside  the  tumor  and  the  absence  of  the  sijrnptoms  and  signs  of 
pregnancy.  On  the  other  hand,  the  presence  of  the  early  signs  and  symptoms  of 
pregnancy  does  not  speak  against  an  extra-uterine  tumor  being  a  new-growth  or 


Fig.  350. — Mh3.  L.,  Rethoversio  Uteri,  with   Pregnancy  on  Top  and  at  Side  of  it. 

Diagnosis  at  first,  retroversio  uteri  gravidi,  then,  when  abdominal  tumor  did  not  subside  on  catheterization  and  the 

fetus  was  felt  above  left  Poupart'a  ligament,  correct  condition  discovered.     Laparotomy,  recovery. 


inflammatory,  because  milk  in  the  breasts,  subjective  symptoms,  softening  and 
discoloration  of  the  cervix  and  vagina  occur  in  many  of  the  latter  pathologic  condi- 
tions— indeed,  even  under  normal  circumstances.  The  author  has  seen  colostrum 
run  in  fine  streams  from  the  nipple  of  a  nullipara  thirty-eight  years  old,  and  has 
expressed  milk  from  the  breasts  of  a  woman  eight  years  after  her  last  child. 

Pyosalpinx  cannot  always  be  differentiated  from  tubal  gestation,  and  they  may 
coexist.  The  presence  of  fever,  leukocytosis  (the  polynuclear  ncutrophiles) ,  excessive 
tenderness,  evidences  of  acute  or  recent  gonorrhea,  and  bilateral  tumor  usually 
settle  the  diagnosis,  but   they  may  all  occur  in  extra-uterine  pregnancy.     If  by 

Thf  soruiii  diagnosis  r)f  propnanry  will  aid  pnwcrfullv  in  climinntinfi  ^vnecolofiic  fondi- 
tions.     (See  page  2.57.) 


EXTRA-I'TERINE    PREGNANCY 


393 


mistake  the  Ix'lly  is  opened  uiul  uu  acute  i)y()sali)inx  found,  it  is  wiser  not  to  attempt 
its  removal  at  this  time,  because  sucli  operations  have  a  higli  primary  mortalit3\ 

In  rare  instances  the  differential  diagnosis  of  rupture  of  a  gestation-sac  with 
collapse  must  be  made  from  rupture  of  a  pus-tube,  the  twisting  of  an  ovarian  tumor, 
bursting  of  an  appendiceal  abscess,  of  the  gall-bladder,  i)erforation  of  the  stomach 
or  duodenum,  nephrolithiasis,  ureteral  stone,  rupture  of  the  splenic  artery,  jjut  the 
scope  of  this  work  forbids  going  so  far  into  the  subject. 

Acute  appendicitis  has  not  seldom  been  mistaken  for  extra-uterine  pregnancy, 
and  when  real  pregnancy  co-exists,  the  differential  diagnosis  cannot  always  be  made. 


Al'PEiNDICITIS 

1.  No  si}2;ns  or  symptoms  of  pregnancy. 

2.  Pain,  nausea  and  vomit  infj;,  fever. 

3.  Tenderness  and  rigidity  high  up. 

4.  Leukocytosis  usual. 

5.  Patient  flushtnl  and  excited.     At  very  be- 

ginning there  may  have  been  a  httle  dizzi- 
ness. 

6.  Uterus  and  adnexa  normal. 

7.  Feel  a  tumor  high  up  in  pelvis. 

8.  No  uterine  symptoms. 


Ectopic  Gestation 

1.  Present. 

2.  Pain  worse,  vomiting  less;    fever  absent  or 

less. 

3.  Tenderness  and  rigidity  much  less  and  low- 

down. 

4.  Leukocytosis  equivocal. 

5.  Pale  and  faint  or  apathetic. 


6.  The  characteristic  findings. 

7.  Tumor  low  in  pelvis. 

8.  Discharge  of  decidua. 


In  all  cases  where  the  diagnosis  is  uncertain  the  patient  should  be  put  in  a  well- 
equipped  hospital,  there  to  rest  in  bed  until  developments  occur  which  shed  enough 
light  to  allow  a  positive  staterilent.  Whenever  an  anesthetic  is  to  be  given  for 
the  examination  the  patient  likewise  must  be  in  a  hospital,  to  be  ready  for  immediate 
laparotomy  if  the  sac  should  be  burst  by  the  manipulations. 


Fig.  3o1. — Diagram  Illustrating  Conditions  Found  in  Fig.  350. 


The  author  has  never  found  it  necessary  to  use  a  sound  or  to  curet  the  uterus 
to  make  a  diagnosis.  In  one  instance  the  patulous  cervix  invited  the  finger,  which 
entered  the  uterus  and  found  it  empty;  nor  has  puncture  of  a  mass  with  the  ex- 
ploring needle  been  required.  All  these  operations  are  dangerous,  through  possible 
rupture  of  the  sac,  decomposition  of  the  sac,  and  injury  to  the  viscera,  and  are  to  be 
employed  when  all  other  means  fail  and  a  diagnosis  must  be  made.  Further,  the 
information  olitained  is  not  always  unequivocal.  If  the  curet  brings  decidua  and 
no  villi,  the  condition  may  be  either  intra-uterine  or  extra-uterine  pregnancy,  or 


394      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

both  (v.  Ott)  or  neither — only  a  dysmenorrhea!  membrane.  A  large,  thick,  rough 
decidual  membrane  expelled  from  the  uterus,  giving  a  more  or  less  complete  cast 
of  the  cavity,  without  chorionic  villi,  is  almost  pathognomonic  of  ectopic  gestation. 
It  may  be  expelled  after  the  operation. 

Skiagraphy  has  been  used  to  aid  the  diagnosis,  but  has  not  been  very  satis- 
factory as  yet,  for  obvious  reasons.  In  the  late  months  the  rc-ray  will  be  helpful. 
A  lithopedion  would  show  well,  but  it  could  not  be  differentiated  from  a  calcareous 
fibroid  unless  the  outline  of  the  fetal  bones  were  discernible. 

In  the  later  months  the  diagnosis  is  mainly  concerned  with  differentiating 
whether  a  given  fetus  is  intra-  or  extra-uterine.  These  points  will  aid  the  decision: 
Hist  or}"  of  unusual  occurrences;  of  rupture  in  the  early  months;  pelvic  peritoneal 
sj^nptoms;  invalidism;  painful  fetal  movements  located  in  one  place  all  the  time; 
continual  pain  and  abdominal  distress;  irregular  hemorrhage  and  discharge  of 
decidua;  finding  the  empty  uterus  alongside  the  tumor;  fetal  movements  active 
and  very  superficial,  seeming  to  be  almost  beneath  the  skin;  same  of  the  fetal  body, 
but  it  is  not  easy  to  make  out  the  presentation,  etc.;  heart-tones  exceptionally 
strongly  audible,  but  sometimes  not  to  be  heard  at  all;  sac  exhibits  no  contractions; 
round  ligaments  are  not  palpable  on  the  sac,  as  they  are  on  the  sides  of  the 
uterus;  the  tumor  is  not  symmetric  and  easily  definable,  like  a  pregnant  uterus; 
the  examination  is  painful  and  unsatisfactory. 

PROGNOSIS 

Naturalh",  it  is  impossible  to  give  satisfactory  figures  in  such  a  multicolored 
disease  as  this.  Without  doubt  the  outlook  has  been  painted  too  dark,  for  very 
many  ectopic  ova  die,  are  expelled  from  the  tube  as  abortions  or  by  rupture,  and 
the  patients  recover  without  a  diagnosis  having  been  made.  Many  women  recover 
under  expectant  treatment,  but,  of  course,  all  the  children  die.  In  the  cases  which 
go  to  term  the  fetus  is  usually  deformed  or  not  viable.  Sittner  collected  179  cases 
and  finds  that,  from  the  condition  of  the  fetuses,  one  may  allow  the  pregnancy  to 
go  on  unless  the  symptoms  of  the  mother  are  threatening.  Most  authorities  find 
the  opposite  conditions.  Fifty  per  cent,  of  the  fetuses  are  deformed,  according  to 
von  Winckel — the  head  in  75  per  cent.;  the  pelvic  end  in  50  per  cent.;  the  arms  in 
40  per  cent.  Pressure  by  neighboring  organs  causes  compression,  decubitus,  im- 
pressions, infractions,  etc.,  of  the  body,  and  disease  also,  as  hydrocephalus,  menin- 
gocele, cranioschisis.  These  are  due  to  amnionitis,  insufficient  liquor  amnii,  and 
cramping.  Amniotic  bands  and  velamentous  insertion  of  the  cord  are  common, 
and  the  placenta  may  be  thick  and  hard,  or  infiltrated  with  hemorrhages. 

It  is  interesting  to  note  that  polyhydramnion  can  occur  in  extra-uterine  gesta- 
tion, though  oligohydramnion  is  the  rule  and  accounts  for  the  frequent  fetal  de- 
formities. Hydatid  mole  and  chorio-epithelioma  have  also  been  observed.  Hy- 
peremesis  gravidarum  and  eclampsia  may  enter  as  complications  (Pinard,  Spiegel- 
berg,  Horwdtz). 

Schauta  found  75  recoveries  and  166  deaths  in  241  cases  treated  expectantly, 
and  quotes  Veit  as  saying  the  mortality  of  ectopic  gestation  with  hematocele  is 
25  to  28  per  cent.     Death  results  from  hemorrhage,  shock,  or  sepsis. 

The  prognosis  as  to  health  is  also  bad,  because  the  condition  leaves  peritonitic 
adhesions,  which  often  result  in  sterility;  if  untreated,  decomposition  and  abscess 
cause  hectic  fever,  invalidism,  etc. 

TREATMENT 

There  is  no  expectant  treatment  for  a  growing  ectopic  gestation.  The  "ex- 
plosive body"  (Werth)  must  be  removed  from  the  abdomen  as  soon  as  possible.  If 
the  diagnosis  is  made  before  rupture  of  the  sac,  or  during  a  tubal  abortion,  the  indi- 


EXTRA-UTERINE    PREGNANCY  395 

cation  is  to  remove  the  ovum,  preferably  l)y  laparotomy.     Under  such  circum- 
stances the  operation  is  easy,  reseml)ling  an  onUnary  salpingectomy. 

If  the  j^rcf^nancy  is  advanced  beyond  the  fourth  nujntli,  the  fetus  having  con- 
siderabU^  size,  the  adhesions  of  the  sac  to  neighboring  organs  being  extensive  and 
firmer,  and,  most  important,  the  vascular  connections  of  the  sac,  especially  the 
placental  region,  being  much  greater,  the  operation  becomes  more  and  more  for- 
midable. In  si)ite  of  Sittner's  statistics,  therefore,  it  is  best  to  interfere  as  early  as 
possible,  and  not  to  wait  for  the  child  to  be  viable.  Exce])tionally,  or  through 
religious  scrupl(>s,  the  patient  may  demand  d(>lay  to  save  the  child,  and  in  this  event 
she  must  be  put  in  a  hospital  to  await  the  time  of  operation.  At  the  end  of  preg- 
nancy it  is  recommended  to  wait  for  the  fetus  to  die  and  operate  seven  to  twenty 
days  thereafter,  the  object  being  to  ]:)(>rniit  thromljosis  of  the  placental  vessels  and 
the  consequent  diminution  of  the  ])lood-su})ply  to  the  ])arts  (Litzman).  This  ad- 
vice is  seldom  followed  by  experienced  abdominal  surgeons,  and  the  results  of  im- 
mediate operation  compare  very  favorably  with  those  of  the  waiting  poHcy. 

The  operation  should  bo  undertaken  only  by  one  skilled  in  abdominal  surgerj',  because 
complications,  hemorrhage,  injury  to  intestine,  ureters,  etc.,  are  very  common.  If  the  pregnancy 
is  intraligamentous  or  tubal,  without  many  adhesions,  it  is  often  possible  to  pedunculate  the  tumor 
as  one  does  an  ovarian  cyst,  after  tying  the  ovarian  vessels  at  the  brim  and  clamping  the  broad 
ligament  at  the  uterus.  The  placenta,  together  with  the  sac,  may  then,  little  by  little,  be  dissected 
off  the  floor  of  the  pelvis,  clamping  and  tying  the  vessels.  The  bleeding  areas  are  dried  by  suture, 
cautery,  packing,  or  sewing  the  peritoneum  over  them.  When  the  placenta  is  attached  to  the 
rectum,  the  sigmoid,  the  small  intestine,  or  the  omentum,  one  will  come  upon  innumerable  large 
and  small  blood-vessels  running  from  these  organs  onto  the  sac.  These  blood-vessels  are  so  thin 
walled  that  they  seem  to  have  only  two  layers  of  cells,  for  they  break  under  the  hghtest  touch, 
and  the  field  is  instantly  flooded  with  blood.  It  may  be  necessary  in  such  a  case  to  open  the  sac, 
remove  the  child  and  as  much  of  the  sac  and  placenta  as  is  safe,  leaving  the  rest,  but  sewing  the 
edges  of  the  sac  to  the  abdominal  wall  after  firmly  packing  it.  While  it  is  most  desirable  to  remove 
the  whole  ovum,  this  way  may  lead  more  surely  to  success.  The  remnants  or  the  whole  of  the 
placenta  separate  and  are  discharged  by  suppuration  in  the  course  of  four  to  sixteen  weeks.  AA'hen 
the  placenta  is  on  the  anterior  abdominal  wall,  the  primary  hemorrhage  is  great,  but  it  may  be 
checked  by  pressure  or  compression  of  the  aorta  high  above  the  bifurcation,  as  has  been  done  by 
the  author  at  cesarean  sections.  In  one  of  the  author's  cases  the  hemorrhage  from  vascular  ad- 
hesions absolutely  frustrated  all  attempts  at  hemostasis  by  a  skilful  surgeon  and  himself.  The 
placenta  was  adherent  to  the  omentum  and  gut,  the  former  being  simply  a  mesh  of  brittle  arteries 
and  veins.  In  a  similar  case  Momburg's  belt  might  possibly  be  tried.  Several  cases  have  been 
operated  by  simply  removing  the  fetus  and  cord,  sewing  up  the  sac,  and  leaving  it  for  later  ab- 
sorption.    The  results  do  not  recommend  the  procedure. 

Treatment  of  Rupture  and  Tubal  Abortion.— Since  the  differential  diagnosis 
may  not  be  possible,  both  conditions  are  treated  alike.  There  seems  no  doubt  but 
that  the  best  treatment,  as  soon  as  the  diagnosis  of  rupture  of  the  sac  vnih  intra- 
peritoneal hemorrhage  has  been  made,  is  to  open  the  belly  and  remove  the  pregnant 
organ.  Salt  solution  is  given  by  hj^Dodermoclysis,  and  the  belly  quickly  opened. 
The  author  uses  ether  anesthesia.  Blood  may  shoot  up  several  inches  from  the  in- 
cision. One  grasp  locates  the  uterus;  it  is  pulled  up  into  the  womid,  and  a  clamp 
put  on  the  broad  ligament  of  the  affected  side.  Another  grasp  brings  the  sac  into 
view,  and  a  clamp  is  put  on  its  pelvic  side.  Fresh  l)leeding  is  thus  checked,  and  the 
removal  of  the  sac  is  now  undertaken  deliberately.  A  search  is  made  for  the  fetus, 
which  is  usually  found  very  near  to  the  site  of  rupture.  The  largest  clots  are 
scooped  out,  but  no  time  is  wasted  in  the  peritoneal  toilet,  and  the  belly  is  rapidly 
closed.  Salt  solution  is  given  continuously  under  the  breasts  throughout  the  opera- 
tion and  after  it,  not  intravenously,  except  in  very  critical  cases. 

If  one  is  called  to  a  case  when  the  primary  hemorrhage  has  ceased,  the  patient 
recovering  from  the  shock,  one  may  wait  a  few  days,  but  must  be  ready  to  operate 
on  the  first  suspicion  of  renewed  hemorrhage.  Preparations  must  be  made  at  home 
or  the  woman  sent  to  a  hospital.     My  ovm  preference  is  for  immediate  operation. 

If  a  hematocele  forms,  which  is  easily  determined  by  the  hardening  and  form- 
ing of  the  pelvic  blood-mass,  one  may  remove  same  by  laparotomy,  bj'  vaginal  inci- 


396 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


sion  and  drainage,  or  may  allow  it  to  become  absorbed.  Fehling  thus  treated  91 
cases  successfully.  The  patient  must  be  kept  under  hospital  observation  until  the 
mass  is  very  hard  and  firm — that  is,  until  it  is  certain  that  the  fetus  is  dead  and  that 
there  is  no  danger  of  further  hemorrhage.  She  should  stay  in  bed  until  absorption 
is  about  completed.  Absorption  takes  four  weeks  to  four  months,  depending  on  the 
size  of  the  blood-tumor.  While  most  small  hematoceles  become  absorbed,  the  large 
ones  are  very  slow,  and  if  they  do  not  rupture,  allowing  renewed  bleeding  which 
demands  operation,  they  not  seldom  suppurate,  in  either  case  causing  prolonged 
invalidism  and  leaving  permanent  damage  in  the  pelvis  and  consequent  sterility. 
This  is  especially  true  if  the  fetus  had  attained  some  size.     Such  patients  do  better 


Uterus 


Ruptured  tube  forming  part  of  hematocele 
Fig.  352. — Appear.\nce  on  Opening  Belly  after  Rupture  of  Pregnant  Tube.     Mrs.  L. 


with  operation,  and  the  author  prefers  the  abdominal  to  the  vaginal  method  (Fig. 
352),  since  it  gives  better  control  of  all  eventualities. 

If  a  hematocele  forms  but  the  pains  continue,  and  especially  if  the  patient  has 
fainting  spells,  one  should  decide  that  hemorrhage  is  recurring  and  operate  at  once. 
Should  the  temperature,  chills,  rapid  pulse,  pain,  and  peritonitic  symptoms  point 
to  infection  of  the  gestation-sac,  it  must  be  drained  as  soon  as  possible.  Suppurat- 
ing hematoceles  are  broadly  opened  through  the  posterior  culdesac  as  one  does  a 
pelvic  aV)scess,  and  a  soft-rubber  tul)e  inserted,  without  any  attempt  to  remove  clots 
and  without  irrigation.  If  the  pregnancy  is  further  advanced,  but  accessible  from 
below,  the  same  method  is  employed.  If  it  is  already  an  abdominal  pregnancy, 
the  belly  is  to  be  opened,  the  sac  sewed  to  the  edges  of  the  incision  and  opened  the 
next  day  A\ath  the  cautery,  thus  avoiding  infecting  the  general  peritoneum.  Its 
septic  contents  are  removed  piecemeal  and  slowly,  requiring  days  or  weeks. 


EXTRA-UTERINE    PREGNANCY  397 

Voit,  in  1884,  operated  first  lor  uiinipiiircd  tul)ul  gestation.  Veil  also  operated  first,  ac- 
cordinji  to  Wcrth,  for  iiitnipcritoiicid  licniorrliafi''  in  1878,  tiicn  Tail  in  1880  and  188.'j,  though 
Iviwisli  and  I'arry  liad  ^sll^ifJ;(•.sl(■d  the  idea.  One  of  the  (jhwolctc  met  JKjd.s  of  treatment  of  thr- eetopic 
pregnancy  witli  living  fetus  was  the  attempt  to  kill  the  fetus  by  mcjrphin  injected  into  its  body  or 
int(j  the  lifiuor  anmii,  or  by  drawing  off  the  liquor  amnii,  or  by  electricity. 

Hobb  IjeUeves  it  is  not  advisable  to  operate  if  shock  is  too  pn/fcjund.  The  majority  of 
accoucheurs  favor  inunediatc;  rather  than  postponed  operation,  since  it  is  impossible  to  make  sure 
that  bl(>eding  is  not  going  on,  and,  further,  it  is  desired  to  give  saline  solution,  which  may  not  be 
done  until  tiie  torn  vessels  have  been  clos(!d.  My  own  exjierience  is  in  favor  of  immediate  opera- 
tion.    It  requires  only  two  minutes  to  get  clamps  onto  the  broad  ligament. 

Watkins  recommends  uterine  curetage  to  remove  the  decidua,  which  othcrwi.se  comes  away 
piecemeal,  attended  by  bloody  flow  or  fetor.  In  several  of  my  cases  the  decidua  did  not  come 
away  at  all. 

The  postoperative  course  is  often  marked  by  fever.  In  the  absence  of  peritonitic  sj'mptoms 
this  may  be  ascribed  to  absorjition  of  blood.  Some  operators  are  careful  to  remove  all  the  blood 
from  the  peritoneal  cavity,  believing  that  it  has  a  to.xic  action.  My  practice  is  to  leave  mo.st  of 
it,  on  the  theory  that  it  is  partly  reabsorbed  and  used  again.  I  have  never  seen  any  harm  from  this 
treatment. 

Literature 

Campbell:  Memoir  on  Extra-uterine  Pregnancy,  Edinburgh,  1840.  Quoted  by  Ramsbotham,  Obstetrics,  p.  570. — 
Galabin:  Brit.  Med.  Jour.,  March,  1903,  p.  6Gi.—Hammacher:  Arch.  f.  Gyn.,  1910,  vol.  xcii,  Bd.  2,  p.  59-4. — 
Hirst  and  Knipe:  Surg.,  Gyn.,  and  Obst.,  1908,  vol.  vii,  p.  456;  also  Richter:  Zentralbl.  f.  Gyn.,  1912,  p.  175. — 
Maennel:  "On  the  Anatomy  of  Hematocele,"  Zcitschr.  f.  Geb.  u.  Gyn.,  1908,  vol.  Ix,  p.  212. — Xoble:  Amer.  .Jour. 
Obst.,  1901,  vol.  xliii,  p.  497. — Xorris:  Surg.,  Gyn.,  and  Obst.,  August,  1909,  p.  124. — Pinard,  Spiegelberg, 
Horwitz:  Zeitschr.  f.  Geb.  u.  Gyn.,  vol.  ix,  p.  110. — Schauta:  Lehrb.  d.  Gyn.,  1900,  p.  407. — Sittner:  Jour.  .\mer. 
Med.  A-ssoc,  1907,  p.  407  rcf. — Smith:  "  Repeated  Ectopic  Gestation,"  Amer.  Jour.  Ob-st.,  September,  1911 ;  ibid.. 
Jour.  Amer.  Med.  Assoc,  April  13,  1912,  p.  1114. — Wcibel:  Monatsschr.  f.  Geb.  u.  Gyn.,  vol.  xxii,  p.  748. — Werth: 
Handbuch  d.  Geb.,  vol.  ii,  p.  2. — v.  Winckel,  F.:  "Uber  die  Missbildungen  ektopischentwickelten  Fruchten, 
Wiesbaden,  1902. — Young  and  Rhea:  Boston  Med.  and  Surg.  Jour.,  February  23,  1911. — Literature  on 
Interstitial  Pregnancy  in  L'Obstetrique,  May,  1911,  p.  493. 


CHAPTER  XXXI 
DISPLACEMENTS  OF  THE  UTERUS 

ANTEFLEXION  AND  ANTEVERSION 

Normally,  the  uterus  is  anteverted,  and  during  the  first  months  of  pregnancy 
this  anteversion  is  increased,  the  fundus  lying  heavily  on  the  bladder  (Fig.  110,  p. 
84) .  Pregnancy  occurring  in  an  antefiexed  uterus  displaces  the  fundus  downward, 
also  pressing  on  the  bladder  and  diminishing  its  capacity,  but  in  both  instances  the 
uterus  is  soon  directed  upward  into  the  abdomen  by  the  obtusely  placed  pubis,  and 
incarceration  does  not  occur  unless  adhesion  or  neoplasmlockstheorganin  the  pelvis. 
Anterior  displacements,  according  to  Grailly  Hewitt,  cause  hyperemesis  gravidarum, 
and  proper  treatment  is  curative.     In  rare  cases  this  is  true. 

Late  in  pregnancy  the  uterus  always  becomes  anteverted,  owing  to  the  dis- 
tention of  the  anterior  abdominal  wall.  When  this  becomes  pathologic,  we  call  it 
pendulous  abdojnen  (venter  propendens,  ventre  en  besace,  Hangebauch),  and  in 
advanced  cases  the  fundus  may  be  inverted,  pointing  downward,  and  hanging  be- 
tween the  knees.  In  primiparse  pendulous  belly  is  very  rare,  and  usually  indicates 
the  existence  of  a  contracted  pelvis,  twins,  or  some  condition  preventing  engagement 
of  the  fetal  head.  Occasionally,  about  the  eighth  month,  the  belly-wall  gives  way 
suddenly,  the  uterus  falling  forward.  Striae  gravidarum  are  usually  present  in 
great  numbers  in  these  cases.  One  would  naturally  expect  pendulous  abdomen  to 
be  absent  in  athletic  women  and  common  in  those  of  indolent  habit,  but  the  author's 
experience  shows  that  both  are  equally  affected.  It  is  probable  that  a  congenital 
weakness  of  the  abdominal  plates  may  exist  and  be  causative  of  pendulous  belly, 
as  well  as  enteroptosis.  Multiparae  suffer  more  commonly  from  this  affection,  and 
it  increases  with  the  number  of  children.  The  other  factors  are  contracted  pelvis, 
increased  inclination  of  the  pelvis,  kyphosis,  lordosis,  spondylolisthesis,  very  large 
fetus,  twins,  polyhydramnion,  frequent  child-bearing,  and  tumors  complicating 
pregnancy.  Improper  habits  also  cause  weakening  of  the  abdominal  supports;  such 
are  constipation,  wearing  ill-fitting  corsets  or  high-heeled  shoes,  carrying  children 
or  weights  on  the  protuberant  belly. 

During  pregnancy  pendulous  abdomen  causes  a  sense  of  weight  and  distention, 
dragging  pains  in  the  loins,  in  the  belly,  and  at  the  costal  insertions  of  the  recti,  often 
frequency  of  urination,  intertrigo  of  the  lower  abdomen  and  thighs,  occasionally 
varices  and  edema  of  the  vulva.  The  diastasis  of  the  recti,  which  by  the  laity  is 
called  "rupture,"  may  be  so  marked  that  the  uterus  falls  forward,  covered  only  by 
the  peritoneum,  a  thin  layer  of  fascia,  and  the  skin,  allowing  the  surface  and  the 
contents  of  the  uterus  to  l^e  felt  with  startling  distinctness,  and  sometimes  even 
the  color  of  the  organ  showing  through — hernia  uteri  gravidi  abdominalis.  In  such 
cases  locomotion  may  be  hindered. 

During  labor  pendulous  abdomen  may  cause  serious  dystocia.  The  uterus  is 
thrown  so  far  forward  that  its  axis  forms  an  acute  angle  with  the  pelvic  axis;  the 
cervix  is  pulled  up  into  the  hollow  of  the  sacrum,  sometimes  even  above  the  promon- 
tory; dilatation  is  delayed,  and  the  posterior  uterine  wall  is  overstretched.  This, 
together  with  obstructed  labor  because  of  malposition  of  the  fetus  and  disturbed 
mechanism,  invites  rupture  of  the  uterus.  Malpresentations,  such  as  shoulder 
and  Ijreech,  are  common  in  these  cases,  because  the  head,  in  spite  of  strong  pains, 
cannot  get  down  into  the  pelvis.     Malpositions,  especially  anterior  parietal  bone 

398 


DISPLACEMENTS    OF  THE    UTERUS 


399 


presentation,  are  especial!}'  jjiomc  \o  occur,  us  can  be  seen  in  Fig.  353.  Prolapse 
of  the  cortl  and  cxtreinitics  nuiy  also  cause  dystocia,  and,  owing  to  tlie  peculiar  slmpe 
of  the  uterine  tumor,  diagnosis  is  difficult.  In  the  child  facial  paralysis  has  been 
observed  from  pressure  of  the  neck  against  the  pubis,  and  the  author  found  shorten- 
ing of  the  stcruoclcMdomastoid  muscle,  with  temporary  torticollis,  as  the  result  of 
the  extreme  lat(M'iflcxiou  of  the  fetal  neck.  Should  tlie  slujrtened  muscle  tear  dur- 
ing sjjontam'ous  labor  or  operative  delivery  and  jjecome  inflamed,  a  permanent  wry- 
neck may  result.  The  child  is  exposed  to  all  the  dangers  of  the  abnormal  mech- 
anism of  labor,  and  the  fetal  mortality  is,  therefore,  higher. 

Treatment. — Prevention  accomplishes  a  good  deal.     The  corset  should  be  re- 
moved us  soon  as  the  fact  of  pregnancy  existing  is  established,  and  the  woman's 


Fig.  353. — Pexdulous  Bellt, 


living  should  be  ordered  as  is  described  under  the  Hygiene  of  Pregnancy.  During 
the  latter  months  of  pregnancy  the  abdomen  should  be  supported  by  a  properly 
fitting  binder.  Most  of  the  "maternity  corsets"  on  the  market  exert  pressure  on 
the  fundus  in  a  downward  direction,  when  the  proper  action  is  one  of  support  from 
below.  The  ordinary  surgical  binder  with  straps  over  the  shoulders  meets  the  indi- 
cations best,  the  principle  being  well  shown  in  the  supporter  illustrated  by  Hirst 
(Fig.  354). 

After  delivery  one  should  attempt  to  restore  the  tonus  of  the  abdominal  wall 
as  fully  as  possible  by — (a)  Prevention  of  the  accumulation  of  gas  and  feces  in  the 
bowel  (these  keep  the  muscle  overdistended) ;  (6)  preventing  infection,  which  lames 
the  intestinal  wall ;    (c)  keeping  the  patient  recumbent  for  at  least  a  week,  and  let- 


400 


THE  PATHOLOGY  OP  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


ting  her  resume  her  household  duties  slowly;  (d)  using  some  sort  of  abdominal  sup- 
port after  getting  out  of  bed;  (e)  bj'  systematic  gymnastics  and  massage  of  the 
abdominal  muscles. 

In  cases  of  fully  developed  pendulous  belly  during  pregnancy  the  binder  here 
illustrated  should  be  worn  as  soon  as  the  uterus  rises  out  of  the  pelvis ;   the  patient 


Fig.  354. — Patterson's  Abdominal  Supporter. 
This  gives  the  best  principle  of  abdominal  support  (redrawn  from  Hirst). 

should  lie  much  on  the  back,  and  the  physician  should  examine  her  in  the  last  weeks 
to  discover  a  malpresentation. 

During  labor  the  binder  should  l^e  worn,  or  the  uterus  may  be  pulled  up  by  a 
towel  slung  over  the  shoulders  and  held  in  place  by  another  around  the  belly.  In 
some  cases  it  is  best  for  the  attendant  to  push  the  pendent  fundus  upward  during 
every  pain  until  the  head  enters  the  pelvis.  The  author  has  often  accomplished 
engagement  by  letting  the  patient  sciuat  in  an  aboriginal  attitude  (Fig.  355).  This 
procedure  is  also  recommended  by  King.     The  thighs  force  the  uterus  up,  and  the 


DISPLACEMENTS    OF  THE    UTERUS 


401 


child  is  straightened  and  brought  witii  its  axis  to  correspond  with  that  of  the  inlet. 
As  a  rule,  after  the  heatl  engages  lal)()r  j)rocee(ls  rapidly,  but  sometimes  the  widely 
separatcid  recti  cannot  obtain  a  purchase  on  the  uterus  with  its  contents,  and  delay 
in  the  second  stage  arises  or  notation  stops.  Unless  forcej)s  are  applied,  the  uterus 
may  rupture.  The  exaggerated  lithotomy  position  (Fig.  495),  which  is  the  squat- 
ting position  with  the  patient  on  the  back,  is  especially  useful  at  this  stage  of  labor, 
and  should  always  be  tried  before  resorting  to  forceps.  After  delivery  of  the  head 
the  anterior  shoulder  may  stem  on  the  pubis  and  cause  delay — the  body  of  the  child 
is  to  be  lifted  up  by  a  hand  pulling  up  the  abdomen.     In  lireeeli  presentations,  as 


y 


Fig.  35.5. — Squatting  Position  Used  by  Indians. 

soon  as  labor  ceases  to  progress,  the  anterior  foot  of  the  child  should  be  brought  down 
- — this  adjusts  the  fetal  axis  to  that  of  the  pelvis. 

Edema  and  prolapse  of  the  anterior  wall  of  the  cervix  as  the  head  descends  in 
the  pelvis  require  treatment,  which  consists  in  gently  forcing  the  structures  up  over 
the  head  by  the  internal  fingers  while  the  outside  hand  supports  the  fundus. 


ANTEFIXATION  OF  THE  UTERUS 

While  the  furor  for  the  operative  treatment  of  retrodisplacements  of  the  uterus 
is  steadily  subsiding,  enough  has  been  done  to  provide  a  new  and  not  infrequent 
form  of  dystocia.  The  uterus  has  been  fastened  to  the  abdominal  wall  by  fixation 
or  suspension;  to  the  bladder — vesicofixation ;  to  the  vagina — vaginofixation;  and 
even  under  the  bladder  in  the  vagina — the  Watkins-Wertheim  operation.  Further, 
its  ligaments  have  been  shortened,  folded,  or  transplanted — indeed,  the  very  mul- 
tiphcitv  of  the  procedures  proves  the  fact  that  not  one  is  the  ideal  method. 
^26 


402      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

The  Alexander  and  allied  operations,  where  the  ligaments  are  shortened  or 
transplanted,  as  in  that  of  Andrews  (sewn  behind  the  uterus),  usually  give  little 
real  trouble  during  pregnancy  and  labor.  Abortion  is  slightly  more  frequent,  and 
abdominal  pain,  from  the  tugging  of  the  uterus  at  its  shortened  ligaments,  is  usually 
complained  of.  The  round  ligaments  grow  during  pregnancy,  and  after  it  undergo 
involution  as  ordinarily.  Often  the  result  of  the  operation  is  impaired  by  the 
changes  wrought  bj'  gestation.  Only  symptomatic  treatment  can  be  employed  for 
the  disturbances  during  pregnancy. 

Ventrofixation  and  ventrosuspension  (often  the  former  results  when  the  latter  is 
intended)  and  adhesion  of  the  uterus  to  the  abdominal  wall  following  celiotomy  not 
seldom  cause  serious  dystocia.  Lindfors,  in  68  cases  of  labor,  found  the  cervix  was 
high  in  27,  transverse  presentation  in  31,  and  trouble  in  third  stage  in  10.  There 
were  30  versions,  13  cesarean  sections,  10  high  forceps,  5  embryotomies,  5  tampo- 
nades for  postpartum  hemorrhage,  and  many  other  operations  necessary.  There 
were  3  deaths.  It  is  claimed  by  Lindfors,  if  the  operation  is  properly  performed, 
there  is  almost  no  danger  of  trouble  with  succeeding  pregnancies.  In  146  cases 
collected  by  Lapthorn  Smith  there  was  trouble  36  times — 10  abortions  and  3  deaths. 
In  my  own  experience  these  have  occurred:  Abortion,  shoulder  and  breech  presen- 
tation, obstructed  labor  requiring  cesarean  section,  placenta  prsevia,  inertia  uteri 
and  its  sequences,  retention  of  placenta,  postpartum  hemorrhage. 

Pain  in  the  scar  is  common,  and  occasionally  hyperemesis  may  require  inter- 
ference during  pregnancy.  Williams  quotes  Andrews'  collection  of  395  cases,  and 
adds  36  cases  of  cesarean  section.  Dickinson  reports  2  deaths — one  from  rupture 
of  the  uterus  and  one  from  late  shock  after  cesarean  section. 

The  frequency  of  abortion,  difficult  labor,  postpartum  hemorrhage,  and  the 
necessity  for  capital  operations  to  overcome  obstruction  should  forbid  the  practice 
of  ventral  fixation  in  child-bearing  women,  an  opinion  also  held  by  Cragin  and  Polak. 

]\Iuch  depends  on  the  site  of  the  fixation  scar.  If  in  the  fundus,  the  worst  forms 
of  dystocia  occur.  Then  the  anterior  wall  can  take  little  part  in  the  dilatation  of 
the  uterus.  It  hypertrophies  and  forms  a  roof  over  the  inlet,  while  the  posterior 
wall  thins  and  stretches  to  form  the  cavity  of  the  uterus.  The  cervix  is  thus  pushed 
toward  the  sacrum  by  the  gromng  anterior  wall,  and  pulled  up  out  of  the  pelvis  by 
the  tugging  of  the  posterior  uterine  wall.  One  may  find  the  external  os  on  the 
promontory  or  above  it,  and  the  internal  os  up  on  the  liraibar  spine.  More  or  less 
asymmetry  is  the  rule,  the  fundus  stretching  to  one  side.  One  finds  the  tubes, 
ovaries,  and  round  ligaments  more  or  less  parallel  with  Poupart's  ligaments. 

Vaginofixation  caused  such  serious  dystocia  that  its  performance  on  child- 
bearing  women  was  very  soon  abandoned.  Now,  unless  the  tubes  are  resected, 
insuring  sterility,  it  is  very  seldom  practised.  Uniting  the  round  ligaments  instead 
of  the  fundus  to  the  vagina  is  open  to  the  same  objections. 

Since  the  fundus  in  this  operation  is  attached  to  the  relatively  immobile  vagina, 
the  cervix  points  to  the  sacrum,  and  the  same  conditions  will  arise  as  in  ventro- 
fixation, only  more  exaggerated.  The  pelvic  inlet  is  roofed  over  by  the  hypertro- 
phied  anterior  cervical  and  uterine  wall;  the  os  is  high  up  in  the  abdominal  cavity, 
and  can  be  traversed  by  the  finger  only  after  the  whole  hand  has  been  passed  into 
the  vagina;  the  l^ladder  is  entirely  an  aljdominal  organ;  the  posterior  wall  of  the 
uterus,  having  constituted  almost  solely  the  available  uterine  wall,  is  much  thinned; 
the  round  ligaments,  tubes,  and  ovaries  converge  to  a  common  point  just  behind  the 
pubis  (Fig.  356).  Abdominally,  one  finds  a  triangular  uterine  tumor  with  the  broad 
base  at  the  inlet,  and  can  feel  the  round  ligaments  as  they  converge  toward  the 
pubis.     Sometimes  the  scar  is  visibly  retracted. 

During  pregnancy,  which  is  not  common  after  the  operation,  the  uterus  tugs 
at  its  false  attachments  and  may  break  them,  which  is  more  likely  in  abdominal 
fixations.     This  process  causes  much  pain  and  symptoms  of  peritoneal  irritation^ 


DISPLACEMENTS   OF   THE    UTERUS 


403 


Abortion  occurs  in  onc-foui-tli  of  the  cases  and  aiiiKninf^  bladder  symptoms  are  the 
rule.     Labor  often  comes  on  prematurely. 

Labor  is  complicated  by  premature  rupture  of  tlie  bag  of  waters  and  prolapse 
of  the  cord;  abnormal  presentation,  usually  shoulder;  slow,  weak  pains,  or  strong 
but  inefficient  pains,  liocause  of  the  vault  of  the  vap:ina  being  obstructed  by  the 
thick  se])tum;  ))ostpartum  hemorrhage.  All  manipulations  are  rendered  laborious 
because  the  uterine  cavity  is  tlifhcult  of  access,  since  the  hand  has  to  pass  a  crooked 


Corvi.i 


Anterior  uterine 
~~  wall,  site  of  fixation 


Fig.  Ij.36. — Mi<s.  M.     Conditions  \t  Term  after  VAGiNonx-^TioN.     Cesare.vn  SECTiOJf. 


canal  and  then  operate  over  the  l^order  of  a  ledge.     Even  the  lateral  posture  does 
not  facilitate  the  operative  procedures  verj'  much. 

Treatment. — A  woman  w^ho  has  had  an  operation  fixing  the  uterus  in  an  ab- 
normal location  requires  careful  watching  during  pregnancy.  Annoying  SNTuptoms 
can  be  only  partly  relieved.  Threatened  abortion  requires  rest  in  bed  and  opiates; 
if  the  abortion  occurs,  the  accoucheur  must  see  that  the  uterus  is  absolutely  empty, 
and  that  the  drainage  of  its  cavity  is  good.     As  the  woman  nears  term  frequent 


404      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

examinations  should  be  made  to  determine  the  behavior  of  the  cervix.  If  it  is 
pushed  backward,  upward,  and  higher  into  the  abdominal  cavity,  trouble  in  labor 
will  surely  arise,  and  appropriate  measures  should  be  instituted.  Such  a  course  of 
pregnancy  after  ventral  operation  may  indicate  reopening  the  belly  and  release  of 
the  adherent  fundus,  allo^^dng  gestation  to  go  to  term.  After  vaginofixation  such 
an  operation  would  be  impracticable.  If  the  woman  goes  into  labor,  a  quick  de- 
termination is  to  be  made  as  to  how  much  an  obstruction  the  cervico-uterovaginal 
septum  wall  make.  If  the  hand  can  pull  the  cervix  down  and  easily  bring  it  into 
the  axis  of  the  pelvis,  it  is  probable  that  nature  will  succeed  alone  or,  by  means  of 
the  metreurynter,  version,  forceps,  etc.,  the  case  can  be  successfully  terminated 
with  ordinary  methods;  but  if  the  cervix  is  long,  high  above  the  promontory,  and 
hard  to  pull  down,  a  cutting  operation  will  usually  be  necessary. 

In  ventrofixations  either  a  vaginal  or  an  abdominal  cesarean  section  may  be 
selected,  but  the  former  is  quite  difficult  of  execution,  because  of  the  inaccessibility 
of  the  cervix.  In  cases  where  a  typical  vaginofixation  has  been  done  with  the  usual 
stripping  of  the  bladder  from  the  anterior  cervical  and  uterine  wall,  the  septum 
may  safely  be  split  medially  from  the  external  os  almost  to  the  pubis,  without  danger 
of  injuring  any  organ.  Since  one  seldom  knows  what  operation  has  been  done,  it  is 
wisest  to  open  the  abdomen  in  these  bad  cases.  In  infected  cases  a  Porro  operation 
is  indicated,  and  it  is  usually  technically  difficult,  because  of  the  extensive  adhesions, 
the  immense  varicosities  in  the  broad  ligaments,  and  the  abnormal  location  of  the 
bladder  and  blood-vessels.  A  word  of  warning  is  given  to  the  operator  attempting 
to  deliver  from  below,  to  remember  how  thin  the  posterior  wall  of  the  uterus  is, 
and  that  the  whole  organ  is  fixed  on  the  pelvis,  for  which  reason  rupture  is  to  be 
feared.  In  performing  version,  access  to  the  parts  which  lie  in  the  anterior  pocket 
above  the  ledge  separating  the  uterine  cavity  from  the  vagina  may  be  obtained  by 
turning  the  patient  on  her  side  and  the  operator  inserting  the  hand  from  behind. 
After  delivery,  either  vaginally  or  abdominally,  provision  for  uterine  drainage  must 
be  made  by  gauze  or  tube,  because  the  fundus  may  be  lower  than  the  cervix,  and 
the  lochia  may  accumulate  in  the  anterior  pocket. 


POSTERIOR  DISPLACEMENTS 

Retroversion  and  retroflexion  are  rare  in  nulliparae,  and  when  they  do  occur, 
usually  cause  sterility,  but  in  women  who  have  borne  children  both  displacements 
are  common,  and  less  often  are  the  cause  of  acquired  sterility. 

Causation. — While  the  pregnant  uterus  may  become  retroflexed  or  retroverted 
as  the  result  of  a  sudden  increase  of  the  intra-abdominal  pressure  when  the  bladder 
is  full,  for  example,  through  cough,  fall,  straining,  it  is  usual  that  the  pregnancy 
occurs  in  a  uterus  already  displaced. 

As  a  rule,  the  uterus  slowly  draws  itself  up  out  of  the  pelvis — that  is,  sponta- 
neous restitution  occurs.  Sometimes,  because  of  adhesions  binding  the  fundus  in 
the  pelvis,  or  because  of  shrinking  and  inflammatory  thickening  of  the  muscle  and 
serosa  at  the  angle  of  the  flexion,  or  because  of  tumors  or  a  prominent  sacrum,  which 
interfere,  spontaneous  restitution  is  hindered  and  the  retroflexion  becomes  estab- 
lished. It  is  impossible  to  guess  at  the  frequency  of  the  condition,  because  surely 
many  pregnancies  occur  in  retrodisplaced  uteri  and  terminate  unobserved,  by  the 
rising  of  tho  organ  in  the  abdomen  or  by  abortion. 

Clinical  Course. — Unless  the  displacement  of  the  uterus  is  complicated  by 
adhesions,  no  symptoms  are  complained  of  until  the  uterus  begins  to  press  on  the 
neck  of  the  bladder.  Sometimes  there  is  a  sensation  of  fulness  in  the  pelvis,  with 
bearing  down,  or  pains  radiating  from  the  sacral  and  luml)ar  plexuses.  At  the  end 
of  the  third  month  bladder  symptoms  appear — frequent  desire  to  urinate,  great 
pain,  and  the  necessity  to  strain  to  pass  water,  the  feeling  that  the  viscus  has  not 


DISPLACEMENTS    OF   THE    UTERUS 


405 


been  cniptuMl,  aiul  Ihcii,  usu;ill>-  coiniiiji;  on  more  (»r  less  suddenly,  rctciiticni  oi  the 
urine.     The   lihiddcr   hcconics  enormously   distended,   containing,   in  one  of  the 


Fig.  357. — Retroflexio  Uteri  Gravidi.  Fig.  3.58. — Retroversio  Uteri  Gr.'IVidi. 

Arrows  show  the  direction  of  development.      Note  differences  in  the  cervix. 


Fig.  3.50. — Fn.vxz's  C.\se  of  Partial  Ixcarceration  of  the  Retroflexed  Gravid  Uterus. 


author's  cases,  96  ounces  of  urine,  and  in  a  case  reported  by  Blundell,  nearly  two 
gallons.  Constant  dribbling  may  occur,  that  is,  retention  with  overflow — inconti- 
nentia or  ischuria  paradoxa.     There  may  be  edema  of  the  extremities.     Consti- 


406 


THE    PATHOLOGY   OF   PREGNANCY,    LABOR,    AND    THE   PUERPERIUM 


pation  and  diarrhea  are  occasionally  noted.  Decided  symptoms  occur  long  before 
the  room  in  the  pelvis  is  entirely  filled  by  the  growing  uterus,  and  usually  bring  the 
patient  to  the  physician.  Rarely  the  woman  waits  until  the  uterus  is  tightly 
wedged  in  the  pelvis.  As  a  rule,  the  sj^mptoms  begin  in  the  third  month  and  the 
case  is  terminated  by  the  fifth,  but  sometimes  the  pregnancy  has  proceeded  to  the 
eighth  month,  and  in  partial  retroflexion,  to  term. 

Four  terminations  of  these  cases  are  possible:  (1)  Spontaneous  rectification; 
(2)  abortion;    (3)  partial  restitution;    (4)  incarceration. 

1.  Spontaneous  rectification  is  the  rule  about  the  third  or  fourth  month,  the 
fundus  rising  past  the  promontory  and  falling  forward.  Contraction  of  the  mus- 
cular fibers  of  the  anterior  uterine  wall,  aided  by  the  round  ligaments,  accomplishes 


Rigid  ledge  of 
uterine  muscle 


Fig.  360. — Reteoflexio  Uteri. 
A  retroflexed  uterus  had  been  pushed  up  out  of  the  pelvis  by  means  of  a  colpeurynter  in  the  fourth  month,  and  the 
pregnancy  proceeded  to  term.     Labor  was  normal,  but  because  of  hemorrhage  the  placenta  had  to  be  removed,  which 
was  difficult  on  account  of  its  inaccessible  location.     The  flexion  of  the  uterus  had  persisted  throughout. 


this,  and  it  is  favored  by  putting  the  patient  to  bed,  thus  relieving  the  displaced 
uterus  of  the  abdominal  pressure.  The  change  usually  requires  some  days  or  weeks, 
but  may  occur  rapidly  in  twenty-four  hours  or  between  two  examinations.  Pelvic 
adhesions  may  delay  the  restitution,  but  usually  the  adhesions,  even  when  exten- 
sive, are  stretched,  torn,  and  even  absorbed.  If  the  adhesions  are  too  strong,  or 
if  the  changes  in  the  structure  of  the  uterine  wall  are  permanent,  the  uterus  is  dis- 
torted in  the  direction  of  the  attachment  of  its  wall,  which  portion  is  drawn  out 
sac-like,  the  balance  of  the  uterus  dilating  to  accommodate  the  ovum.  Fig.  361 
shows  such  a  case.  Spontaneous  cure  is  commoner  in  retroflexion  than  in  retro- 
version, because  in  the  former  the  corpus  has  a  firm  body  to  pull  against — the  cervix. 
2.  Abortion  is  a  frequent  termination  of  retroflexed  pregnant  uteri;  indeed, 
habitual  early  abortion  is  often  caused  by  this  malposition.     The  lack  of  room  does 


DISPLACEMENTS    OF  THE    UTERUS 


407 


not  cause  the  abortion,  hut  t  lie  uterine  action  is  started  by  disturbance  in  the  uterine 
and  pelvic  circulation,  by  chronic  endometritis  the  result  of  the  congestion,  with 
hemorrhages  in  the  decidua,  and  by  chronic  metritis,  which  periiaps  was  the  original 
cause  of  the  (hsplacement.  Owing  to  the  strong  contractions  during  the  course  of 
abortion,  the  uterus  usually  rises  in  the  abdomen,  thus  hiding  the  cause  of  all  the 
trouble,  ))ut  aiding  the  emptying  of  the  ovum  antl  the  lochial  discharges.  Rarely — 
and  in  these  cases  there  are  adhesions — the  drainage  of  the  uterus  is  incomplete 
because  the  fundus  is  lower  than  the  cervix. 

3.  Incomplete  restitution  may  result  in  a  condition  known  as  retroflexio  uteri 
partialis.  This  term  is  applied  to  those  cases  where  part  of  the  fundus  is  retained 
in  the  pelvis,  the  anterior  wall  ex])anding  in  the  abdomen  to  form  the  ovum  con- 
tainer.    Many  forms  of  the  uterus  are  possible.     (See  Figs.  359-361.)     They  are 


Shows  that  culdo- 
sac  need  not  be 
opened  to  gain 
access  to  uterine 
cavity 


Thick  bladder 


Cervix 


Fia.  361. — Sacciform  Diu\tation  of  the  Uterus  at  Term. 


due  to  inveterate  adhesions,  tumors,  or  to  changes  in  the  uterine  muscle  or  serosa 
at  the  point  of  the  flexion. 

These  cases  may  terminate  normally  at  term,  the  deformity  and  dislocation  of 
the  cervix  being  finally  overcome.  Abortion  or  premature  labor  may  occur,  or 
incarceration  which  demands  early  interference,  and  if  at  term,  operation. 

A  condition  known  as  sacciform  dilatation  of  the  uterus  maj'  be  confounded  with 
partial  restitution.  The  cervix  is  found  behind  or  above  the  pubis;  the  culdesac 
is  filled  mth  part  of  the  dilated  cervix  or  the  lower  uterine  segment  (Fig.  361). 
It  is  usually  a  simple  matter,  by  means  of  the  finger  or  the  vulsella,  to  pull  the 
cervix  to  the  median  line,  and  then  complete  delivery  in  the  natural  or  ordinary 
operative  method,  but  Depaul,  w^ho  vtTote  a  good  paper  on  the  subject,  was  unable 
in  his  case  to  find  the  os,  and  the  patient  died  undelivered,  though  he  had  made  an 
opening  through  the  posterior  uterine  wall. 

4.  Incarceration  of  the  growing  uterus  in  the  pelvis  is  the  most  serious  outcome, 
and  the  symptoms  which  demand  interference  come  from  the  bladder.  This 
organ  cannot  be  emptied  properly,  becomes  enormously  distended,  reaching  even 


408 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


to  the  ensiform,  and  becomes  inflamed.  The  cause  of  the  retention  of  the  urine 
is  compression  and  distraction  of  the  urethra,  and  sometimes  edema  of  the  neck  of 
the  bladder  from  the  intense  congestion.  Ischuria  paradoxa,  or  constant  dribbhng, 
may  excoriate  the  parts,  especially  if,  in  addition,  the  uterus  becomes  infected  and 
a  septic  serous  discharge  issues  therefrom.  Uremia  may  occur  when  the  urine 
dams  back  into  the  kidneys,  but,  curiously  enough,  eclampsia  has  not  been  observed, 
though  Halbertsma  says  that  compression  of  the  ureters  is  a  cause  of  eclampsia. 
If  the  retention  of  the  urine  is  of  slow  development,  the  bladder  hypertrophies, 
but  in  all  cases  of  any  standing,  with  or  without  catheterization,  cystitis  and 


Bladder 


Urethra 


Cervix 


Fig.  362. — Wyder'.s  Case  of  Incarcekatiox  of  the  Retroflexed  Gravid  Uterus  with  Gangrene  of  Bladder. 


ammoniacal  decomposition  develop.  Hemorrhages  into  the  wall  and  into  the  bladder 
have  been  noted.  The  bladder  may  rupture  into  the  peritoneal  cavity,  with  acutest 
peritonitis  and  death,  or  into  the  connective  tissue  with  septic  urinary  infiltration, 
which  is  almost  always  fatal.  Or  the  l^laddcr-wall  becomes  necrotic,  in  part  or 
wholly,  the  intestines  adhere  to  its  outside,  and  if  the  bladder-wall  is  removed  or 
broken  by  sloughing,  the  urine  accumulates  in  a  new  sac  formed  by  the  adherent 
structures.  This  usually  ruptures  and  causes  general  peritonitis.  Gangrene  and 
separation  of  all  or  part  of  the  mucosa  are  not  necessarily  fatal,  because,  if  the  uterus 
is  emptied,  the  slough  may  be  expelled  through  the  urethra.  The  cause  of  the 
gangrene  is  infection  of  the  necrotic  mucosa,  and  the  germs — usually  Bacterium 


DISPLACEMENTS   OF   THE    UTERUS 


409 


coli — Siiin  access  either  Ilii'()iiji;h  the  mclln-a  or  by  the  catliclcr,  or  from  a<llicrcut 
l[)owel.  Anemia  of  tiu^  bladder  from  overdisleiitiou  or  rupture  of  one  part  of  the 
mucosa,  with  urinary  extravasation  between  the  layers,  has  been  given  as  a  cause 
of  the  necrosis.     Death  may  result  fiitm  urinary  sepsis  (Fig.  362). 

The  bladder  claims  our  chief  interest,  but  the  bowel  sometimes  sliows  symp- 
toms, such  as  tympany,  constipation,  and  vomiting.  Occasionally  a  mucous  diar- 
rhea occurs.     Ileus  is  exceetlingly  rare. 

Incarceration  of  the  uterus  may  lead  to  abortion  or  to  septic  infection  of  the 
uterine  contents,  the  bacteria  passing  through  from  the  bladder,  or  upward  from 
the  decomposing  urine,  which  dribbles  into  the  vagina  continually.  Perforation 
and  rupture  of  the  uterus,  with  death  from  peritonitis,  have  been  noted  to  follow 

prolonged  incarceration,  and  in  rare  instances  the  uterus 
was  expelled  through  the  rectum  or  through  the  posterior 
wall  of  the  vagina,  it  and  its  contents  being  delivered 


Fig.  303 


Fig.  361. 
Figs.  363-300.— Mrs.  F.,  Pbimipara. 


Fig.  305. 


Fig.  306. 


Retroversio  Uteri  Adherenta  with  Prouvpse  of  Ov.\ries  ix  Cri-nESAC; 
Pregnancy. 


Some  pain  and  irritation  of  bladder;  attempted  reposition  in  office  at  eight  weeks  failed;  knee-chest  position 
thrice  daily  with  air  into  vagina;  at  three  months  could  feel  posterior  wall  drawn  out  and  anterior  wall  bulging  upward 
(very  thin  woman) ;   spontaneous  restitution  at  fourth  month.    The  four  figures  indicated  the  process  which  took  place. 


outside.  Even  very  late  spontaneous  restitution  of  the  uterus  may  occur,  but  we 
do  not  wait  for  it  in  practice. 

Diagnosis. — This  is  seldom  difficult  if  a  careful  examination  is  made.  Any  preg- 
nant woman  giving  a  history  of  dysuria  or  dribbling  urine  should  be  examined  for 
retroflexio  uteri.  Al)dominally,  one  sees  and  feels  the  distended  bladder  as  an  elastic 
tumor  giving  a  good  wave  of  fluctuation.  If  the  bladder-wall  is  hypertrophied,  the 
tumor  may  be  hard.  After  catheterization,  which  is  invariably  necessary,  the 
changed  abdomen  is  striking.  Vaginally,  one  finds  the  cervix  pressed  upward 
against  tlie  pul)is  or  even  above  the  pul)is,  while  the  culdesac  is  filled  with  a  soft 
tumor  which  bulges  into  the  vagina  and  may  even  (late)  distend  the  perineum. 

The  differential  diagnosis  must  be  made  from  extra-uterine  pregnancy,  fibroid 
on  the  posterior  wall,  and  incarcerated  ovarian  tumor.  Concerning  ectopic  gesta- 
tion, the  reader  is  referred  to  the  appropriate  chapter,  but  here  the  warning  may  be 
repeated  to  be  sure  that  one  really  has  to  deal  only  with  a  retroflexed  uterus  before 
attempting  to  replace  it.  Demonstration  of  the  uterus  alongside  the  tumor  in  the 
culdesac  is  needed  to  settle  the  existence  of  a  neoplasm  in  the  pelvis,  but  if  the  wo- 
man is  pregnant  and  a  neoplasm  co-exists,  the  diagnosis  is  formidable. 


410  THE    PATHOLOGY   OF   PREGNANCY,    LABOR,    AND    THE    PUERPERIUM 

Retroflexio  Uteri  Gravidi  Pregnancy  with  Ovarian  Tumor 

1.  Symptoms  of  incarceration  early.  1.  Absent  or  very  late. 

2.  Bladder  symptoms  pronomiced.  2.  Absent  or  inconsiderable. 

3.  Tumor  in  question  symmetric  and  soft  all  3.  Usually   asymmetric,    hard,    and   tense   all 

over.  over  or  in  places. 

4.  There  is  no  other  tumor  above  the  pelvis.  4.  Often  can  feel  the  pregnant  uterus  above 

inlet  and  to  one  side. 

5.  Mo\'ing  the  cer\dx  imparts  an  impulse  to      5.  The  upper  tumor  (the  uterus)  can  be  moved 

the  tumor.  independently  of  the  tumor. 

6.  The    fornices    are    flattened,    at    least   not       6.  The  fornices  are  drawn  up  high,  sometimes 

drawn  up.  even  above  the  pubis. 

7.  The  tumor  in  the  culdesac  may  contract.  7.  Never. 

8.  ^lay  distinguish  fetal  parts.  8.  Never. 

9.  May  outline  the  round  ligaments  per  rectum.  9.  Not  positive  (in  one  case  strands  simulated 

these). 

Incarceration  of  a  pregnant  horn  of  a  double  uterus  and  partial  retroflexion 
of  the  uterus  both  give  diagnostic  problems  which  may  not  be  solved  except  by 
laparotomy,  and  countless  mistakes  have  been  made. 

Diihrssen,  among  others,  emphasizes  the  differences  between  the  clinical  course 
and  diagnostic  findings  in  retroflexion  and  those  of  retroversion,  but  practically 
the  two  conditions  are  the  same.  Retroversion  may,  as  pregnancy  goes  on,  be- 
come a  flexion;  retroversion  produces  symptoms  of  incarceration  later  because 
the  cervix,  pointing  toward  the  abdominal  cavity,  can  develop  in  this  direction; 
retroversion  is  less  likely  to  reduce  itself  and  is  harder  to  correct  artificially.  In 
retroversion  one  finds  the  cervix  pointing  toward  the  navel;  in  retroflexion  the 
cervix  points  toward  the  coccyx,  and  one  feels  the  angle  between  it  and  the  fundus. 

Prognosis. — Most  cases  of  retrodisplacement  terminate  by  spontaneous  re- 
duction or  respond  easily  to  art,  and  nowadays,  when  women  consult  the  physician 
so  readily,  a  neglected  case  is  a  rarity.  Gottschalk,  quoted  by  Diihrssen,  collected 
67  cases  of  death  in  which  were  16  cases  of  uremia  and  exhaustion,  7  of  sepsis, 
18  of  peritonitis,  11  of  rupture  of  the  bladder,  3  of  pyemia,  2  of  rupture  of  the 
peritoneum  and  vagina,  5  errors  of  art,  1  ileus,  and  4  unknown.  The  danger  of 
rupture  of  the  bladder  occurs  both  from  overdistention  and  from  brusk  attempts 
to  replace  the  uterus;  the  bladder  has  been  punctured  by  the  catheter  and  severe 
hemorrhage  into  it  may  result  from  too  rapid  withdrawal  of  the  urine.  The  uterus 
may  be  torn  by  attempts  to  replace  it,  but  the  greatest  source  of  danger  is  reten- 
tion of  urine,  with  cystitis,  gangrene,  or  ascending  infection,  etc. 

Treatment. — If  the  condition  is  discovered  very  early,  one  may  wait  a  while 
to  see  what  nature  will  accomplish.  A  gentle  attempt  to  replace  the  uterus  may  be 
made  at  the  first  examination,  and  if  successful,  a  hard-rubber  pessary  is  introduced, 
to  be  worn  until  the  end  of  the  fourth  month.  Otherwise  the  patient  is  instructed 
to  take  the  knee-chest  position  three  times  a  day,  and  to  sleep  on  the  side,  with  the 
buttocks  slightly  elevated.  If,  after  three  weeks,  the  condition  is  unchanged  or 
worse,  the  woman  is  put  to  bed,  and  a  determined  effort  for  cure  is  made. 

First,  the  bladder  must  be  emptied  and  kept  empty.  When  the  uterus  is 
incarcerated  this  is  not  so  easily  done,  because  the  urethra  is  very  long,  flattened, 
distorted,  edematous,  or  the  bladder  itself  divided  into  two  compartments,  only 
one  of  which  is  accessible  to  the  catheter.  Care  must  be  taken  to  avoid  producing 
a  false  passage,  and  a  soft  catheter  is  the  best  instrument.  It  may  be  necessary 
for  the  physician,  not  the  nurse,  to  use  a  silver  male  catheter.  Aids  to  catheteriza- 
tion are:  Sims  or  knee-chest  position;  using  the  right  sized  catheter — No.  12  to 
No.  15  French  scale;  pushing  up  the  fundus  or  pushing  back  the  cervix  with  two 
fingers  in  the  vagina;  pulling  down  the  cervix  with  a  vulsellum  (not  recommended 
by  author);  allowing  warm,  sterile  olive  oil  to  flow  through  catheter  while  being 
inserted;  extreme  gentleness  and  much  patience.  If  the  retention  has  been  great 
and  prolonged,  all  the  urine  should  not  be  withdrawn  in  one  sitting,  and  the  rate 
of  flow  must  be  very  slow.     After  an  interval  of  three  hours  the  bladder  may  be 


DISPLACEMENTS   OF   THE    UTERUS 


411 


completely  emptied,  the  reasons  for  this  advice  hcing  that  the  sudden  relief  of  so 
iinineiise  an  ahdoiniuul  distention  and  peritoneal  stretchinf^  ma}'  cause  shock,  and 
the  blood  rushing  into  the  anemic  mucous  membrane  of  the  bladder  may  produce 
a  hemorrhage  in  it. 

By  saline  cathartics  and  glycerin  enemata,  using  small  uinoiiiits  of  Jicjuid, 
the  bowels  are  kept  free  and  tympany  i)revented. 

Reposition  of  the  uterus  is  usually  easily  accomplished  after  the  bladder  is 
emptied,  and  it  is  aided  by  employing  the  knee-chest  position,  by  pulling  the  cervix 
down  with  a  vulsellum  (the  instrument  shown  in  Fig.  G90  is  better),  and  pushing  the 
fundus  ui)ward  and  to  the  side.  The  fundus  should  be  brought  to  slip  alongside 
and  avoid  the  promontory,  by  pressure  with  two  fingers  in  the  vagina  or  one  in  the 


Fig.  367. — Mrs.  D.,  PRiMip.4.n.\.  Showing  Torsion  of  Uterus  from  Adhesions. 
Appendicitis  with  peritoniti.s  four  years  ago;  pain  at  frequent  intervals  throughout,  and  painful  uterine  contractions 
at  end  of,  this  pregnancy;  threatened  abortion  at  throe  months,  therefore  rest  in  bed;  troublesome  tympany;  labor  at 
term;  very  severe  pains  and  desire  to  urinate  with  carh  contraction;  spontaneous  delivery,  boy,  S  pounds;  incarcer- 
ated placenta;  hour-glass  contraction;  hemorrhage;  manual  removal  of  placenta,  which  was  partly  adherent  in  left  horn 
of  uterus  under  the  spleen,  requiring  introduction  of  hand  nearly  to  elbow;  uterus  spirally  twisted;  remained  open, 
filling  with  blood;    tamponade;   recovery.     Uterus  adherent  to  abdominal  wall  at  point  indicated  by  shading. 


rectum,  aided  by  anesthesia,  and  using  great  gentleness  and  patience.  Too  great 
force  may  rupture  the  uterus,  may  tear  a  vascular  adhesion,  may  cause  hemorrhage 
into  the  bladder  or  even  burst  it,  and  may  bring  on  abortion.  Women  have  died 
because  of  too  violent  manipulations.  Even  after  reposition  bladder  necrosis  may 
occur  the  damage  having  already  been  done.. 

If  manipulation  will  not  restore  the  uterus,  one  may  temporize  a  short  time, 
employing  the  following  measures:  (a)  Knee-chest  position  every  four  hours  for 
fifteen  minutes,  with  continuous  rest  in  bed  on  the  side,  with  the  hips  elevated, 
and  frequent  emptying  of  the  bladder  and  rectum.  In  the  absence  of  s^-mptoms 
of  cystitis,  and  without  retention,  one  may  w^ait.  Urotropin,  5  grains,  medicinal 
methylene-blue,  1  grain,  are  to  be  given  four  times  daily  in  these  cases;  (6)  a  col- 
peurynter  with  16  ounces  of  water  is  placed  in  the  vagina,  and  the  foot  of  the  bed 
elevated  18  inches.     Some  authors  recommend  mercury  to  fill  the  colpeurynter. 


412  THE   PATHOLOGY   OF  PREGNANCY,    LABOR,    AND   THE   PUERPERIXJM 

One  may  continue  these  gentle  ejfforts  for  several  weeks  until  successful,  but 
must  not  delay  until  cystitis  or  aggravation  of  the  condition  indicates  their  futility. 
Laparotomy  has  frequently  been  done  and  the  uterus  easily  raised,  the  adhesions 
being  broken  up,  or — and  this  seems  to  have  been  overlooked — simply  by  allowing 
air  to  get  under  the  retroverted  fundus.  The  belly  is  opened  in  the  interests  of  the 
child,  and  is  permissible  only  when  the  bladder  is  not  gangrenous,  and  in  the  ab- 
sence of  symptoms  of  acute  peritonitis — this  because  the  protective  adhesions 
around  a  gangrenous  bladder  may  be  ruptured,  or  the  softened  uterus  may  tear. 


Tig.  368. — Prolapse  of  Cystocele  and  Rectocele  During  Labor. 

The  incision  is  to  be  begun  high,  at  or  above  the  navel,  and  then  enlarged  downward 
after  being  assured  that  the  bladder  is  not  in  the  way. 

If  conditions  are  not  right  for  laparotomy,  the  uterus  must  be  emptied,  but,  owing 
to  the  inaccessible  cervix,  this  may  be  difficult.  A  sharply  curved  sound  or  male 
bougie  may  enaVjle  one  to  puncture  the  membranes,  and  during  the  resulting  con- 
tractions the  uterus  will  lift  itself  up  and  empty  itself,  or  permit  the  accoucheur 
to  flo  it.  If  one  cannot  reach  the  os,  the  puncture  may  be  made  through  the  bulging 
posterior  uterine  wall,  using  an  aspirating  needle  and  syringe.  In  one  case  Bumm 
drew  off  enough  liquor  amnii  to  allow  the  replacement  of  the  uterus,  and  abortion 
did  not  follow. 

Posterior  hysterotomy,  with  removal  of  the  whole  ovum  in  one  sitting,  may  also 
be  done,  and  reference  to  Fig.  361  will  show  that  it  is  not  always  necessary  to  open 


DISPLACEMENTS   OF   THE   UTERUS 


413 


the  peritoneal  cavity.  If  this  operation  is  attempted  and  the  culdesac  opened, 
one  should  try  to  replace  the  uterus  by  combined  manipulati(ju  before  incising  it. 
If  successful,  the  pregnancy  may  go  to  term.  To  ])r(3veut  njcurrence  the  vagina  is 
tamponed  for  several  days  and  then  a  large  Smith  jjcssar}-  worn  until  the  uterus 
is  too  large  to  fall  back. 

(langrcne  of  the  bladder  is  diagnosed  by  the  discharge  of  foul  urine,  with 
flocculi  of  pus  and  shreds  of  meml)rane,  in  the  presence  of  septic  fever.  Cysto- 
scopically,  very  little  can  l)e  seen,  but  the  severe  cystitis  and  localized  necroses  with 
hemorrhages  may  be  found  before  gangrene  has  set  in.  As  soon  as  the  diagnosis 
of  gangrenous  cystitis  is  made  the  bladder  is  to  be  widely  opened  from  the  vagina, 
loose  pieces  of  tissue  removed,  and  freest  drainage  provided.     Urotropin,  alternating 


Fig.  369. — Acute  Elongation  of  the  Cervix  at  Eight  Months  (Chicago  Lying-in  Hospital). 


with  salol,  is  administered,  5  to  8  grains  four  times  a  day.  Urinary  infiltration 
of  the  perivesical  spaces  is  to  be  sharply  watched  for,  and  on  its  discovery  the  whole 
region  immediately  and  broadly  incised,  above  or  below  the  pubis,  or  both,  and 
the  freest  possible  drainage  established.  It  is  unsafe  to  open  the  uterus  or  induce 
abortion  after  gangrene  of  the  bladder  has  begun  because  of  sepsis;  therefore  it 
is  best  to  drain  the  bladder  and  await  developments.  The  uterus  may  be  replace- 
able after  a  iew  weeks,  or  more  safely  attacked  after  the  bladder  has  cleansed 
itself  somewhat.  When  the  uterus  has  become  infected,  it  must  be  emptied,  or, 
if  this  is  impossible,  extirpated.  Nowadays  these  neglected  cases  are  extremely 
rare,  because  the  women  consult  the  physician  earlier. 

Partial  retroflexion  of  the  gravid  uterus  requires  treatment  on   similar  lines 
if  threatening  symptoms  arise.     At  term,  if  it  is  impossible  to  bring  the  cervix 


414      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

into  the  axis  of  the  pelvis,  one  may  have  to  dehver  through  the  posterior  cervical 
wall  or  do  an  abdominal  cesarean  section. 

Distortion  of  the  uterus,  by  its  adherence  to  the  abdominal  wall,  to  the  sides 
of  the  pelvis,  the  rectum,  etc.,  may  give  rise  to  serious  dystocia,  as  has  been  seen 
in  the  instance  of  antefixations.  Figs.  363  and  367  give  diagrams  of  two  cases 
recentl}^  under  the  care  of  the  author,  and  the  brief  histories  indicate  the  commoner 
complications  and  treatment. 

PROLAPSE  OF  THE  PREGNANT  UTERUS 

Procidentia  may  occur  in  the  very  early  months,  and  unless  replaced  leads  to  abortion,  but 
Wimmer  reports  a  case  of  a  six  montlis'  gestation  outside  the  vulva,  and  this,  according  to  Braun 
Fernwald,  is  tlie  only  authentic  one  on  record  where  the  pregnancy  was  so  far  advanced.  Relax- 
ation and  prolapse  of  the  vagina,  with  partial  prolapse  of  the  uterus  outside  the  vulva,  are  not  very 
rare.  They  may  occur  during  pregnancy  as  the  result  of  severe  trauma,  because  a  tendency  to  pro- 
lapse existed  before,  or  a  prolapsed  uterus  may  become  pregnant.     (See  Findley.) 

Spontaneous  retraction  of  the  prolapsed  portion  usually  occurs,  and  after  the  fourth  month 


FiQ.  370. — Hypertrophic,  Edematous,  and  Prolapsed  Cervix  in  Pregnancy. 
Diagram  of  internal  findings  of  Fig.  369. 

the  tendency  to  fall  disappears;  indeed,  the  patient  may  feel  better  during  pregnancy  than  at 
other  times,  since  the  uterus  is  in  place.  If  spontaneous  reduction  does  not  take  place,  it  is  a 
simple  matter  to  return  the  womb  and  hold  it  in  position  by  tampons  or  an  air  pessary  until  it  is 
too  large  to  come  down.  Ulcerations  of  the  cervix  are  to  be  cauterized  with  10  per  cent,  silver  nit- 
rate and  all  infections  cured  before  labor  starts  in.  Rest  in  bed,  1 :  3000  permanganate  douches 
three  times  daily,  and  roborant  diet  will  accomplish  this. 

An  irreplaceable,  completely  prolapsed  uterus  is  to  be  emptied. 

Extrusion  of  cystocele  and  rectocele  during  pregnancy  is  a  very  annoying  condition,  the 
e-xposod  parts  sometimes  being  eroded,  usually  varicose,  and  occasionally  inflamed.  Pruritus 
may  be  obstinate,  and  the  author  has  obsc^rved  several  cases  of  mycosis  vulvas  under  these  condi- 
tions.    Rest  in  the  horizontal  position  is  to  be  advised,  also  extreme  cleanliness. 

Eversion  of  the  vaginal  walls  occurs  in  multipariB  in  the  second  stage,  during  the  strong 
bearing-down  efforts,  especially  if  the  cervix  is  rigid  and  does  not  retract  above  the  head  (Fig. 
368).  The  cervix  may  appear  outside  the  vulva  as  far  as  one  or  even  eight  inches,  and  will  not 
go  back  under  pressure.  Delivery  is  more  or  less  difficult,  depending  on  the  degree,  but  usually 
possible,  though  many  of  the  children  die;.  If  labor  has  to  be  operative,  two  assistants  should 
hold  back  the  edges  of  the  cervix  and  the  everted  vagina  with  specula  while  the  delivery  is  being 
effected. 

Hirst  collected  27  cases  of  vaginal  enterocele,  to  which  the  author  can  add  one,  occurring  in  the 
service  of  the  Chicago  Lying-in  Hospital  Dispensary.  Here  the  hernial  opening  in  the  posterior 
culdesac  was  2J^  inches  across,  but  the  coils  of  the  intestine  could  be  very  easily  replaced.  The 
treatment  of  cystocele  and  rectocele  during  labor  is  sjmiptomatic,  the  parts  being  replaced  as 
much  as  possible  and  held  back  with  the  fingers  so  that  the  advancing  head  can  slip  through  the 
space  thus  prcn-irjed. 

Hypertrophic  elongation  of  the  cervix  rarely  complicates  labor.  Conception  is  hindered 
and  dysmenorrhea  usually  calls  for  treatment,  the  cases  seldom  coming  to  the  accoucheur  imtil 


DISPLACEMENTS    OF   THE    UTERUS 


415 


thoy  have  been  ()|)crat(Ml  on.  Smiictiiiics  the  scarrcil  cervix  tjivcs  tn)ul)li'.  In  one  case  the 
author  :itiii)iit:itc(l  tlircc  (•ciitiiiictcr.s  of  a  loiiK  cervix,  which,  e\-eii  as  lati;  as  lh<-  fourth  month, 
the  time  llie  operation  was  done,  was  visil)le  at  the  vulva.  I  Iceiation  and  possible  infection  wore 
the  reasons  for  interference.      Labor  was  uneventful. 

Acute  enlargement  of  the  cervix  with  edema,  described  first  by  ( iueniot  in  1 S72,  and  of  which 
Jolly,  in  I'.tOl,  was  able  to  collect  10  cases,  is  (|uite  a  rare  occurrence  during  pregnancy,  labor,  and 
the'p'uerperiuin.  The  author  can  add  one  case  occurrinfi  duriiifi;  i)reKnancy  as  the  result  of  a  sud- 
den violent  strain  ([''ifi-  -W.)).  The  fornices  of  the  vafj;ina  were  normally  placed,  and  there  were 
no  bladder  svmptoms.  Several  days  had  elapsed  since  the  accident,  and  the- exposed  portion 
of  the  cervix  was  dry,  cracked,  and  partly  eroded.     It  was  disinfected,  replaced,  and  n.'tamed  l>y  a 


Fig.  371. — Edematous  Anterior  Lip  of  Cervix,  Causing  Dystocia. 


tampon;  the  prolapse  did  not  recur,  and  hxbor  was  normal.  Williams  refers  the  condition  to  an 
angioneurosis,  but  in  most  of  the  cases  a  history  of  injury  has  been  obtained. 

During  labor,  when  the  head  is  arrested  high  up,  the  cervix  becomes  swollen  and  may  pro- 
lapse as  a  dark-blue,  hemorrhagic,  edematous  mass  (Fig.  371).  The  protuberant  cervix  is  to  be 
tenderly  pushed  up  and  held  in  position  during  the  pains.  Soon  the  head  slips  down  past  it. 
During  forceps  delivery  it  must  be  held  back  with  two  fingers  dm-ing  each  traction.  It  may 
require  incision.  uj       •     i       ii 

Hernia  of  the  gravid  uterus  in  the  inguinal  canal,  through  the  umbilicus  or  abdominal  w  an, 
and  diastasis  of  the  recti,  allowing  an  actual  hernial  protrusion,  have  been  observed. 

Literature 

Cragin:  "Ventrofixation,"  Surg.,  Gyn.,  and  Obstet.,  1908,  vol.  vii,  p.  i5.—Depaul:  Arch,  de  Tocologie,  1876.— Duhrssen: 
Arch.  f.  Gyn.,  vol.  Ivii,  p.  70.  Gives  literature.  Findley:  Jour.  Amer.  Med.  Assoc..  December  30,  1911.— ^oHj/; 
Zeitschr.  f.  Geb.  u.  Gyn..  vol.  Hi,  p.  39fi.— .V/arm.  Cameron,  and  Fry:  "Celiotomy  in  Retroflexio  Uten  Gravidi," 
Amer.  Jour.  Obstet.,  July,  August,  1S9S.— FiViarrf  nnrf  Varnier:  Annales  de  Gyn.  et  d'Obst.,  1SS6,  p.  339.  and 
1SS7,  p.  S7. — Wimmer:    Handbuch  d.  Geb.,  v.  Winckel,  vol.  ii,  p.  355. 


CHAPTER  XXXII 
ABORTION  AND  PREMATURE  LABOR 

It  is  said  that  almost  half  of  the  child-bearing  women  have  had  a  miscarriage 
before  the  thirty-fifth  year.  Hegar  said  that  there  is  one  abortion  to  eight  labors, 
but  in  all  probability  it  is  more  frequent  than  this.  In  the  author's  private  obstet- 
ric practice  24  per  cent,  of  the  women  gave  a  history  of  abortion,  which  is  probably 
below  the  actual.  A  specialist's  practice  does  not  represent  the  ordinary  run  of 
cases,  because  so  many  of  his  patients  are  primiparse  or  women  who  have  had  diffi- 
cult confinements  or  miscarriages  before. 

Stumpf  and  Franz  collected  large  statistics,  but  they  are  of  questionable  value, 
as,  indeed,  are  nearly  all  statistics,  because  one  cannot  get  complete  information. 
Hospital  figures  do  not  represent  the  conditions  of  private  practice,  because  compli- 
cated cases  are  sent  to  the  hospital,  and  statistics  from  both  sources  are,  therefore, 
invalidated.  Further,  many  abortions  occur  in  the  first  weeks  and  pass  under  the 
diagnosis  of  delayed  or  profuse  menstruation.  Finally,  very  many  abortions  are 
deliberately  concealed.  In  general,  regarding  abortion  it  may  be  said  that  it 
occurs  more  frequently  in  multiparse  than  in  primiparae,  perhaps  because  there  are 
more  multiparse,  but  probably  also  for  other  reasons;  oftener  in  the  city  than  in  the 
country,  because  of  the  prevalence  of  gonorrhea,  the  easy  accessibility  of  the  abor- 
tionist, etc.;  oftener  among  the  lower  classes — but  criminal  abortion  is  probably 
more  frequent  in  the  educated  classes;  more  frequent  in  the  first  three  months  of 
gestation,  and,  of  the  three,  commonest  during  the  third  month;  more  frequent 
after  the  thirtieth  year.     Race,  civil  state,  and  color  seem  to  have  no  influence. 

The  reasons  for  the  more  frequent  occurrence  of  abortion  from  the  eighth  to 
the  twelfth  week  are :  The  ovum  is  not  strongly  attached,  and  is  weak  and  suscepti- 
ble to  outward  influences;  marked  changes  are  going  on  in  its  circulation;  since 
the  woman  is  not  sure  of  her  pregnancy,  she  takes  no  care  of  herself;  the  women  con- 
sider it  no  crime  to  get  rid  of  the  ovum  before  "quickening,"  and  think  abortion 
not  dangerous  in  the  early  months. 

Much  disagreement  exists  regarding  nomenclature.  Miscarriage  is  a  term 
used  by  the  laity  for  every  interruption  of  pregnancy  before  term,  and  the  word 
"abortion"  is  resented  as  implying  a  criminal  process.  In  scientific  description 
it  is  best  to  drop  the  former  and  retain  the  latter.  "Immature  labor"  has  been 
used  to  designate  the  interruption  of  pregnancy  from  the  sixteenth  to  the  twenty- 
eighth  week,  and  "premature  labor"  from  then  on,  the  term  abortion  being  limited 
to  the  period  before  the  sixteenth  week.  The  author  agrees  with  those  writers  who 
apply  the  word  abortion  to  all  interruptions  of  pregnancy  before  the  child  is  viable, 
that  is,  before  the  twenty-sixth  to  the  twenty-eighth  week,  and  the  expression 
premature  labor  to  those  terminations  of  gestation  after  the  child  is  viable,  but  before 
term. 

Causation. — A  study  of  the  etiology  of  abortion  has  very  great  importance 
as  an  aid  to  science,  of  treatment,  of  the  prevention  of  subsequent  accidents,  and 
medicolegally.  Therefore  in  all  cases  the  accoucheur  should  search  carefully 
for  the  underlying  cause  and  make  a  note  of  all  his  findings. 

A  classification  of  the  causes  must  be  arbitrary,  since  they  are  very  numerous 
and  interact  on  each  other.     They  are  fetal,  maternal,  and  paternal. 

416 


ABORTION    AND    PREMATURE    LABOR  417 

Fetal. — Death  of  the  fetus  always  Ijrings  on.  abortion,  and  every  fatal  anomaly 
of  the  fetal  l)0(ly  or  its  api^endages  is,  therefore,  an  eticjhjgic  factor. 

Diseases  of  llie  Cliorion. — Ilydjilidiforin  doKenoration  almost  alvvaj's  interrupts  jjrcKnanfy, 
only  a  few  cases  heinfi;  on  reeonl  as  having  fionti  to  term.  Hc^morrhaK''  i.s  usually  furious  when  the 
uterus  aftenipts  to  empty  itself. 

I'ldt-nilnl  Diseases. — Syphilis,  hypertrophic  ciKlarteritis,  excessive  wliile  infarct  formation, 
apoplexies  of  the  jjlacenta,  placenta  praivia. 

Diseases  of  the  Cord. — Torsion,  knots,  stenosis,  wliich  latter  is  usually  located  at  the  placental 
or  navel  insertion. 

Diseases  of  the  Amnion. — ,\cute  pcjlyhyilramnioii,  olifrohydramnicjii,  aiiiniotio  adhesions  to 
the  fetus,  cau.sinfj;  its  (l(>ath. 

Diseases  of  the  Fetal  Bixh). — .Vnom:dies  of  growth;  congenital  W(!akne.ss  from  ill  parents; 
alcoholism,  anemia,  saturnism,  tobacco,  etc.;  single  and  double;  monsters  (rather  commonly 
found,  and  they  would  be  oftcner  discovered  by  projjcr  search);  acute  infectious  disea.se.s — 
typhoid,  recurrent  fever,  malaria,  measles,  scarlatina,  cholera,  etc.;  chronic  infections — 
tul>erculosis,  sj'philis  (usually  after  the  fifth  month);  asphyxia  of  the  child  from  low  blood-pres- 
sure (anemia,  sjmcope,  shock)  or  from  hemorrhages  into  the  plactsnta  in  nephritis  of  the  mother — 
apoplexia  placentic;  insolation,  continuous  high  temperature  being  most  dangerous;  sudden  high 
t(>mperature  is  also  dangerous,  but  the  fetus  tolerat(>s  a  gradual  rise  better  (Runge);  toxemia, 
either  autogenic  or  exogenic,  under  th.e  former  being  hyperemesis  gravidarum,  chorea,  eclampsia, 
etc.;  under  the  latter,  alcohol,  tobacco  (especially  noticeable  in  cigar-makers),  lead,  carbon 
m'onoxid,  etc. 

How  does  the  death  of  tiie  fetus  cause  abortion?  (1)  The  ovum  does  not  }>e- 
come  a  foreign  body  and  stimulate  the  uterus  to  effect  its  expulsion,  because  the 
vascular  connections  may  be  kept  up  for  months  and  the  chorion  be  so  well  nour- 
islied  that  it  grows.  If  the  ovum  is  destroyed,  this  explanation  would  hold.  (2) 
When  the  fetus  dies,  the  stimulation  of  the  growth  of  the  ovum  ceases  and  the  altera- 
tion of  the  endometrial  reflex  brings  on  abortion — purely  hypothetic.  (3)  The  fetus 
may  develop  a  hormone,  which,  reaching  the  blood,  inhibits  uterine  action,  failing 
which,  a])ortion  results;  the  corpus  luteum  does  not  grow  after  fetal  death,  and  its 
restraining  influence  is  lost — h]y'7:)othetic. 

Between  the  death  of  the  fetus  and  its  expulsion  a  period  varying  from  a  few 
hours  to  days,  weeks,  or  months  may  elapse.  This  is  called  missed  abortion. 
Pieces  of  placenta  may  remain  in  the  uterus  as  long  as  nine  months  (author)  and 
eleven  months  (Playfair).     Ries  found  villi  sixteen  years  after. 

Maternal  Causes. — Chronic  endometritis  is  the  most  frequent  cause  of  abortion, 
and  especially  of  the  habitual  early  interruption  of  pregnancy.  It  acts  b}^  predis- 
posing to  hemorrhages  in  the  decidua  which  kill  the  fetus  or  stimulate  uterine  con- 
tractions; by  rendering  the  uterus  irritable  and  intolerant  of  the  ovum;  bj'  raising 
barriers  against  the  gro\\i:h  of  the  placenta;  by  not  allowing  the  ovum  to  obtain 
a  solid  nidus  or  a  well-located  one  (placenta  prsevia).  Endometritis  deciduae 
glandularis  produces  a  condition  called  hydrorrhcea  gravidarum,  attended  by  the  sud- 
den periodic  discharge  of  accumulated  secretions,  and  on  one  of  such  occasions  the 
uterus  may  be  urged  to  action.  Acute  gonorrhea  and  peri-uterine  infection,  for 
example,  salpingitis  or  appendicitis,  occasionally  interrupt  gestation. 

Chronic  metritis  is  the  usual  accompaniment  of  endometritis,  and  renders  the 
womb  still  more  intolerant  of  gestation — the  "irrital)le  uterus"  of  the  older  Avriters. 
The  uterine  muscle  cannot  hypertrophy  and  expand  as  it  should. 

jNIalformations  and  diseases  of  the  uterus,  infantilism,  single  or  double-horned 
uteri,  fibroids,  polypi,  lacerations  of  the  cerinx,  especially  with,  coincident  cervicitis 
and  endometritis,  amputated  cervix — all  are  sometimes  causative.  Retroflexion 
and  retroversion  have  already  been  referred  to  as  frequent  causes  of  abortion; 
indeed,  sometimes  when  abortion  is  threatened  replacement  of  the  uterus  allows 
the  gestation  to  go  to  term. 

Acute  infectious  diseases  of  the  mother  often  cause  abortion,  as  was  said, 
through  the  disease  passing  over  and  killing  the  fetus,  but  they  act  also  by  causing 
an  endometritis  which  shows  a  strong  tendency  to  become  hemorrhagic.  The 
sudden  rise  of  temperature  may  stimulate  the  uterus  to  action,  as  also  may  the 


418      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

hypercarbonization  of  the  blood  in  those  diseases  which  are  attended  by  cyanosis — 
for  example,  pneumonia.  Hemolysis  also  affects  the  fetus  through  the  anemia 
of  the  mother. 

Sepsis  should  be  added  to  the  list  of  infectious  diseases.  It  gains  entrance  to 
the  uterus  during  pregnancy  and  kills  the  ovum  primarily  or  secondarily.  In  cows 
epidemic  abortion  sometimes  occurs,  and  the  pathogenic  organisms  have  been  de- 
tected on  the  penis  of  the  bull  which  had  served  the  sick  animals  (Wallace) . 

INIaternal  syiDhilis  is  a  frequent  cause  of  abortion,  either  by  passing  over  to  the 
child  or  by  destroying  it  through  changes  in  the  decidua. 

Trauma  or  violence  is  very  frequently  advanced  by  the  patient  to  explain  the 
accident,  but  unless  it  is  applied  to  the  uterus  direct,  we  must  assume  that  one  of 
the  predisposing  causes — endometritis,  etc. — is  really  active.  A  special  predisposi- 
tion must  exist  to  explain  those  cases  where  a  slight  jar,  a  misstep,  a  nervous  shock, 
an  automobile  ride,  and  other  mild  occurrences  bring  on  abortion.  On  the  other 
hand,  the  severest  injuries,  mental  and  physical,  are  sometimes  inflicted  on  the 
gravida  without  disturbing  the  uterus.  Thomas  quotes  a  case  where  a  pregnant 
woman  jumped  from  an  upper  window,  falling  through  a  shed  onto  a  stone  flagging, 
but  carried  through  to  term,  and  reports  another  where  a  heedless  boy  threw  a 
dead,  bleeding  black  snake  around  his  sister's  neck,  and  in  spite  of  the  fact  that  she 
suffered  from  hysteric  syncope  and  convulsions  for  several  days,  the  pregnancy,  then 
at  four  months,  went  to  term.  The  child  was  not  "marked."  Excessive  coitus 
is  a  frequent  cause  of  abortion  in  the  newly  married.  Operations  come  under  the 
heading  of  trauma,  and,  unless  some  predisposition  exists,  usually  do  not  affect 
the  pregnancy.  The  author  has  removed  fibroids  from  the  pregnant  uterus,  in 
one  case  exposing  the  chorion,  and  has  amputated  the  cervix,  without  inciting  con- 
tractions. On  the  other  hand,  a  slight  operation  on  a  distant  organ  may  result  in 
miscarriage.  Ovarian  tumors  have  repeatedly  been  extirpated  safely  (66  per  cent, 
of  cases),  as  have  also  breast  and  other  tumors.  It  is  usually  the  shock  and  the 
sepsis  which  bring  on  the  abortion.  Appendicitis  cases  are  especially  prone,  prob- 
ably because  of  the  infection.  Removal  of  both  ovaries  during  pregnancy  has 
brought  out  the  fact  that  they  are  not  needed  for  labor,  because  the  pregnancy  and 
parturition  have  so  often  proceeded  naturally.  It  seems  that  double  ovariotomy 
in  the  early  months  is  more  dangerous  to  gestation  than  later,  and  the  fact  is  ex- 
plained on  the  theory  that  the  secretion  of  the  corpus  luteum  is  necessary  for  the 
groAvth  of  the  ovum  and  uterus.  Criminal  traumatism,  for  example,  puncture  of 
the  ovum,  insertion  of  catheters,  etc.,  does  not  come  under  this  heading,  nor  does 
the  administration  of  drugs — sabine,  ergot,  cantharides,  which  have  to  be  given  in 
pioisonous  doses  to  be  effective  in  emptying  the  uterus. 

Anesthesia  may  cause  death  of  the  fetus  if  too  prolonged  or  attended  by  great 
cyanosis,  as  is  the  continuous  nitrous  oxid  method.  Extraction  of  teeth  under 
brief  nitrous  oxid  gas  anesthesia  is  allowable,  a  dentist  in  this  city  who  has  ad- 
ministered it  over  12,000  times  having  assured  the  author  that  he  has  never  thus 
caused  an  abortion. 

It  is  necessary,  especially  in  medicolegal  cases,  to  decide  whether,  in  a  given 
instance,  the  accused  injury  really  caused  the  abortion,  and  this  point  can  seldom 
be  determined.  As  criteria  may  be  mentioned:  the  ovum  must  be  macroscopically 
and  microscopically  healthy,  and  show  no  other  cause  for  its  expulsion,  and  the 
death  of  the  ovum  and  its  expulsion  must  be  proved  to  have  occurred  very  shortly 
after  the  traumatism. 

Paternal  Causes. — Without  doubt  some  men  produce  a  sperma  which  is  too 
weak  to  give  the  ovum  the  necessary  generative  impulse.  Observation  of  many 
cases  of  male  sterility  has  convinced  the  author  of  the  truth  of  this  statement,  and 
examination  of  the  semen  in  these  instances  has  shown  a  paucity  of  spermatozoids, 
or  such  as  were  short-lived  or  inactive.     Syphilis,  tuberculosis,  general  paresis, 


ABORTION    AND    PREMATURE    LABOR 


419 


general  debility,  perhaps  from  excessive  coitus  or  from  alcoholism,  will  produce 
such  conditions.     It  is  said  that  abortion  is  frequent  in  cows  that  were  covered  by 
a  sexually  exhausted  bull.     A  man  with  a  purulent  discharge  in  the  semen  may 
cause  an  infection  in  the  uterus,  with  sej^tic 
abortion.     Men  workers  in  lead,  phosphorus, 
mercury,  etc.,  are  not  seldom  sterile.     It  is  a 
well-established  fact  that  .r-ray  operators  be- 
come sterile,  and  it  would  be  intcn-esting  to  dis- 
cover if  their  total   sterility  is  preceded  l)y  a 
series  of  al)ortions  in  their  wives. 

Premature  labor  is  produced  Ijy  the  same 
factors  that  bring  on  abortion,  but  syphilis 
plays  the  most  common  role  here,  it  being  esti- 
mated that  from  50  to  80  per  cent,  of  the  cases 
are  thus  caused.  Next  comes  nephritis,  with 
placental  hemorrhages  or  infarcts.  Twins  often 
come  prematurely  because  of  the  lack  of  room 
in  the  uterus,  and  any  tumor  in  the  abdomen 
which  is  large  enough  may  interfere  with  the 
development  of  the  uterus. 

Habitual  abortion  means  that  successive  pregnancies  are  interrupted,  usually 
at  the  same  period  of  development. 

Sj'philis  is  usually  found  as  the  active  factor,  and   more  especially  in  mis- 
carriages of  the  later  months.     Each  successive  abortion  occurs  at  a  later  period 


Decidua 

vera 


Blood-clot  in  the  rc-floxa 

Fig.  372. — Cast  of  Uterus  Showing  Decidua 
\'EnA  AND  Decidua  Reklexa  Long  Drawn 
Out  and  Containing  the  Ovum  and  a 
Blood-clot. 


Fig.  373. — Decidual    Cast  of    Uterus    a    Little 
Further    Advanced   than   Fig.   372,  Showing 
THE  Shape  of  the  Cavity. 
Note  shaggy  maternal  surface  of  decidua. 


Fig.  374. — Same  as  Fig.  373,  Showing  Cast  Opened  at 
One  Side. 
The  decidua  is  thinner  at  the  edges,  where  it  lay  in  the 
corners  of  the  uterine  cavity,  and  shows  the  opening  of  the 
glands.  The  decidua  reflexa  is  torn,  allowing  the  ovum 
partly  to  escape. 


until  a  living  child  is  born,  ])ut  it  perishes  from  congenital  syphilis,  and  finally  the 
disease  has  become  so  attenuated  that  a  viable  child  is  delivered.  Appropriate 
treatment,  of  course,  will  cut  the  process  short,  and  a  living  healthy  child  is  de- 
livered at  term. 

Chronic  endometritis  is  more  frequently  a  cause  of  repeated  early  abortion  than 


420 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


in  the  later  months,  and  it  is  not  seldom  combined  with  uterine  displacement. 
Each  abortion  aggravates  the  endometritis,  a  "vicious  circle"  being  established. 

Nephritis,  diabetes,  or  constitutional  disorder  should  always  be  searched  for 
in  these  cases.  The  influence  of  the  father  may  not  be  forgotten.  He  may  not 
be  capable  of  procreating  a  viable  child.  Chronic  lead-poisoning  is  well  known  to 
have  such  an  effect,  ■  and  probably  other  poisons  have  similar  action.  Finally, 
there  is  a  class  of  cases  where  none  of  the  preceding  conditions  can  be  found,  yet 
the  woman  cannot  carry  a  child  through  to  term.     With  improved  diagnosis — e.  g., 


Collapsed  cavity 
of  decidua  reflexa 


C/^> 


"^'H^ 

'  •*('%'^ 

-■*'<.<' 


Fig.  37.5. — ^Whex  the  Naked  Ovtjm,  Shown  Below, 
IS  Expelled,  all  the  Decidua  are  Left  in  the 
Uterus. 


Fig.  376. — Cervical  Abortion,  the  Ovum  Still  in  the 
Reflexa  and  the  Placenta  Drawn  Out,  but  Ad- 
herent AT  ITS  Base. 


Wassermann  reaction — the  number  of  such  instances  is  becoming  rarer.      (See 
ChaptcT  LXXV,  Induced  Labor.) 

Mechanism. — As  in  the  description  of  the  mechanism  of  labor,  in  abortion  we 
also  discuss  three  factors — the  powers,  the  passages,  and  the  passengers.  Uterine 
action  accomplishes  nearly  all  the  work  of  abortion  except  the  expulsion  of  the 
loosened  ovum  from  the  vagina,  whicli  the  abdominal  muscles  do.  The  bony 
passages  practically  never  come  into  consideration,  and  the  soft  parts  very  seldom, 
but  the  ovum  plays  an  important  part.  In  the  first  two  months  the  decidua  is 
thick,  vascular,  and  friable,  the  ovum  small,  soft,  and  compressible.  It  requires 
considerable  effort  by  the  uterus  to  separate  and  expel  the  former,  while  the  little 
ovum  slips  out  unobserved.  From  the  eighth  to  the  twentieth  week  the  placenta 
plays  the  main  role;   it  is  relatively  large,  separates  with  difficulty,  especially  from 


ABORTION    AND    PREMATURE   LABOR 


421 


the  uterine  cornua,  and  such  removal  is  usually  attended  by  profuse  hemorrhage. 
After  the  twentieth  week  the  fetus  is  the  most  important  passenger,  and  the  char- 
acter of  the  labor  resembles  more  and  more  that  at  term.  Separation  of  the  (jvum 
occurs  in  the  spongy  layer  of  the  decidua,  and  since  the  regressive  changes— the 
necrosis — have  not  progressed  far,  this  is  often  incomplete,  and  pieces  of  membrane 
or  placenta  are  likely  to  be  retained,  especially  in  the  tubal  corners.     One  may, 

therefore,   distinguisli    three    fairly  well- 
defined  periods: 

First  Period. — In  the  first  six  to 
eight  weeks  the  whole  ovum  is  usually 
born,  covered  by  the  decidua,  and  it  is 
often  possible  to  reconstruct  the  condi- 
tions which  existed  in  the  uterus,  as  in 
Figs.  372,  373,  374.  An  ovum  may  be 
expelled  naked,  as  in  Fig.  375,  or  covered 


Decifluii  vcr;i 


Fig.  377. — Incomplete   Abortion — Three  Months. 
,  When  the  fetus  only  is  expelled,  all  the  secundines  re- 
main in  the  uterus. 


Fig.  37S. — Placenta  Protruding  Polypoid  into  Vagina 
AND  Partly  Attached,  Inviting  Sepsis.  Thick  De- 
cidua still  in  Uterus. 


with  portions  of  the  decidua.  Whenever  the  ovum  alone,  covered  b}-  the  shaggy 
coat  of  villi,  is  expelled,  one  must  conclude  that  the  deciduie  still  remain  in  the 
uterus,  and  will  require  another  effort  of  nature,  which  is  often  attended  by  pro- 
fuse hemorrhage.  In  a  few  cases  the  deciduse  dissolve  and  come  awaj'  in  pieces  in 
the  lochia.  Should  the  external  os,  as  in  primiparae,  offer  resistance  and  not  dilate, 
the  ovum  is  arrested  in  the  distended  cervix,  the  internal  os  closing.  This  was  called 
cervical  pregnancy  by  Rokitansky,  but  a  better  term  is  cervical  abortion  (Fig.  376). 
Simple  dilatation  of  the  constricted  os  is  sufficient  to  liberate  the  ovum.  True 
cervical-isthmial  pregnancy  occurs  (Devraigne). 


422 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


Second  Period. — Several  courses  are  taken  by  the  abortive  process  during  the 
third  and  fourth  months.  First  the  whole  ovum  is  expelled — the  fetus  in  an  intact 
sac  and  a  large  part  of  the  decidua  covering  it.  This  may  be  called  the  typical 
course,  and  offers  the  best  prognosis  for  the  mother,  since  hemorrhage  is  usually 
mild,  interference  is  seldom  necessary,  and  the  remains  of  the  decidua  come  away 
with  the  lochia. 

Second,  the  membranes  rupture,  the  fetus  is  extruded,  the  cervix  closes,  and 
the  uterus  has  to  make  a  second  effort  to  expel  the  secundines  (Figs.  377  and  378). 
During  the  interval,  owing  to  partial  separation  of  the  placenta,  hemorrhage  is 
profuse,  infection  of  the  placenta  may  occur,  and  interference  of  some  sort  is  usually 
necessary,  all  of  which  cause  a  worse  prognosis. 

Thirdly,  the  decidua  refiexa  and  the  chorion  break,  allowing  the  fetus  in  the  amni- 
otic sac  to  escape.  A  beautiful  specimen  is  here  shown  (Fig.  379).  The  accoucheur 
must  remember  that  the  uterus  still  contains  the  placenta,  chorion,  and  deciduse. 

In  abortion  the  uterine  contractions  act  the  same  as  in  labor,  and  dilatation  of 


Decidua 
vera  being 
separated 


Fig.  379. — Fetus  in  Amniotic  Sac  Lntact. 


Fig.  3S0. — Beginning  Abortion  at  Sixth  Week. 


the  cervix  is  produced  in  the  same  way,  but,  owing  to  the  vascularity  of  the  decidua, 
hemorrhage  occurs  as  soon  as  the  contractions  begin,  because  the  decidua  loosens 
from  the  uterine  wall.  This  separation  begins  at  the  cervix,  proceeds  to  the  fundus 
(Fig.  380),  being  latest  in  the  tubal  corners.  Hemorrhages  into  the  decidua  and 
into  the  ovum  occur  and  aid  in  the  separation.  Upon  the  delivery  of  its  contents 
the  uterus  contracts  down  on  itself  and  involution  begins.  This  is  slower  and  more 
likely  to  be  incomplete  after  abortion  than  after  labor  at  term.  After-pains  are 
sometimes  observed,  and  milk  not  rarely  appears  in  the  breasts.  In  abortion, 
even  before  the  fifth  month  of  gestation,  there  may  be  considerable  engorgement  of 
the  mammiE. 

Abortion  after  the  fifth  month  is  really  a  labor  in  miniature,  and  needs  no 
further  description.  Breech  and  abnormal  presentations  are  commoner,  and  the 
whole  ovum  is  not  seldom  extruded  intact.  Expulsion  of  an  unbroken  ovum  is 
very  rare  in  the  last  months  of  pregnancy. 

Symptoms. — C'linicall}',  we  speak  of  three  forms  of  abortion, — threatened,  in 
progress  or  inevitable,  and  incomplete  abortion, — but  four  classic  symptoms    are 


ABORTION   AND    PREMATURE    LAHOR  423 

present  with  all.  These  arc:  ulcriiic  pain,  uterine  licniorrhago,  softeninj;  and 
dilatation  of  the  eervix,  presentation  or  expulsion  of  all  or  parts  of  the  ovum. 

Threatened  abortion  is  indicated  by  a  bhjody  (lischarfi;e  from  the  uterus,  and 
sometimes  by  sli{i;ht  drawing  pains  in  the  back  and  pelvis,  similar  to  menstrual 
sensations.  The  blood  may  come  with  a  gush  or  ooze,  or  appear  as  a  brownish, 
flaky  mucus.  Pain  may  be  a  slight  symptom,  or  there  may  be  only  a  sense  of  weight 
in  the  pelvis.  On  vaginal  examination  the  uterus  may  feel  harder  than  normal, 
which  is  because  it  is  contracting.  Softening  and  dilatation  of  the  c(!rvix  seldom 
occur  in  threatened  abortion,  but  the  author  has  had  several  cases  where  the  cervix 
opened  so  that  the  finger  felt  the  lower  pole  of  the  ovum,  and  yet,  after  subsidence 
of  the  symptoms,  the  pregnancy  went  to  term.  An  abortion  may  appear  threaten- 
ing for  hours,  days,  or  even  months,  and  yet  pregnancy  go  to  full  term.  Again, 
suddcnily,  profuse  hemorrhage  occurs,  pains  set  in,  and  the  process  becomes  in- 
evitable. 

Abortion  in  progress  presents  the  same  symptoms,  but  the  hemorrhage  is 
greater,  the  pains  stronger  and  more  regular,  resembling  those  of  labor.  Softening 
and  dilatation  of  the  cervix  proceed  from  above  dow'nw^ard,  and  the  shortening  of 
the  neck  of  the  womb  is  easily  followed  by  the  finger  in  the  vaginal  fornices,  or,  when 
the  OS  is  opened,  inside  the  cervix,  at  which  time  also  the  ovum  or  the  edges  of  the 
sepai'ated  decidua  may  be  felt.  The  symptoms  vary,  of  course,  with  the  mechan- 
ism of  the  abortion. 

If  the  wdiole  ovum  is  expelled  complete  in  one  effort  of  the  uterus,  the  hemor- 
rhage is  usually  moderate,  and  the  pains  cease  as  soon  as  the  ovum  escapes  from  the 
cervix.  In  multiparse,  because  of  the  open  cervix,  the  abortion  is  easier  and 
quicker  than  in  primi parse.  If  the  decidua  remains,  it  is  dissolved  and  comes  away 
in  the  profuse  lochial  discharge,  sometimes  giving  it  an  offensive  odor,  but  seldom 
causing  fever,  though  it  may  leave  behind  a  chronic  thickening  of  the  endometrium. 

If  the  membranes  break,  the  fetus  escaping  naked  or  clothed  only  in  its  amnion, 
the  remainder  is  expelled  after  minutes  or  hours,  or,  because  of  the  profuse  hemor- 
rhage which  usually  occurs,  or  the  fever  which  results  from  decomposition  of  the 
mass,  the  accoucheur  has  to  interfere  and  clean  out  the  uterus.  Hemorrhage  and 
pains  may  cease  in  the  interval,  during  which  time  the  case  is  called  one  of  incom- 
plete abortion. 

Incomplete  abortion  means  that  the  process  has  started,  but  that  the  uterus  is 
not  entirely  rid  of  its  contents.  This  does  not  include  the  retention  in  the  uterus 
of  a  whole  but  dead  ovum — which  is  "missed  abortion."  Incomplete  abortion  is 
a  dangerous  condition,  because  of  its  immediate  and  remote  bad  sequelae:  (o) 
The  cervix  partly  closes  after  the  escape  of  the  fetus,  and  the  placenta,  membranes, 
and  thick  decidua  gradually  break  down  and  are  discharged  in  the  lochia.  In 
these  cases  the  lochia  are  profuse  and  bloody,  sometimes  with  an  odor,  and  continue 
thus  until  the  last  vestige  is  removed.  Chronic  endometritis  is  almost  alwaj's  the 
final  result  of  such  a  process  (Fig.  381).  (6)  A  complete  interval  of  rest  may  be 
noted  until,  after  hours,  days,  or  even  months,  the  uterus  suddenly  expels  its  con- 
tents, (c)  Decomposition  sets  in,  the  pieces  soften  and  are  exfoliated,  a  layer  of 
granulations  separating  the  live  from  the  dead  tissue,  or  the  bacteria  break  through 
this  barrier,  sepsis  and  sometimes  death  resulting,  (d)  A  placental  pol^p  is  formed, 
the  attached  portion  of  the  placenta  being  well  nourished,  layers  of  fibrin  being 
deposited  and  organized  on  the  outside  until  a  pedunculated  tumor  is  created, 
which  may  protrude  from  the  cervix.  S^iicytioma  malignum  is  not  so  common 
in  these  cases  as  in  hydatid  moles. 

Diagnosis. — Threatened  Abortion. — If  the  fact  of  normal  pregnancy  is  known, 
uterine  hemorrhage  and  uterine  pains  signify  that  interruption  of  gestationthreatens. 
It  is  not  easy  to  diagnose  early  pregnancy  when  the  uterus  is  contracting,  l^ecause 
then  it  simulates  other  conditions,  for  example,  fibroid,  chronic  metritis,  ectopic 


424      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIITM 

ovum.  On  bimanual  examination  the  large,  contracting  and  relaxing  uterus,  the 
beginning  softening  and  shortening  of,  the  cervix,  and  the  bloody  discharge  show 
that  some  abnormal  process  is  going  on.  The  rule  is  to  treat  every  case  of  hemor- 
rhage, after  a  period  of  amenorrhea  occurring  in  a  woman  capable  of  reproduction, 
as  one  of  abortion. 

Differential  diagnosis  must  be  made  from  ectopic  gestation,  hemorrhage  from 
cervical  erosions  (not  rare),  varices  (very  rare),  hydrorrhcea  gravidarum,  and,  in 
addition,  all  the  conditions  not  associated  with  pregnancy,  for  example,  neoplasms 
and  malpositions.  When  pregnancy  and  threatened  miscarriage  are  associated 
with  a  neoplasm,  truly  complicated  conditions  are  presented  for  differentiation. 

Inevitable  abortion  is  more  easily  determined — the  cervix  is  shortened  or  even 
dilated,  allowing  the  finger  to  feel  the  ovum,  and  pieces  of  the  decidua  or  of  the  ovum 
are  expelled;  hemorrhage  is  more  profuse,  the  bag  of  waters  ruptures,  and  painful 
uterine  contractions  are  usually  present.  These  signs  enable  us  to  say  that  an 
abortion  is  inevitable,  but  in  rare  instances  the  cervix  may  close,  the  hemorrhage 
ceasing,  and  pregnancy  goes  on  to  term.  The  discharge  of  decidua  is  usually  con- 
sidered positive  evidence  of  an  unavoidable  abortion,  but  the  author  had  one  case 
of  double  uterus  where  the  decidua  was  discharged  from  one  side,  the  other  being 
pregnant.  The  ru^Dture  of  the  membranes  may  be  simulated  by  hydrorrhcea  gravi- 
darmii,  or  graviditas  exochorialis  (q.  v.  p.  518).  After  pregnancy  is  determined 
the  differential  diagnosis  in  abortion  has  to  deal  only  with  ectopic  gestation,  and  the 
latter  must  always  be  taken  into  consideration.  Rarely  the  extrusion  of  a  fibroid 
or  a  pol}^^  simulates  an  abortion. 

Incomplete  Abortion. — Is  the  uterus  empty?  Here  the  history  of  the  passage 
of  the  fetus  or  of  portions  of  the  placenta  may  be  useful,  but  unless  the  parts  have 
been  seen  by  competent  eyes,  the  information  must  be  questioned.  We  decide 
that  something  is  left  in  the  uterus  vv^hen  a  woman  who  has  had  an  abortion  con- 
tinues to  have  irregular  hemorrhages,  with  or  without  pains,  or  discharges  bloody 
lochia,  'vnih.  occasional  clots  or  bits  of  tissue,  for  a  long  time.  Examination  will 
reveal  a  large,  soft,  subinvolutecl  uterus,  which  sometimes  contracts,  with  a  succu- 
lent, patulous  cervix  through  which  the  finger  feels  shreds  of  decidua,  placenta,  or 
clots.  Microscopic  examination  of  discharged  or  cureted  pieces  of  tissue  may  show 
chorionic  villi.  In  some  cases  the  diagnosis  as  to  whether  the  uterus  is  empty  or 
not  may  be  impossible  without  a  curetage.  The  differential  diagnosis  must  be 
made  from  subinvolution,  endometritis  post-abortum,  ectopic  gestation,  fibroids, 
polypi,  and  occasionally  even  the  diagnosis  of  a  previously  existing  pregnancy 
comes  up.  Even  the  microscope  may  fail  to  settle  the  question.  The  cureted 
material  may  show  large  and  convoluted  uterine  glands  (Opitz),  but  these  are  not 
pathognomonic.  Hyaline  degeneration  of  the  uterine  vessels  gives  more  positive 
information. 

Prognosis. — Few  women  die  from  hemorrhage  during  abortion  because,  if 
the  bleeding  is  marked,  the  patient  faints  and  clotting  stops  the  small  blood-vessels. 
It  is  much  different  at  term.  If  the  hemorrhage  is  long  continued,  the  unavoidable 
small  loss  during  the  abortion  may  prove  fatal.  Death  is  usually  due  to  infection 
introduced  frcjm  without,  for  example,  by  the  criminal  abortionist  or  by  the  phy- 
sician through  a  lack  of  asepsis.  It  must  be  remembered  that  coitus  can  cause 
infection  of  the  uterus,  which  results  in  abortion,  and  may  be  followed  by  fatal 
septicemia.  It  is  usual,  however,  in  cases  of  septic  abortion,  to  suppose  that  an 
abortionist  has  been  at  work.  If  the  uterus  has  been  perforated  and  sepsis  results, 
death  is  the  more  common  termination. 

The  prognosis  as  to  health  is  worse  than  after  labor  at  full  term.  Involution 
is  slower,  lasting  several  months,  and  if  infection  has  occurred,  the  uterus  may  never 
be  normal  again,  but  remains  the  seat  of  chronic  metritis  and  endometritis.  Endo- 
metritis post-abortum  (Fig.  381),  characterized  by  the  prolonged  persistence  of 


ABORTION    AND    PREMATURE    LAIJOR 


425 


V 


groups  of  decidual  cells  and  hypertrophy  oC  the  mucosa,  is  a  frequent  sequel  of 
al)ortion,  as  is  also  pelvic  i)eritonitis  or  cellulitis.  In  after  years  women  who  have 
had  one  or  several  ahorticjus  (-(jme  to  the  gynecologist  comj)laiuing  <jf  backache, 
sterility,  and  leukorrhea,  and  tlie  examination  shows  a  large;,  hard  uterus,  hyper- 
trophied  cervix,  a  retroversion  or  retroflexion,  thickening  of  the  broad  ligaments, 
antl  tenderness  along  the  sacro-uterine  folds.  Such  women  may  be  invalids  for 
life  or  rc(|uire  capital  operations  in  order  to  be  cured. 

Treatment. — Threatened  Ahurlion. — It  is  inadvisable  to  examine  a  W(jman 
threatened  by  abortion  because  of  the  danger  of  aggravating  the  uterine  contrac- 
tions or  causing  hemorrhages  to  separate  more  of  the  decidua  and  ovum;  therefore 
it  is  done  only  when  a  diagnosis  must  be  made,  and  then  with  the  greatest  gentle- 
ness. Rest  in  bed  is  the  best  treatment,  and  morphin  may  be  given  to  procure 
absolute  quiet  of  patient  and  uterus.  Laudanum  in  20-minim  doses  per  rectum 
every  four  hours  will  usually  suffice,  but  it  may  be  necessary  to  give  more,  watching 
carefully  the  action  of  the 
drug.  The  bowels  are  not 
disturbed  for  the  first  three 
days,  then  castor  oil  is 
given,  its  action  being  an- 
ticipated l)y  an  olive-oil 
enema,  the  latter  to  avoid 
the  patient's  straining  to 
evacuate  hard  feces.  If 
the  bleeding  ceases,  the 
patient  may  be  allowed 
more  freedom  in  bed,  and 
after  five  days  may  get 
up,  but  should  resume  her 
duties  very  slowly,  return- 
ing to  bed  on  the  slightest 
show  of  blood;  if  the  bleed- 
ing continues,  a  bimanual 
and  specular  examination  is 
made,  and  if  the  cervix  is 
inflamed  and  eroded,  appli- 
cations of  nitrate  of  silver 
(10  per  cent.)  and  douches 
of  permanganate  of  potash, 
1 :  3000,  are  ordered.     If  the 

bleeding  recommences  every  time  the  patient  becomes  at  all  active,  the  abortion 
is  inevitable,  a  mole  having  probably  been  formed.  One  maj^  not  allow  repeated 
hemorrhages  to  debilitate  the  woman.  The  author,  in  several  cases  of  placenta 
prsevia  near  term,  has  obtained  a  history  of  hemorrhages  in  early  pregnancy. 

Inevitable  Abortion. — ]\luch  difference  exists  in  the  treatment  of  abortion  in 
progress  as  practised  by  different  authors,  and,  indeed,  no  one  plan  will  apply  to 
all  cases.  A  method  that  is  ideal  for  the  first  twelve  weeks  must  be  modified  to- 
ward the  end  of  the  fifth  and  sixth  months,  and  again  cUfferent  conditions  are  pre- 
sented for  treatment,  as  may  be  seen  by  reverting  to  the  pages  on  the  Mechanism 
of  Abortion.  The  ideal  treatment  would  be  ''watchful  expectancy,"  meeting  the 
indications  as  they  arise,  similarly  to  our  conduct  during  labor,  ])ut  expediency  may 
demand  more  active  interference.  The  patient  may  live  far  removed  from  medical 
help,  or  the  physician  cannot  remain  at  the  bedside  during  the  prolonged  course — 
sometimes  days — of  some  abortions;  moreover,  nothing  would  be  gained  by  it, 
since  the  child  is  always  lost. 


Fig.  3S1. — Endometritis  Post-abortum. 


426 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


If  the  hemorrhage  is  continuous,  whether  profuse  or  not,  the  cervix  and  vagina 
are  to  be  tamponed.  Objections  to  the  tampon  on  the  score  of  its  inviting  sepsis, 
being  painful,  and  causing  retention  of  urine  are  of  Httle  weight.  The  author 
treats,  indirectly,  through  the  Chicago  Lying-in  Hospital  Dispensary,  hundreds 
of  abortions  each  year,  and  practises  the  treatment  here  recommended  with  uni- 
form success. 

Technic. — Everything  needed  is  arranged  near  the  bed  or  table,  so  that  the  operator,  who 
usually  has  little  assistance,  may  wait  on  liimself.  The  patient  is  asked  to  empty  the  bladder, 
or  she  is  catheterized  before  the  tampon  is  inserted.  The  genital  region  is  shaved,  as  for  any 
gjTiecologic  operation,  scrubbed  with  soap  and  warm  water,  and  then  thoroughly  washed  with 
1:1000  biclilorid.  Lately,  painting  Ynih.  tincture  of  iodin  is  recommended.  The  accoucheur 
sterilizes  his  hands,  draws  on  sterile  rubber  gloves,  and  washes  the  vagina  and  cervix  gently  but 
thoroughly  -nith  1  per  cent,  lysol  solution.  For  the  tamponade  the  dorsal,  Sims'  lateral,  or  knee- 
chest  position  may  be  used:  the  former  is  the  usual,  the  last  a  very  good  one  if  short  of  help. 
^Tienever  possible  the  author  uses  a  table  for  such  work.  A  perineal  retractor,  long  dressing 
forceps,  scissors,  and  catheter  are  the  only  instruments  needed.     First  the  cervix  is  packed  with 


Fig.  3S2. — Cervix  P.\cked  with  Gauze  and  Vagina  with  Cotton  in  the  Treatment  of  Abortion. 


a  Strip  of  narrow,  plain,  sterilized  gauze,  which  extends  up  into  the  uterus  (Fig.  .382).  Then 
the  vault  of  the  vagina  is  filled  with  pieces  of  dry,  thoroughly  sterile  cotton,  or  the  same,  squeezed 
dry  out  of  a  0..5  per  cent,  lysol  solution.  After  one  layer  of  cotton  is  placed  around  the  cervix 
it  is  firmly  tamped  into  the  fornices  and  the  second  layer  then  put  in,  the  packing  and  tamping 
into  place  being  executed  by  two  fingers.  The  upper  two-thirds  of  the  vagina  are  thus  tightly 
and  evenly  plugged,  but  the  lower  third  needs  only  a  loose  pack,  wliich  is  good  too  because  it 
relieves  the  urethra  from  pressure.  A  gauze  pad  is  laid  against  the  vulva,  a  X-binder  applied,  mak- 
ing moderate  count  erpressure,  and  the  patient  put  to  bed.  A  properly  applied  tampon  will  stop 
hemorrhage  absolutely,  and  every  practitioner  ought  to  be  able;  to  insert  it.  Often  the  author 
has  removed  a  "tampon"  consisting  of  three  to  six  lumps  of  cotton  pulled  off  a  roll  and  placed 
in  the  vagina,  without  any  attempt  at  aseptic  preparation  of  the  parts. 

The  tampon  is  allowed  to  remain  for  from  sixteen  to  twenty-four  hours, 
and  is  not  removed,  even  if  the  temperature  rises.  During  the  interval  pains  almost 
always  supervene,  which  means  that  the  uterus  is  trying  to  expel  its  contents.  No 
medicine  should  be  given  to  allay  this  pain,  nor  does  the  author  use  ergot,  which  is 
recommended  by  some.  Often  the  pains  cease  suddenly,  and  one  surmises  that  the 
uterus  has  emptied  itself  above  tlie  tampon.  A  convenient  hour  is  selected  for  the 
removal  of  the  tampon,  but  preparations  should  have  been  made  for  curetage  under 


ABORTION  AND  PUEMATURE  LAHOU  427 

anesthesia  if  this  should  he  foiiiid  necessary.     Often  tli(^  entire  ovum  is  found  l\in<; 
on  the  tampon,  its  s('|);iiat  ion  luixinji;  Ix'cn  aided  hy  the  clamming  haclc  of  the  blood, 


Fio.  383. — Author's  Utkrine  Curet. 

This  is  half  sharp,  the  shank  is  flexible,  and  a  ring  is  inserted  in  the  handle,  so  that  the  instrument  may  be  held  securely 

and  at  the  same  time  delicately.     All  curets  are  dangerous  and  should  be  used  with  the  same  care  as  a  scalpel. 

and  its  expulsion  having  been  accomplished  ])y  the  uterine  contractions.     All 
that  is  needed  in  such  cases  is  to  go  over  the  uterus  lightly  with  a  half-sharp  curet, 


Fig.  3S4. — Ccret.vge  with  Finger. 


to  make  certain  that  pieces  are  not   retained — especially  in  the  tubal  corners. 
Some  authors  advise  against  this  curetage,  but  the  writer  does  it  in  all  cases,  be- 


428 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


lieving  that  the  patients  make  quicker  and  completer  recoveries  when  the  uterus 
is  left  absolutely  smooth  and  clean.  Without  doubt  much  damage  is  caused  by  the 
curet  in  the  hands  of  an  unskilful  practitioner,  but  this  is  no  reason  for  condemning 
it — rather  should  we  seek  to  qualify  the  jDractitioner  to  use  all  safe  means  for  the 
patient's  benefit. 

If,  when  the  packing  is  removed,  the  cervix  be  found  still  closed,  it  is  best  to 
tampon  again  and  empty  the  uterus  on  the  following  day.  Forcible  dilatation  of  the 
cervix  is  an  unsafe  operation,  and  one  the  author  avoids  whenever  possible. 

For  cleaning  the  uterus  the  finger  excels  all  instruments,  and  should  be  used  to 
dilate  the  cervix,  if  this  is  needed;  but  sometimes  it  may  be  necessary  to  resort  to  steel 
dilators,  either  of  the  glove-stretcher  pattern,  a  Goodell  or  Bossi,  or  the  bougies  of 


Fig.  385. — Squeezing  out  the  Loosened  Contents  of  the  Uterus  by  Bimanual  Compression. 


Hegar.  All  are  dangerous,  and  even  in  the  hands  of  experts  have  time  and  again 
ruptured  the  uterus,  with  fatal  results.  Some  authors  still  recommend  laminaria 
tents,  but  the  writer,  in  all  his  experience,  has  never  used  one.  Packing  the  uterus 
and  cervix  with  gauze  softens  and  dilates  the  parts  sufficiently  to  allow  all  necessary 
operating. 

When  the  cervix  is  open  to  admit  one  finger,  the  uterus  is  to  be  emptied,  pref- 
erably under  ether  anesthesia.  If  the  ovum  protrudes  through  the  os,  it  may  be 
grasped  by  the  fingers  or  a  polypus  forceps  and  withdrawn  from  the  uterus;  then 
the  uterine  cavity  is  revised  by  the  finger,  and  rough  places  smoothed  over  with  the 
curet  (Fig.  383).  If  the  ovum  is  still  in  the  uterus,  it  is  completely  loosened  by  the 
finger  aided  by  the  outside  hand  (Fig.  384).  After  it  is  freed  from  all  its  attach- 
ments, combined  pressure  by  the  two  hands  may  squeeze  it  out  into  the  vagina 


ABORTION   AND    PREMATURE    LABOR 


429 


(Fig.  385).  Should  this  Httlo  inamLuiver  not  succeed,  the  free  portion  of  the  ovum  is 
grasped  by  an  ovum  forceps  (Figs.  386  and  387)  and  gently  withdrawn.  Excessive 
care  is  to  be  observed,  first,  to  make  sure  that  the  ovum  is  really  floating  free  in  the 
cavity  of  the  uterus,  and,  second,  to  be  absolutely  certain  that  the  forceps  do  not 
bite  into  the  uterine  wall.  The  latter  accident  has  happened  repeatedly  and  the 
operator  been  staggered  to  find  omentum  or  intestine  in  the  grasp  of  the  instrument. 
This  accident  may  be  avoided  by  first  separating  the  ovum  l)y  the  finger,  inserting 
the  forceps  under  the  guidance  of  the  finger,  and  then  rotating  the  blades  of  the 


Fig.  3S6. — Two  Sizes  of  Ovum  Forceps. 

forceps  during  the  act  of  closing  them,  a  little  trick  which  the  author  has  attempted 
to  illustrate  in  Fig.  389;  on  the  least  suspicion  that  more  resistance  is  encountered 
than  is  to  be  expected  the  instrument  must  be  released.  After  the  main  portion  of 
the  ovum  is  removed,  the  finger  is  inserted  and  the  endometrium  scraped  clean  and 
smooth.  Since  rubber  gloves  are  used,  we  lose  the  assistance  of  the  finger-nail. 
If  the  cervix  is  large  enough,  the  finger  is  covered  with  gauze,  and  thus  the  thick 
deciflua  may  be  rubbed  off,  but  usually  in  early  abortions  it  is  necessary  to  use  the 
curet.  In  using  the  curet  the  uterus  is  to  be  pulled  down  by  means  of  a  vulsellum 
forceps  (Fig.  392).     This  straightens  the  canal  and  brings  the  organ  within  reach. 


Fig.  3S7. — Ovrxt  Forceps. 


The  curet  is  passed  up  to  the  fundus  uteri  with  the  gentleness  of  the  passing  of  a 
urethral  sound,  being  held  lightly  and  delicately  in  the  fingers,  not  in  the  fist.  Ex- 
erting slight  pressure  on  the  scraping  edge  of  the  curet,  the  instrument  is  drawn  down 
and  out  of  the  cervix  with  a  single  slow,  even,  gentle  sweep.  It  is  cleansed  Ijy  moving 
it  to  and  fro  in  a  solution  of  Ij'sol,  then  reinserted,  and  the  process  repeated,  first 
going  over  the  posterior  wall,  then  the  anterior,  then  the  corners  of  the  uterus,  then 
the  fundus  from  one  tubal  opening  to  the  other.  No  to-and-fro  movements  are 
made  in  the  uterus;  each  stroke  of  the  curet  must  lie  from  above  do■\^^lward  and  out. 
The  broadest  curet  that  will  go  through  the  cervix  is  to  be  used,  but  the  smaller 


430 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


ones  may  be  needed  for  cleaning  out  the  tubal  corners.     By  placing  two  fingers  in 
the  vagina  one  can  control  the  movements  of  the  curet  on  the  anterior  and  posterior 


Fig.  391. 


Fig.  390. 


Figs.  388,  389,  390,  and  391. — A  and  B,  Faulty  Method  of  Using  Ovum   Forceps.     C  and  D,  Correct  Method 

OF  Using  Ovum  Forceps. 

walls  (Fig.  393),  and  by  palpating  the  fundus  through  the  abdomen  one  can  follow 
it  as  the  upper  portions  and  tubal  corners  are  scraped,  thus  avoiding  the  danger  of 


Fig.  392. — Vcl.'sellu.vi  Forceps  with  Teeth  Protected  to  Prevent  Injury  to  Rubber  Gloves  while  Operating. 


perffjration  (Fig.  394).     Now  the  finger  revises  the  uterus,  and  any  piece  of  tissue 
found  adherent  is  loosened  or  removed  by  the  curct. 

Before  the  end  of  the  twelfth  week  the  removal  of  the  ovum  is  easily  accom- 


ABORTION'    AND    PREMATURE    LABOR 


431 


plishod,  and  dilatation  of  tlic  cervix  lo  admit  one  fin}i;('r  is  usually  sufficient.  After 
this  period  the  fetus  is  larger  and  more  dilatation  is  refiuired,  for  whicli  reason  the 
tampon  should  be  used  to  procure  it,  or  a  small  colpeurynter  is  employed.  Again 
the  author  warns  against  rapid  dilatation  with  steel  divulsors.  If,  at  the  time  of 
operation,  the  cervix  is  not  large  enougii  to  deliver  the  fetus  entire,  it  may  be  de- 
livered after  morcelU'nunit.  With  tiie  fingers  in  the  uterus  a  foot  is  drawn  down, 
and  with  scissors  the  body  is  si)lit  along  the  spine,  grasping  successively  higher  por- 
tions of  the  trunk.  Heed  is  paid  to  the  sharp  little  bones,  and  all  attention  con- 
centrated on  preventing  injury  to  the  cervix.  With  a  sharp-pointed  scissors  the 
skull  is  punctured,  and  the  iiead  squeezed  fiat  with  the  ovum  forceps  and  deliveretl. 
If,  inadvertently,  the  trunk  is  i)ulle(l  of^"  the  head,  the  operator  may  have  not  a  Httle 
trouble  in  engaging  the  round,  floating  l)ody  in  the  grasp  of  the  ovum  forceps. 


\  ^/ 


Fia.  393. — Fingers  Follow  Evert  Movement  of  Curet. 


Fig.  387  shows  a  good  instrument  to  use  in  this  emergency — an  old-fashioned  stone 
forceps;  the  blades  are  opened  in  the  uterus,  and  the  head  pressed  into  them  by  the 
abdominal  hand.  A  better  way,  in  .difficult  cases,  when  the  cervix  is  very  long, 
thick,  and  hard,  is  to  make  a  transverse  incision  in  the  vagina  at  its  junction  with 
the  cervix,  push  the  bladder  from  the  anterior  wall,  and  incise  the  uterus,  as  in 
vaginal  cesarean  section.  Any  one  who  has  attempted  to  remove  a  five  months' 
fetus  through  a  long,  hard,  closed  cervix  will  appreciate  its  diflftculties. 

Accidents. — Hemorrhage  in  usually  mild;  only  rarely  is  it  necessary  to  pack,  and  the  author 
recommends  narrow  gauze  impregnated  with  a  mild  antiseptic  (for  example,  weak  iodin),  placed 
with  a  curved  dressing  forceps  or  the  tubular  ]:)acker  shown  on  p.  90S.  If,  when  called  to  an  abor- 
tion, the  woman  is  in  shock  from  loss  of  blood,  the  uterus  and  vagina  are  to  be  quickly  packed,  salt 
solution  administered,  and  the  emptying  of  the  uterus  left  until  the  next  day,  by  which  time  re- 
covery from  the  effects  of  the  hemorrhage  has  occurred. 

Perforation  of  the  uterus  is  a  not  infrequent  occurrence  and  not  seldom  fatal.  It  is  due  to 
ignorance  of  tlie  dangers  of  curetage  and  rough  handling  by  the  operator,  but  may  also  occur 
to  the  most  skilful,  because  the  uterine  wall  is  sometimes  pathologically  soft  and  friable.     This  is 


432 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


Fig.  394. — Showixg  how  a 
Uterus  is  Easily  Per- 
forated  WHEN  Retro- 


especially  true  in  septic  cases.     The  placental  site  feels  rough,  and  the  fissures  in  it  allow  the 
finger  or  curet  to  enter  the  mucosa  (Fig.  395),  giving  the  impression  that  there  is  a  piece  of 

placenta  still  adherent.  Thus  the  operator  is  mis- 
guided, and  soon  perforates  into  the  peritoneal 
cavity.  If  the  uterus  is  soft,  the  curet  may  be 
punched  through  its  wall,  especially  if  the  oper- 
ator uses  force  on  the  upstroke.  Branched  or 
bougie  dilators  may  rupture  the  cervix  and  lower 
uterine  segment,  and  the  polypus  or  ovum  forceps 
may  grasp  and  tear  off  the  inverted  uterine  wall,  as 
in  Fig.  390.  All  these  accidents  may  be  avoided  by 
using  the  fingers,  where  possible,  and  by  observance 
of  the  rules  for  their  prevention.  If  a  perforation 
occurs,  the  case  immediately  assumes  a  serious 
aspect  and  requires  most  careful  consideration. 
Should  there  be  the  least  suspicion  of  injury  to 
the  bowel  or  the  omentum,  the  belly  is  to  be  opened 
immediately,  the  damage,  if  any,  repaired,  the 
uterus  opened,  cleansed,  and  sutured,  after  which 
it  is  drained  through  the  vagina.  In  the  assurance 
that  the  viscera  have  not  been  hurt,  vaginal  anter- 
ior hysterotomy  is  to  be  performed,  the  uterine 
cavity  emptied,  the  rent  lightly  packed  with 
gauze,  leading  this  into  the  vagina,  and  then  the 
uterus  closed  as  after  vaginal  cesarean  section. 
This  method  is  safer  than  to  attempt  to  curet  the 
uterus  and  to  try  to  avoid  the  site  of  injury.  There 
is  always  the  danger  of  enlarging  the  perforation 
and  of  injuring  the  bowel  in  thus  operating  blindly. 
A  single  perforation  of  the  uterus  may  be  treated 
by  packing,  though  the  accoucheur  always  takes  a 
little  risk  here  if  the  finger  cannot  confirm  the  diag- 
nosis of  the  extent  of  the  damage. 

In  clean  cases  the  above  treatment  will  almost 
alwa3^s  save  the  patient,  but  if  the  abortion  was  septic,  especially  if  the  infection  was  streptococcic, 
a  uterine  perforation  is  usually  fatal.  For  this  reason  immediate  extirpation  of  the  uterus  is  the 
best  treatment  for  such  an  accident — -vaginally,  if  there  is  positively  no  injury  to  the  bowel; 
otherwise  abdominally,  with  the 
needed  repair  of  the  viscera.  Should 
the  radical  operation  be  impossible, 
the  contents  of  the  uterus  must  be 
removed,  after  vaginal  hysterotomy, 
if  necessary;  then  the  uterus  and  the 
pelvis  are  to  be  broadly  drained. 
After-treatment  consists  of  sitting 
the  patient  up  in  bed  to  insure  drain- 
age and  the  free  administration  of 
saline  solution  per  rectum.  The 
uterine  gauze  is  removed  in  thirty- 
six  hours;  that  in  the  culdesac  of 
Douglas  in  sixty  hours,  being  re- 
placed or  not,  depending  on  the 
patient's  condition.  It  is  wise  to 
discover,  before  treating  an  abortion 
case,  whether  any  one  has  passed  in- 
struments into  the  uterus,  because 
a  perforation  may  have  thus  been 
made,  which  later  is  laid  at  the  door 
of  the  honest  practitioner. 

Acule  Dilatation  of  the  Uterus. 
— Occasionally,  while  cureting  a 
uterus,  the  curet  slips  far  beyond  a 
normal  depth  and  the  operator  fears 
he  has  perforated  the  organ.  E.\- 
amination  shows  no  puncture,  and 
the  conclusion  must  be  drawn  that 
the  uterus  dilated  suddenly,  or  that 
the  instrument  passed  into  the  tube. 
The  author  has  observed  two  cases 

where  the  uterus  seemed  to  dilate  enormously  during  early  pregnancy,  a  phenomenon  also  ob- 
served by  Biittncr,  of  Geneva. 

Incomplfde  Operation. — Rarely  the  accoucheur  may  be  unable  to  empty  the  uterus  com- 
pletely, which  occurs  more  commonly  after  the  fourth  month.  The  cervix  offers  unexpected  re- 
sistance, or  the  morcellation  of  the  fetus  is  impossible  and  preparations  have  not  been  made  for 


Fig.  30,'). — Placental  Site  in  Abortion. 
The  sliglitly  rai.scd  cleft  surface  gives  the  impression  that  pieces  of  pla- 
centa are  still  adherent. 


ABORTION   AND    PREMATURE    LABOR  433 

a  cutting  optTation.  Whotlicr  the  case  is  clean  or  not,  the  mode  of  proceduro  here  is  to  pack  tiic 
uterus  firmly  with  wealc  iodin  gauze.  Usually  pains  start  up,  and  alter  twenty-four  hours, 
on  removing  th(!  i)acking,  the  remnants  of  the  ovum  come  with  it.  During  the  operation  of  nior- 
cellation  the  pieces  of  fetus,  placenta,  etc.,  delivered  should  be  spread  on  a  towel  and  fitted  to- 
gether, thus  removing  all  doubt  as  to  how  much  remains  in  the  uterus. 

Extra-uterine  j)regnancy  must  be  thought  of  before  every  curetage,  and  a  careful  bimanual 
examination  made  to  eliminate  it.  Such  an  operation  on  the  uterus  would  almost  surely 
cause  rupture  of  tlu;  sac.  Imleed,  it  is  necessary  to  make  a  careful  bimanual  examination  as  a 
routine  practices  before  operating,  to  discover  the  existence  of  adnexa  tumors,  for  example,  preg- 
nancy, pus-tubes,  appendicitis,  and  to  determine  the  position  and  mobility  of  the  uterus. 

Incomplete  Abortion. — After  the  diagnosis  of  material  remaining  in  the  uterus 
lias  been  matle,  the  best  treatment  is  its  removal,  without  trusting  entirely  to  nature's 
efforts.  Two  courses  are  advised:  one,  immediate  curetage,  dilating  the  uterus 
if  necessary;  the  other,  packing  the  uterine  cavity,  tampon  of  the  vagina,  and  wait- 
ing for  the  contractions  of  the  uterus  to  expel  its  contents.  The  author  recommends 
the  latter  course  for  general  practice.  If  the  patient  is  in  a  good  maternit\^  hospital, 
and  on  the  first  examination  the  cervix  is  found  soft  and  open  for  the  finger,  the 
uterus  may  be  cleared  of  its  contents  at  once  and  the  case  thus  definitively  ended. 
After  the  tamponade  of  the  uterovaginal  tract  the  treatment  is  the  same  asthat  given 
under  /Vbortion  in  Progress. 

Septic  Abortion. — When  the  cavity  of  an  aborting  uterus  becomes  infected,  we 
speak  of  septic  abortion.  Most  of  such  cases  are  the  result  of  criminal  interference 
by  midwives  or  other  abortionists,  but  sometimes  the  woman  herself  passes  instru- 
ments into  the  cervix  or  injects  fluids  of  some  kind — usually  irritating  antiseptics. 
Thomas  tells  of  a  physician's  wife  who  had  pushed  an  umbrella  rib  up  through  her 
diaphragm.  The  author  had  a  case  where  the  belly  was  found  full  of  milk,  which 
the  unfortunate  woman  had  injected  into  the  uterus.  The  diagnosis  in  such  in- 
stances is  very  difficult,  because  the  patient  generally'  denies  the  facts.  A  thorough 
])hysical  examination  of  the  whole  body  will  not  fail  to  locate  the  trouble  in  the 
genitalia,  and  then  the  demonstration  of  gestation  will  clinch  the  diagnosis.  The 
signs  and  s^'mptoms  of  infection  will  be  considered  under  Puerperal  Fever. 

Schottmiiller,  in  100  cases  of  septic  abortion,  found  the  following  bacteria: 

Streptococcus  putridus 29  times 

Staphylococcus 26      " 

Bacterium  coli 19      "' 

Streptococcus  vaginalis 8      " 

Streptococcus  erj'sipelatis 6      " 

Bacterium  phlegmonis  emphysematosije  (Frankel) 5      " 

Bacterium  coli  hemolj'ticum once 

Gonococcus 

Streptococcus  viridans " 

Bacillus  paratj'phus  B " 

The  Streptococcus  putridus  could  be  frequently  demonstrated  in  the  blood,  even  in  those 
cases  where  the  process  was  believed,  from  clinical  manifestations,  to  be  purely  local,  i.  e.,  a 
sapremia,  and  it  also  caused  violent  salpingitis  and  fatal  peritonitis. 

Formerly  the  accepted  treatment  for  septic  abortion  was  the  immediate  empty- 
ing of  the  uterus,  dilating  the  cervix,  if  necessary,  but  I  am  now  pursuing  a  more 
expectant  course,  trusting  much  to  nature,  it  having  been  sho^^^l  that  the  inevit- 
able traumatism  is  often  fatal,  a  superficial  and  not  dangerous  infection  being 
converted  into  one  with  strongly  invasive  characters.  A  chill  and  high  fever  often 
follow  curetage  in  septic  abortion,  being  the  expression  of  the  flooding  of  the  sys- 
tem with,  bacteria  and  toxins.  In  cases  of  putrid  infection  the  temperature  soon 
becomes  normal,  but  if  the  pus  cocci  are  present,  especially  an  invasive  strepto- 
coccus, the  woman  becomes  very  sick  and  recovers,  if  at  all,  much  more  slowly.  If 
we  knew  that  this  w^as  the  kind  of  infection  we  had  to  deal  with,  extirpation  of  the 
uterus  would  be  better  treatment  than  curetage,  but,  unfortunately,  science  does 
not  yet  permit  us  to  prove  this  in  time  for  action.  (See  Puerperal  Infection.) 
Parametritis,  perimetritis,  even  general  sepsis  oftener  follow  such  drastic  inter- 
ference than  the  slower  methods.  The  author  is  not  alone  in  this  matter.  Ries  and 
28 


434      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

Watkins,  of  Chicago,  and  Winter,  of  Konigsberg,  recently  published  the  same  views. 
^'eterinarians  have  long  been  aware  of  the  dangers  of  forcibly  cleaning  out  the 
septic  uterus. 

When  the  diagnosis  of  septic  abortion  is  made,  a  careful  history  as  to  its  cause 
is  obtained.  The  physician  must  explain  to  the  patient  the  danger  of  making  false 
statements  or  of  hiding  the  truth.  If  there  is  reason  to  believe  that  she  or  an  abor- 
tionist has  passed  an  instrument  through  the  uterus,  and  if  there  are  symptoms  of 
peritonitis,  the  l^elly  had  better  be  opened  at  once.  Next  to  be  decided  is  whether 
there  is  anj-thing  in  the  uterus.  The  history,  uterine  contractions,  continued  bleed- 
ing, and  the  findings  on  vaginal  examination,  the  large  uterus,  open  cervix,  and 
protruding  masses  will  settle  this  point.     In  cases  of  doubt  leave  the  uterus  alone. 

Where  the  uterus  is  full  of  decomposing  ovular  and  blood  masses,  bleeding 
usually  commands  their  removal,  and  this  must  be  done  in  the  gentlest  possible 
manner.  The  uterus  and  vagina  are  evenly  filled  with  sterile  gauze  by  means  of 
the  tubular  packer,  without  anesthesia.  At  the  end  of  twenty-four  hours  the  gauze 
is  removed,  and  often  the  contents  of  the  uterus  come  with  it.  If  not,  the  uterus 
may  be  tamponed  again.  Pituitrin  and  ergot  may  be  administered.  Only  after 
the  septic  symptoms  have  subsided  may  the  placental  masses  be  removed  by  the 
finger  or  ovum  forceps.  Before  and  after  uterine  interference  in  septic  cases  the 
author  uses  a  douche  of  1  per  cent,  lysol  solution,  and  when  the  uterus  is  emptied, 
a  light  drain  of  gauze  is  left  in  for  from  ten  to  twelve  hours.  This  absorbs  the 
blood,  and,  when  removed,  brings  away  shreds  of  membrane,  leaving  the  uterus 
perfectly  dry.  In  septic  cases  the  finger  should  supplant  the  curet.  After  the 
primary  cleansing  of  the  uterine  cavity  no  local  interference  with  the  reparative 
processes  of  nature  is  allowed  unless  an  abscess  forms  or  other  surgical  indica- 
tions arise. 

In  the  absence  of  hemorrhage  the  expulsion  of  the  retained  fragments  is  to  be 
left  to  nature,  unless  very  special  reasons  exist  for  entering  the  uterus. 

Nummary  of  the  Treatment  of  Abortion. — 1.  Threatened  abortion — Rest  in  bed 
and  opiates. 

2.  Abortion  in  progress— (a)  If  the  hemorrhage  is  marked,  pack  the  cervix  with 
gauze  and  the  vagina  with  cotton;  (&)  next  day  remove  the  tampon;  if  the  ovum  is 
delivered,  empty  the  uterus  with  finger  and  curet;  (c)  if  the  ovum  is  not  delivered 
and  the  cervix  fully  dilated,  remove  the  ovum  by  traction,  expression,  or  by  the  fingers, 
then  revise  the  uterus  with  finger;    {d)  if  the  cervix  is  still  closed,  tampon  again. 

.3.  Incomplete  abortion:  (a)  If  the  cervix  is  open,  empty  the  uterus  at  once; 
(6)  if  closed,  pack  the  uterine  cavity  with  gauze  and  the  vagina  with  cotton;  (c) 
next  day  remove  the  same  and  treat  as  No.  2. 

4.  Septic  abortion:  Treat  as  abortion  in  progress  with  hemorrhage,  procure 
complete  dilatation  by  packing,  and  drain  the  uterus  with  gauze;   avoid  the  curet. 

Habitual  Abortion. — Even  if  the  cause  can  be  found,  it  is  not  always  possible 
to  prevent  the  freciuent  recurrence  of  abortion.  Endometritis,  retroflexion,  lacera- 
tion of  the  cervix,  and,  in  the  later  months  of  this  period,  syphilis,  are  the  most 
common  causes,  and,  if  successfully  cured  before  pregnancy,  may  allow  the  same  to 
be  completed.  Treatment  of  the  husband  in  some  instances  is  successful.  During 
gestation  only  syphilis  and  the  displacements  may  be  treated.  Rest  in  bed  during 
the  time  when  the  abortions  usually  occur,  and  at  the  times  of  the  customary  men- 
strual periods,  care  in  exercise,  abstention  from  coitus,  and  alterative  tonics — 
iron,  arsenic,  and  mercury — are  recommended.  On  theoretic  grounds,  corpus 
luteum  extract  might  l)e  useful. 

Changes  in  the  Ovum  After  the  Death  of  the  Fetus. — If  the  fetus  dies  in  the  early  weeks, 
the  chorion  anrl  the  decidua,  which  arc  nourished  hy  maternal  i)lood,  may  go  on  growing,  but 
hemorrhages — apoplexies — are  very  eonunon  in  the  deeidua,  and  one  causes  another  until  the 
whole  periphery  of  the  ovum  is  invaded.  The  cavity  of  the  amnion  is  crowded  together,  or  the 
blood  may,  in  rare  cases,  break  into  the  ovum  itself.  This  is  called  a  "blood  mole"  (Fig.  396). 
Or  the  membranes  may  undergo  an  eccentric  hypertrophy  and  the  amniotic  cavity  grows  larger, 


ABORTION    AND    PREMATURE    LABOR 


435 


Villi 


fills  with  fluid,  ;in<l  may  be  the  size  of  that  oi  an  ovum  of  two  months.  AdhorinR  to  one  sido  in 
found  a  fetus  of  three  weeks.  When  tlu;  mole  is  older  and,  to  a  certain  extent,  decolorized,  it  i.s 
called  a  "fleshy  mole."  'riiese  moles  usually  cau.se  repeat('d  greater  or  smaller  hemorrhages  until 
finally  tlu;  uterus  e.vpels  them  or  the  attciKlant  interiV-res. 

Hreus  described  a  mole  in  which  the.  amniotic  cavity  w:is  invaded  by  smaller  or  larper  sub- 
chorial hemorrhages,  callinfi;  it  a  tuberous  subcliorial  hematoma.  Tau.ssifj;  gave  it  the  name  of 
hematoma  mole  ( l'"ig.  -i'M).  in  some  une.\|)lained  ca.ses  the  jjlacenta  may  continue  to  grow  after 
fetal  death,  and  an  enlargement  of  the  anuiiotic  (lavity  has  also  been  fouml  by  the  author. 

Later  in  pregnancy,  after  tlu^  fetus  has  attained  .some  l)ulk,  changes  similar  to  those  of  a  dead 
ectopic  fetus  are  obsei-ved,  and  it  may  be  days,  months,  or  years  before  the  ovum  is  cxfjclled. 
These  are  ca.ses  of  "mi.ssed  al)ortion,"  a  term  first  used  by  Oldham.  (1)  Maceration  is  most  (com- 
mon, the  fetus  imbibing  the  (UssoIvcmI  biood-fjigments — f(etus  sanguinolentis.  Its  ti.ssues  are  .soft, 
the  joints  loose,  esi)eci;illy  the  cranial,  the  brain  is  li((uefied,  the  skin  flabby,  the  epidermis  mi.ssing 
in  large  patches,  exposing  the  deep-red  corium,  and  the  cord  thick  and  blood-stained;  the  placenta, 
which  may  go  on  growing  even  after  fetal  death  and  may  attain  remarkable  size,  is  large,  pale, 
and  .s()ft.  It  is  impossible  to  decide  from  these  changes  how  long  tlu;  fetus  has  been  dead,  becau.se 
sometimes,  even  after  many  days,  little  alteration  of  the  tissues  is  found,  and  again  the  disintegra- 
tion occurs  rapidly — due  to  the  presence  of  enzymes  in  tlu;  liquor  amnii.  (2)  Mummification 
occurs  more  rarely.  The  fetus  dries  up,  becomes  leathery,  and  may  give  considerable  trouble  in 
removal  by  morcellation.  Theli(iuor 
anuiii  is  absorbed,  or  represented  Ijy 
a  tliick  yellow  or  greenish  j)aste,  the 
placenta  being  a  tough  white  in- 
farcted  ma.ss.  This  condit ion  occurs 
oftenest  with  twins  when  one  of  the 
fetuses  dies  in  the  early  months  and 
is  pressed  against  the  uterine  wall  Ijy 
the  growing  twin — fa'tus  compressu.- 
or  pap3'raceus  (Fig.  422  on  p.  -IGo 
shows  the  condition).  (3)  Litho- 
pedion  formation.  This  is  excep- 
tional in  the  uterus  itself,  (i)  Sep- 
tic infection  of  the  uterine  contents  is 
common  in  ordinary  but  not  in  cases 
of  "missed  abortion,"  unless  instru- 
mental interference  has  been  prac- 
tised or  coitus  has  been  continued. 
Even  after  months  septic  infection 
may  occur. 

Missed  abortion  seldom  gives 
marked  symptoms.  The  sympa- 
thetic symptoms  of  pregnancy,  nau- 
sea,etc., usually  cease  with  the  death 
of  the  fetus;  the  breast  and  pelvic 
organs  retrogress;  the  uterus  stops 
growing  and  assumes  a  peculiar  non- 
resilient  consistence,  with  frequent 
contractions  (minus  pain),  and  a 
brownish,  sometimes  fetid,  discharge 
appears.  General  symptoms  of 
malaise,  lo.ss  of  flesh,  anorexia,  chilli- 
ness, and  afternoon  temperature  are 

due  to  beginning  decomposition  of  the  ovum  and  demand  interference.  The  diagnosis  of  missed 
abortion  is  made  on  two  bimanual  examinations  with  an  interval  of  a  month  between  them.  The 
uterus  grows  smaller,  not  larger,  harder,  not  softer.  It  is  best  to  wait  two  months  before  deciding 
that  the  ovum  is  dead,  because  sometimes,  normally,  the  uterus  does  not  grow  regularly,  and  again 
a  hydatid  mole  may  cause  an  excessive  enlargement  of  the  uterine  tumor.  From  the  history  one 
learns  that  the  periods  have  been  absent  for  se\-eral  months,  that  a  slight  bleeding,  with  or  with- 
out pains,  had  occurrctl,  since  which  time  the  symptoms  of  pregnancy  had  retrogressed. 

These  points  are  very  useful  in  the  differential  diagnosis  which  has  to  be  made  from  fibroid. 
After  one  is  assured  that  the  ovum  is  dead,  the  uterus  had  best  be  emptied.  The  indolence  of  the 
uterus  in  such  cases  is  sometimes  remarkable,  the  author  having  not  succeeded  in  daj's  of  effort  in 
getting  regular  pains  started,  and  having  finally  to  incise  the  cervix  to  be  able  to  clean  out  the  uterine 
cavity.     Hemorrhage  after  the  curetage  is  the  rule,  and  a  firm  uterine  tampon  is  usually  required. 

Dissolution  of  a  very  early  fetus  and  resorption,  with  regeneration  of  the  dccidua  without  ex- 
foliation of  the  same,  has  been  reported,  but  such  an  occurrence  is  extremely  rare,  and  in  all  proba- 
bility often  is  an  error  of  diagnosis,  the  fetal  and  decidual  structures  having  escaped  unobserved. 

Medicolegal  Aspects  of  Abortion. — When  the  accoucheur  has  to  deal  with  a  criminal 
abortion,  he  should  always  have  counsel,  or  put  the  patient  in  a  hospital,  avoiding  all  appearance 
of  secrecy.  This  would  excite  the  suspicion  of  connivance  at  the  deed.  "\Miile  it  is  impossible  to 
do  so,  it  would  be  best  for  every  one  concerned  if  every  case  of  criminal  abortion  were  reported 
to  the  police  authorities.  Certainly  if  the  patient  dies  the  coroner  must  be  notified,  any  other 
com-se,  as  signing  a  certificate  giving  a  fictitious  cause  of  death,  being  not  alone  reprehensible, 
but  very  hazardous.  An  antemortem  statement  as  to  whom  to  blame  for  the  woman's  condition 
is  very  desirable,  even  though  the  physician  may  not  use  it.     The  physician  should  obtain  an 


ecolorized 
portion 

Aiiiniotic 
cavity 


Fig.  396.— Blood  Mole. 


436 


THE    PATHOLOGY   OF   PREGNANCY,    LABOR,    AND    THE    PUERPEKIUM 


accurate  history,  keep  full  records  of  his  findings  and  the  course  of  the  disease,  and  in  holding  an 
autopsy  on  such  a  case  the  minutest  details  of  the  conditions  found  in  the  pelvis  must  be  observed 
and  noted  carefully  in  duplicate,  especial  search  being  made  for  evidence  of  injury. 

The  accoucheur  is  often  called  to  testify  as  expert  in  accident  cases,  the  woman  suing  for 
damages  on  the  ground  that  an  injury  interrupted  her  pregnancy.  The  abortion  must  follow  very 
shortly  on  the  alleged  injury,  or  the  death  of  the  ovum  must  be  shown  to  have  very  soon  followed 
it,  and  the  ovum  must  be  otherwise  normal,  and  the  woman  present  none  of  the  recognized  causes 
of  abortion,  for  the  niedical  witness  to  be  able  to  assert  for  or  against  the  plaintiff.  Indeed,  in 
these  actions  the  witness  can  usually  only  say  that  it  is  or  is  not  probable  that  the  abortion  was 
caused  bj''  the  accused  injury. 

The  diagnosis  of  a  previous  abortion  may  need  to  be  made,  a  subject  which  was  discussed 
under  the  Diagnosis  of  the  Puerperium. 


Fig.  397. — Hematoma  Mole  (Specimen  op  Chicago  L^ing-in  Hospital). 

Premature  labor  is  a  labor  in  miniature,  and  hardly  requires  separate  discus- 
sion. Abnormal  presentations  are  more  frequent  than  at  term,  the  breech  present- 
ing thrice  as  often.  Shoulder  presentation  is  also  common,  but  usually  nature 
terminates  the  case  by  either  spontaneous  rectification  or  evolution.  (See  Chapter 
L.)  Special  regard  must  be  paid  to  the  child,  because,  owing  to  its  delicacy,  it 
may  be  injured  during  birth.  Cephalic  presentation  is  the  best  for  premature 
babies,  a  fact  always  to  be  borne  in  mind  in  operative  deliveries  before  term;  in- 
deed, the  indication  for  operation  must  be  strict  in  such  cases.  Arrangements  are 
to  be  made  beforehand  to  receive  the  weak  infant  into  a  warm  atmosphere — an 
incubator,  if  possible.     Shock  is  a  vital  factor  with  them. 

Anomalies  in  the  separation  and  expulsion  of  the  placenta  are  pefhaps  a  little 
more  common  than  at  term,  and  the  accoucheur  must  see  that  the  uterus  is  thor- 
oughly emptied  and  in  firm  contraction.  Involution  is  slower  than  at  term.  Ergot 
is  to  be  given  for  ten  days  postpartum. 


Literature 

Devraigne:  "Isthmial  Pregnancy,"  L'Obstetrique,  November,  1011,  p.  961.  Literature. — Oldham:  Rob.  Barnes, 
Lend.  Obst.  Trans.,  vol.  xxiii. — .Schottmuller:  Centralbl.  f.  Gyniik.,  1911,  p.  83. — Slumpf  and  Franz:  Munch. 
med.  Wooh..  1892,  Noa.  43  and  44. — Taussig:  Abortion,  St.  Louis,  1910. — Wallace:  Farm  and  Live  Stock 
of  Great  Britain,  p.  33i.—Wathins:  Surg.,  Gyn.  and  Obst.,  January,  1012.— Winter:  Centralbl.  f.  Gyn.,  1911. 


CHAPTER  XXXIII 
ABRUPTIO  PLACENTA 

Up  to  1664  all  homorrliaj2;os  occurring  during  pregnancy  were  considered  as 
due  to  premature  detachment  of  the  placenta  from  its  supposed  invariable  site,  the 
fundus  uteri.  At  this  time  Paul  Portal  proved  that  the  placenta  could  be  attached 
to  the  cervix  at  the  internal  os.  Rigby,  in  1775,  differentiated  l)etween  cases  of 
detachment  of  the  placenta  situate^;!  above  the  zone  of  the  cUlatation  of  the  uterus 
and  those  below  that  zone.  He  said  that  in  the  latter  class  of  patients,  owing  to  the 
fact  that  the  placenta  must  necessarily  separate  to  allow  the  passage  of  the  child, 
hemorrhage  was  "unavoidable,"  while  in  the  former  the  hemorrhage  is  onty  "acci- 
dental" to  the  separation  of  the  placenta.  "Accidental  hemorrhage,"  a  term  still 
in  use,  especiall}^  by  British  authors,  means  the  premature  separation  of  the  nor- 
mally implanted  placenta.  "Unavoidable  hemorrhage"  is  a  term  seldom  used, 
but  it  means  placenta  prsevia,  the  development  of  the  placenta  in  the  zone  of  dilata- 
tion. The  author  suggests  the  term  "ahruptio  placentce^'  to  take  the  place  of  the 
cumbersome,  generally  used  term,  and  to  go  with  the  short  and  expressive  "pla- 
centa prjBvia."  Al^ruption  of  the  placenta  means  a  forcible  tearing  up  of  the  organ 
from  its  normal  site,  and  in  reality  is  an  abortion  at  or  near  term.  Clinically,  it  is 
usually  easy  to  differentiate  between  placenta  prsevia  and  abruptio  placentae,  but 
the  author  is  convinced  that  many  of  the  milder  cases  of  accidental  hemorrhage  p.re 
due  to  the  detachment  of  the  placenta  situated  low  in  the  uterus,  but  just  above 
the  upper  boundary  of  the  zone  of  dilatation.  The  case  partakes  then  of  the  char- 
acteristics of  both  conditions. 

Al)ruptio  placentse,  if  one  includes  the  milder  cases,  occurs  oftener  than  is 
generally  believed.  Complete  separation  of  the  highly'  situated  placenta  is  rare, 
and  probably  occurs  much  less  often  than  once  in  500  cases.  In  over  15,000  con- 
finements at  the  Chicago  Lying-in  Hospital  there  were  only  12  cases  of  complete 
placental  detachment  with  threatening  internal  hemorrhage,  but  there  were,  in 
ad(Ution,  31  cases  of  partial  detachment,  the  placenta  showing  a  firm  antepartum 
clot,  and  the  clinical  course  of  labor  having  been  distinctly  pathologic.  Accidental 
hemorrhage  occurs  oftenest  at  the  onset  of  or  during  labor  at  term,  but  it  may  occur 
during  the  last  twelve  weeks  of  pregnancy. 

Causation. — Two  general  causes  are  distinguishable:  («)  Diseases  of  the  pla- 
centa and  of  the  decidua,  and  (6)  traumatism.  In  all  probability  the  traumas  usu- 
ally accused  act  on  a  diseased  organ,  and  only  thus  are  effective,  because  the  healthy 
uterus  often  tolerates  all  kinds  of  insults — kicks,  blows,  etc. — without  am'  reaction. 

Of  the  diseases,  chronic  endometritis  plays  the  most  important  role,  and  it 
may  l)e  gonorrheal.  Winter  pointed  out  the  frequency  of  nephritis  in  abruptio 
placentse;  Fehling  had  already  sho'SA'n  the  coincidence  of  placental  infarcts  and 
hemorrhages  in  chronic  nephritis  (the  placenta  albuminurique  of  the  French).  In 
58  cases  collected  by  Hofmeier  nephritis  was  shown  in  33.  Gottschalk  suggests 
that  the  endometrial  changes  and  the  nephritis,  or  the  kichiey  of  pregnancy,  may 
be  interrelated,  i.  e.,  a  toxicosis.  Degeneration  of  the  decidua,  myometritis, 'syphilis 
of  the  placenta,  acute  infectious  diseases  ■^^^th  decidual  hemorrhages,  have  also  been 
found.  Basedow's  disease  and  arterial  sclerosis  liave  been  given  as  causes,  and 
even  a  severe  mental  shock,  through  disturbance  of  the  local  circulation. 

In  the  presence  of  one  of  the  above  conditions  even  a  slight  trauma  may  cause  a 

437 


438 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


separation  of  the  placenta,  and  a  hemorrhage  having  been  once  started,  the  blood 
works  its  way  between  the  soft  layers  of  decidua  and  completes  the  abruption.  A 
jar,  turning  suddenly  in  bed,  coitus,  a  blow  or  kick  on  the  abdomen,  the  action  of  a 
purge,  severe  coughing,  have  all  been  assigned.  In  Holmes'  collection  of  200  cases 
from  the  literature  accident  was  given  in  67. 

During  labor  several  accidents  may  cause  detachment  of  the  placenta,  as 
sudden  emptying  of  a  large  polyhydramnion,  the  loosening  of  the  placenta  which 
sometimes  follows  the  delivery  of  the  first  twin,  the  retraction  of  the  uterus  above 
the  child,  stopped  in  its  progress  by  an  obstruction  in  the  pelvis,  the  operation  of 
version,  when  the  uterine  wall  is  stretched  and  distorted  by  the  rotation  of  the  child, 
during  delivery  of  the  trunk  in  breech 
presentation,  and,  finally,  traction  ex- 
erted on  the  placenta  by  a  cord  actually 
or  relativeh'  too  short. 


Fig.  398. — Abruptio  Placentae.     Internal  ou  ' 
cealed"  Hemorrhage. 


'Con- 


Fig.  399. 


-Abruptio  Placentae;  Combined  Internal  and 
External  Hemorrhage. 


Pathology. — Separation  of  the  placenta  is  always  accompanied  by  marked 
hemorrhage  unless  the  fetus  has  been  dead  long  enough  to  allow  tlirombosis  to 
occur  in  the  uterine  sinuses.  Since  the  full  uterus  cannot  retract  over  its  contents, 
the  sinuses  remain  open  and  the  cavity  of  the  uterus  is  exposed  to  the  full  force  of 
the  arterial  circulation.  The  blood  may  pursue  four  directions:  First  (Fig.  398), 
and  most  rarely,  it  may  bulge  out  the  uterine  wall  toward  the  abdominal  cavity  and 
bulge  into  the  cavity  of  the  ovum,  the  edges  of  the  placenta  remaining  attached  to 
the  uterus;   second,  it  may  dissect  up  the  membranes  all  the  way  round,  severing 


ABRTI'TIO    PLACENTA 


439 


almost  all  the  connections  of  the  ovuui;  third,  it  nm}-  break  into  the  liquor  amnii, 
and  finally  it  may  sock  a  direct  passage  outward  from  tlie  edge  of  the  placenta  under 
the  membranes  through  the  cervix  into  the  vagina  (Fig.  399) .  The  first  three  varie- 
ties are  called  "concealed  hemorrhage,"  and  usually  arc  the  most  serious,  but  in  all 
cases  the  exit  of  the  blood  nniy  be  blocked  by  the  head  or  membranes  or  a  firm  clot 
plugging  the  cervix.  The  uterus  may  be  immensely  distended  by  the  Ijlood,  the 
author  in  one  case  removing  almost  three  pints  of  clots  postpartum.  Madame 
Boivin  believed  that  the  uterus  at  term  could  not  dilate  sufficiently  to  allow  any 
consideral)le  hemorrhage,  but  experience  has  proved  that  a  fatal  intra-uterine 
liemorrhage  may  oc(;ur  without  a  drop  of  blood  showing  externally.     A  few  reports 


Fig.  400. — Abruptio  Placenta. 
Hemorrhage. 


External 


Fig.  401. — Prolapsus  Placext.e. 


are  on  record  where  the  placenta,  fallen  from  its  site,  has  come  to  lie  over  the  internal 
OS — prolapsus  placentae  (Fig.  401).  Most  of  these  cases  were  probably  placenta 
prsevia,  but  a  real  prolapse  of  the  placenta  occurs,  and  it  makes  a  great  deal  of  differ- 
ence in  the  treatment.  In  306  cases  collected  by  Holmes  and  Gooclell  193  showed 
external  hemorrhage.  In  all  the  author's  cases  external  hemorrhage  followed  the 
internal,  so  that  the  rule  is  that  the  bleeding  in  abruptio  placentae  is  first  internal 
or  concealed,  then  combined,  external  and  internal.  The  mildest  case  and,  for- 
tunately, the  most  common,  is  the  purely  external  hemorrhage  (Fig.  400).  "With- 
out doubt  small  hemorrhages  under  the  placenta  occur  frequently  during  the  latter 
weeks  of  pregnancy,  and  organize  without  producing  alarming  s^nnptoms,  but  are 
discovered  by  the  watchful  accoucheur  in  the  evidences  on  the  delivered  placenta; 


440      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

for  example,  infarcts  and  hard  old,  almost  completely  fibrinous  clots,  adherent  to  or 
incorporated  in  the  membranes  or  decidua.  By  reverting  to  the  history  of  a  slight 
trauma,  a  sudden  pain  in  the  belly,  perhaps  a  slight  bloody  show,  the  connection  is 
made  clear.  The  placenta  in  cases  of  abruption  may  show  the  evidences  of  several 
hemorrhages  or  red  infarcts  of  varjdng  dates;  it  may  be  torn  or  compressed  by  the 
clots  (Fig.  402),  or  it  may  show  no  signs  save  a  large  retroplacental  hematoma  sim- 
ilar to  that  which  occurs  in  the  third  stage  of  labor. 

Symptoms. — With  the  exception  of  the  mild  cases  just  mentioned,  abruptio 
placentae  declares  itself  in  stormy  fashion,  and  medical  aid  is  summoned  early. 
The  severity  of  the  sjanptoms  depends  on  the  amount  of  hemorrhage,  and  this 
usually  depends  on  the  degree  of  separation.     When  traumatism  is  the  cause,  a 


Membranes 


Fig.  402. — Placenta  from  Case  of  Abruptio  Placenta. 
Evidently  the  first  hemorrhage — the  blood-clot — occurred  several  hours  before  the  complete  detachment. 

history  of  same  is  given,  but  the  symptoms  may  not  come  on  for  hours  or  even  days 
afterward.  Sudden  severe  pain  in  the  belly,  often  at  the  site  of  the  placenta,  of  a 
tearing  character  at  first,  later  a  dull,  tense  ache,  interrupted  by  colics — these  are 
the  usual  symptoms.  Occasionally  nausea  or  vomiting  occurs.  Now  the  symptoms 
of  acute  anemia  supervene,  and  soon  those  of  shock,  from  sudden  distention  of  the 
uterus,  are  added.  Dizziness,  faintncss,  shortness  of  breath,  precordial  anxiety  and 
oppression,  appear  in  order;  the  woman  yawns  or  sighs  frequently,  and  complains 
of  ringing  in  the  ears,  spots  before  the  eyes,  that  she  sees  everything  black,  and  is 
harassed  by  great  thirst.  Later  she  lies  apathetic  on  the  bed  or  may  faint.  This 
loss  of  consciousness  may  last  a  few  moments  to  a  half-hour,  and  is  replaced  by 
restlessness,  jactitation,  or  even  delirium.  Cramps  in  the  legs,  excessive  thirst, 
vomiting,  unconsciousness,  delirium,  convulsive  twitchings,  involuntary  evacua- 


AHUri'TK)    PLACENTAE  441 

tions,  coma,  death — tliis  is  tlie  usual  order  of  the  symptoms  if  the  Ijleoding  is  not 
stopped.  The  observer  will  note  the  increasing  prostration,  the  growing  pallor  of 
the  skin,  the  white  cheeks  and  gums,  the  sunken  eyes,  the  pearly  conjunctiva?,  the 
cold  extremities  and  face,  often  with  an  icy  sweat,  and  in  cases  of  shock  an  addi- 
tional tinge  of  cyanosis  about  the  lips.  The  pulse  at  the  very  begiiming  may  be 
bounding  and  not  accelerated,  thus  deceiving  the  accoucheur  as  to  the  gravity  of 
the  situation.  In  shock  more  than  in  pure  hemorrhage  the  pulse  at  first  is  likely 
to  be  rapid,  small,  and  compressible.  Later,  the  bleeding  keeping  up,  the  hold  of 
the  arterial  walls  on  the  rapidly  diminishing  blood-stream  becomes  insufficient,  and 
the  heart  has  to  i)unii)  faster  to  keep  the  small  amount  of  blood  in  circulation.  In 
some  instances  the  pulse  weakens  and  grows  more  rapid  pari  passu  with  the  loss  of 
blood.  The  pulse,  therefore,  is  not  always  a  sure  index  as  to  what  is  going  on  in 
the  circulatory  system. 

A'er}'  soon  blood  or  serum,  expressed  from  the  intra-uterine  clots,  appears  ex- 
ternally, but  the  amount  of  blood  is  entirely  disproportionate  to  the  gravity  of  the 
symptoms.  Examination  of  the  belly  will  show  that  the  uterus  is  larger  than  cor- 
responds to  the  given  period  of  pregnancy,  that  it  has  a  board-like  consistence, 
making  it  impossible  to  outline  the  fetus.  An  accessory  tumor,  that  is,  the  sub- 
placental  hematoma,  is  seldom  found.  In  all  the  author's  cases,  including  those  of 
external  hemorrhage,  the  uterus  was  very  tense  and  hard,  but  some  writers  mention 
a  boggy  and  even  atonic  consistence.  One  would  expect  the  board-like  uterus  in 
the  concealed  cases  and  the  relaxed  uterus  where  the  blood  finds  ready  exit.  Tense- 
ness of  the  belly-wall  Ijecausc  of  the  distended  uterus  and  the  pain  is  another  finding. 
The  woman  says  that  the  child  is  not  felt,  but  that  it  was  subject  to  violent  move- 
ments at  the  onset  of  the  accident.  Very  seldom  can  the  fetal  heart  be  heard,  and 
under  such  conditions  a  partial  separation  of  the  placenta  must  be  assumed. 

Labor  usually  comes  on  at  once,  and,  if  the  contractions  of  the  uterus  are  strong 
and  the  os  dilates  quickly,  the  case  terminates  spontaneous!}- — safely  for  the  mother, 
])ut  almost  invariably  fatally  for  the  infant.  More  often  the  woman  dies  unde- 
livered— of  shock  and  hemorrhage — unless  medical  aid  is  rendered.  Should  the 
detachment  occur  during  delivery,  the  pains  take  on  strong  expulsive  action  and 
the  child  is  delivered  very  soon,  often  living,  or,  the  accident  having  l^een  recog- 
nized and  the  conditions  being  favorable,  the  accoucheur  may  save  both  by  timely 
operative  interference.  Rapid  delivery  of  the  second  twin  and  forceps  in  the  second 
stage  are  examples  of  such  operations.  After  the  deliver}'  the  placenta  and  masses 
of  clot  and  fluid  blood  rush  out  of  the  uterus,  and  atony  postpartum  is  a  frequent 
complication,  due  to  overdistention  and  myometrial  disease. 

Diagnosis. — Acute  abdominal  pain,  referred  usually  to  one  side  of  the  uterus, 
sudden  increase  of  the  size  of  the  uterus,  vnih  tension  of  the  abdominal  wall,  soon 
external  hemorrhage,  al^sence  of  the  fetal  heart-tones,  with  the  general  sjnnptoms 
of  increasing  anemia  and  deepening  shock,  constitute  the  foundation  for  the  direct 
diagnosis.  In  the  differential  diagnosis  placenta  praevia,  rupture  of  the  uterus, 
and  extra-uterine  pregnancy  most  frequently  come  up,  but  on  rare  occasions  one 
may  have  to  eliminate  other  non-obstetric  accidents,  as  gall-stone  colic,  rupture  of 
an  appendiceal  abscess,  or  gall-bladder  and  intra-abdominal  injuries. 

AbRUPTIO    PLACEXTiE  PlACEXTA    PrJEVIA 

Symptoms 

1.  Sudden  storm\-  onset.  1.  Rather  quiet  onset. 

2.  Pain,  generally  referred  to  the  placental  site.         2.  Xo  pain,  unless  uterine  contractions. 

3.  Hemorrhage,  internally  or  externally  after         3.  Hemorrhage  always  external  at  start. 

a  while. 

4.  Hemorrhage,    usually    severe — internal    or         4.  First   hemorrhage  generally  mild,   and  al- 

external.  waj's  external. 

5.  Usualh'  only  one  hemorrhage.  5.  Several,  or  history  of  several. 

6.  May  find  a  cause — injury,  jar,  etc.  6.  Usually  no  cause. 


442      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

Abruptio  Placent.e — {Continued.)  Placenta  Pr.evia — (Continued.) 

Symptoms 

7.  Symptoms  of  a  severer  hemorrhage  than        7.  Symptoms  proportionate  to  the  amount  of 

the  amomat  of  blood  externally  shows.  blood  lost  externally. 

8.  Cessation  of  fetal  movements.  8.  No  change  usually. 

9.  Hemorrhage  continues  after  the  rupture  of        9.  Hemorrhage  usually  ceases  in  all  but  the 

the  membranes.  central  variety. 

10.  Hemorrhage  continuous,   sometimes  ceas-       10.  The  hemorrhage  is  increased  by  the  uterine 
ing  during  uterine  contractions.  contractions  (not  constant). 

Signs 

1.  Abdomen  distended,  tense,  and  painful  to         1.  Abdomen  as  usual  at  time  of  pregnancy. 

touch. 

2.  Uterus  tense,  cannot  feel  fetus.  2.  Uterus  soft,  unless  there  is  a  uterine  con- 

traction. 

3.  Fetal  heart-tones  absent.  3.  Almost  always  present. 

i.  Vaginally,  no  placenta  in  reach  of  the  fingers.         4.  Placenta  palpable  in  isthmus  uteri. 
5.  Bag  of  waters  tense — feel  head  easily.  5.  Bag  of  water  loose;    usually  head^not  en- 

gaged. 

Rupture  of  the  uterus  is  often  complicated  with  detachment  of  the  placenta, 
and,  too,  it  is  possible  that  an  abruption  may  tear  the  uterine  wall  or  the  peritoneal 
covering  of  the  uterus.     The  symptoms  of  the  two  conditions,  therefore,  mingle: 

Abruptio  Placent.e  Ruptura  Uteri 

1.  Usually  during  pregnancy.  1.  Usually  during  labor,  unless  from  external 

violence. 

2.  Uterus  enlarged,  tense,  symmetric.  2.  Uterus  small,  at  one  side,  with  neighboring 

tumor — the  fetus. 

3.  Uterus  contracting.  3.  No  uterine  pains. 

4.  Vaginally  feel  fetus  through  the  os.  4.  No  presenting  part,  uterus  contracted  and 

empty. 

5.  Xo  tear  palpable.  5.  May  feel  the  rent  and  sometimes  the  gut. 

With  a  history  of  violent  injury  it  may  be  necessary  to  open  the  abdomen  for 
both  diagnosis  and  treatment. 

Ectopic  gestation  is  indicated  by  the  history,  the  finding  of  the  empty  uterus 
alongside  the  eccentric  and  asymmetric  tumor,  and  the  absence  of  contractions  in 
the  tumor. 

Prognosis. — Gooclell,  in  his  106  cases,  found  54  maternal  and  100  fetal  deaths, 
but  he  collected  only  the  critical  ones,  mostly  of  concealed  hemorrhage.  Later 
writers  include  the  mild  and  more  common  abruptions,  and  the  mortality  is  cor- 
respondingly less.  Still,  the  accident  is  one  of  the  gravest  with  which  the  obstet- 
rician has  to  deal,  and  it  is  safe  to  say  that  one-half  of  the  women  and  95  per  cent, 
of  the  babies  in  complete  detachments  with  concealed  hemorrhage  will  die,  while  a 
larger  proportion  will  be  saved  with  partial  detachment  and  under  skilful  treatment. 

Treatment. — Divides  itself  into  detachment  occurring  during  labor  and  that 
before  dilatation  of  the  cervix  is  begun. 

If  a  woman  having  apparently  a  normal  labor  suddenly  begins  to  bleed,  one 
thinks  at  once  of  premature  detachment  of  the  placenta,  low  insertion  of  the  pla- 
centa, laceration  of  the  cervix,  and  rupture  of  the  uterus.  An  internal  examination 
will  tell  whether  the  bleeding  comes  from  the  last  fibers  of  the  cervix  giving  way  to 
the  passage  of  the  head  or  from  placenta  previa.  Sometimes  the  placenta  may  be 
low  in  the  uterus,  but  out  of  reach  of  the  fingers,  and  here  the  membranes  should  be 
ruptured,  which  is  good  treatment  also  for  detachment  of  the  placenta — at  this 
stage  of  labor — because,  in  the  first  instance,  the  hemorrhage  will  cease  at  once, 
and,  in  the  second,  labor  will  be  so  much  facilitated  that  the  danger  quickly  passes. 
If  the  hemorrhage  continues,  and  especially  if  the  fetal  heart-tones  become  irregular 
or  slow,  a  diagnosis  of  abruption  is  now  made,  and  the  child  should  be  delivered 
without  delay.  If  the  placenta  separates  after  the  first  twin  is  l^orn  or  after  the 
emptying  of  polyhydramnion,  or  during  the  operation  of  version  or  extraction, 
rapid  delivery  is  indicated. 


ABRUPTIO    PLACENTAE  443 

Hard  and  precise  rules  cannot  be  laid  down  for  the  treatment  of  detachment 
of  the  placenta  during  pregnancy,  as  we  are  able  to  do  for  placenta  pra;via.  Three 
ol)j(!cts  must  be  acconiijlished:  the  uterus  nmst  be  emptied, the  hemorrhage  stopped, 
and  the  anemia  relieved.  The  best  treatment  is  that  which  empties  the  ut(!rus 
quickest  and  with  the  least  danger  to  the  mother,  and,  since  the  child  is  almost 
invariably  hjst,  but  little  attention  is  paid  to  it. 

The  indication  being  for  innnediate  delivery,  the  condition  of  the  cervix  will 
decide  which  metlKxl  shall  be  chos(ni.  If  the  cervix  is  soft  and  partly  open,  the 
dilatation  may  be  completed  manually  and  forceps  or  version  done,  depending  on 
the  engagement  of  the  head.  When  the  child  is  dead,  craniotomy  takes  the  place 
of  forceps.  If  the  cervix  admits  only  two  fingers  and  is  only  partly  effaced,  the 
bag  of  waters  is  to  be  pimctured,  a  colpeurynter  is  to  be  inserted  in  the  uterus,  filled 
with  eight  ounces  of  sterile  water,  the  vagina  is  to  be  tamponed  as  tightly  as  possible 
with  dry  sterile  cotton,  and  then  a  binder  put  on,  with  as  much  counter-compression 
as  the  patient  can  stand.  This  is  obtained  with  a  Spanish  windlass  (Fig.  403). 
Ergot  is  administered, — 30  drops  of  the  fluidextract  every  two  hours, — this  being 
tiie  only  condition  in  which  the  author  advises  the  use  of  the  drug  when  the  ovum  is 


^ 


Fig.  403. — Sp.^nish  Windlass  Compression  for  Accidental  Hemorrhage. 
Photograph  at  Wesley  Hospital. 

still  in  the  uterus.  Latterly  I  have  used  pituitrin  to  stimulate  the  pains.  The  wo- 
man is  watched  very  closely,  and  in  the  mean  time  all  preparations  are  completed 
for  eventual  operation,  for  the  treatment  of  postpartum  hemorrhage  and  anemia. 
After  the  accoucheur  considers  the  dilatation  sufficiently  advanced,  the  tampon  is 
removed,  the  cervix  dilated  manually  or  incised,  and  delivery  accomplished. 

Should  the  cervix  be  tightly  closed  and  an  internal  hemorrhage  be  going  on, 
the  case  is  truly  formidable.  Its  gravitj'  must  be  explained  to  the  family  and 
counsel  always  obtained.  The  treatment  is  similar  to  that  just  described.  In  all 
cases  the  accoucheur  should  be  prepared  for  all  kinds  of  operative  deliveries  and  for 
postpartum  hemorrhage,  because  atony  of  the  uterus  is  common  and,  further,  the 
woman  can  ill  afford  to  lose  blood  at  this  late  period. 

Should  the  membranes  be  punctured?  Smellie,  Demuan,  Baudelocque, 
Merriman,  Blundell,  Ramsbotham,  and  Kerr  (for  mild  cases)  recommend  it;  Att- 
hill.  Hicks,  Hamilton,  Burns,  and  Veit  (unless  after  complete  dilatation)  deny  its 
value.  Letting  the  liquor  amnii  escape  may  give  room  in  the  uterus  for  more  blood 
to  fill,  or  increase  the  shock  by  emptying  the  uterus,  or  interfere  with  the  mechan- 
ism of  cervical  dilatation.     These  are  theoretic   objections  which  do  not  hold  in 


444      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

practice,  since  experience  has  shown  that  the  pains  grow  stronger  and  more  efficient; 
that  the  hemorrhage  is  not  increased,  and  that  subsequent  operative  procedures 
are  not  rendered  difficult  by  letting  the  liquor  amnii  drain  away.  If  the  tampon  is 
to  be  used  without  the  colpeurynter,  the  membranes  may  not  be  opened. 

If  the  patient  is  in  competent  hands  and  the  surroundings  permit  it,  cesarean 
section,  eventually  the  Porro  operation  if  postpartum  bleeding  is  too  profuse,  should 
be  performed  when  the  cervix  is  tightly  closed.  Duquet  collected  five  cases,  Kerr 
had  two,  Couvelaire,  one.  Vaginal  cesarean  section,  especially  under  these  cir- 
cumstances, requires  more  skill  and  assistance,  but  may  be  employed  in  selected 
cases.  The  author  has  done  it  thrice  with  success,  and  in  none  of  the  cases  was  it 
necessary  to  extirpate  the  uterus  because  of  intractable  hemorrhage. 

If  the  woman  is  in  deep  shock,  the  question  of  any  operative  delivery  must  be 
carefully  debated.  It  may  be  wiser  to  pack  the  vagina  and  put  on  tight  counter- 
compression  until  the  woman's  condition  improves^  and  the  time  may  be  utilized 
in  giving  saline  solution  and  stimulants.  When  the  accoucheur  is  convinced  that 
the  bleeding  keeps  up,  operation  is  imperative. 

Rapid  dilatation  by  means  of  a  Bossi  dilator  is  dangerous  and  unsatisfactory.  The  tampon, 
packing  the  vagina  so  full  that  it  almost  fills  the  pelvis,  combined  with  powerful  counterpressure 
by  means  of  an  abdominal  binder,  is  very  highly  recommended  by  the  Dublin  School  for  cases  of 
abruption  with  external  hemorrhage.  Accouchement  force,  the  rapid,  ruthless  dilatation  of  the 
cer\dx  and  immediate  delivery,  is  to  be  condemned  as  dangerous  and  unsuccessful.  The  women 
often  bleed  to  death  from  the  lacerations  inflicted.  Craniotomy  should  be  used  in  all  cases  when 
the  child  is  dead,  to  reduce  the  amount  of  dilatation  necessary  for  delivery. 

Rupture  of  the  circular  sinus  of  the  placenta,  allowing  maternal  blood  to  escape 
externally,  is  a  rare  accident,  and  one  which  can  hardly  be  diagnosed.  Even  after 
delivery  of  the  placenta  and  the  demonstration  of  the  opening  in  the  sinus  one  may 
not  assert  such  a  diagnosis  because  these  openings  are  found  on  normal  placentas. 
Treatment  is  the  same  as  for  premature  detachment  of  the  placenta.     (See  Budin.) 

Literature 

Budin:  Femmes  en  Couches,  etc.,  Paris,  1897,  p.  135. — Couvelaire:  Annales  de  Gyn,  October,  1911. — Hofmeier:  Handb. 
der  Geb.,  vol.  ii,  Heft  ii,  p.  1188. — Holmes:  Amer.  Jour.  Obstet.,  1901,  vol.  ii,  p.  762.  Gives  complete  literature 
to  date. — Kerr:  Operative  Midwifery,  p.  601. — Macan:  Dublin  Jour.  Med.  Sci.,  January,  1905,  p.  16. — Rams- 
bolham:  System  of  Obstetrics,  1865,  p.  391. — Seitz:  Arch.  f.  Gyn.,  vol.  Ixix,  p.  76. 


CHAPTER  XXXIV 

PLACENTA  PREVIA 

Placenta  prcevia  is  the  development  of  the  placenta  in  part  or  wholly  within 
the  zon(>  of  dilatation  of  the  uterus.  That  the  placenta  may  be  found  over  the  os 
was  known  since  Hippocrates'  time,  and  is  mentioned  by  Mauriceau,  Deventer, 
Pugh,  and  many  others,  but  they  believed  that  it  had  prolapsed  from  its  normal 
fundal  insertion.  Paul  Portal,  in  1664,  stated  positively  that  the  placenta  may  be 
imi)lanted  over  the  os,  and  Giffard,  Roederer,  Levret,  and  especiall}'  Smellie,  em- 
phasized this  fact.     Rigby,  in  1775,  however,  most  clearly  distinguished  between 


Fig.  404. — Placexta  Previa  Ce.\tr.\li3.     Vel.\.men"tou3  Ixsertion  of  Cord. 
Specimen  of  Northwestern  University  Medical  School. 


placenta  praevia  and  al)ruptio  placentip,  although  it  must  l)e  conceded  that  some 
of  his  cases  were  incorrectly  diagnosed.  Rigby  gave  the  name  unavoidable  hemor- 
rhage to  the  former,  and  that  of  accidental  hemorrhage  to  the  latter,  condition. 
Hemorrhage  in  placenta  praevia  is  unavoidable  because  the  placenta  must  be  sepa- 
rated by  the  advancing  child,  and  this  separation  causes  bleeding,  while  in  abruptio 
placentae  the  hemorrhage  is  accidental— it  is  not  necessary,  even  if  the  placenta  is 

445 


446 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


disunited  from  the  uterine  surface,  that  bleeding  should  occur.  Schaller,  in  1709, 
was  the  first  to  demonstrate  postmortem  the  attachment  of  the  placenta  over  the 
internal  os. 

The  placenta  may  attach  itself  to  any  portion  of  the  uterus,  the  fundal  inser- 
tion being  the  rarest  of  all,  the  posterior  wall  being  the  most  common  site,  next  the 
anterior  wall,  then  the  sides,  and  next  to  the  last  in  frequency  the  lower  uterine 


Fig.  405. — Placenta  Previa  Mabginalis. 


Fig.  406. — Placenta  Pb.bvia  Lateralis. 


segment — the  isthmus  uteri.  The  lower  edge  of  the  placenta  must  be  at  least  10 
cm.  from  the  internal  os,  and  well  above  the  upper  border  of  the  isthmus  uteri,  to 
be  normal.  When  the  inferior  border  lies  just  at  the  isthmus  uteri,  we  speak  of 
low  insertion  of  the  placenta;  when  this  edge  just  reaches  the  internal  os,  it  is 
called  placenta  prsevia  marginalis  (Fig.  405) ;  when  only  part  of  the  opening  of  the 
cervix  is  covered,  we  speak  of  placenta  praevia  lateralis  or  partialis  (Fig.  406),  and 


Fig.  407. — Placenta  Previa  Totalis  or  Centralis. 


Fig.  408. — Placenta  Pr.evia  Cervicalis. 


when  the  os  is  completely  roofed  over,  placenta  prsevia  centralis  or  totalis  (Fig. 
407).  Since  in  the  last  class  of  cases  the  placenta  lies  almost  entirely  in  the  isthmus 
uteri,  this  might  be  called  placenta  isthmialis.  All  these  terms  are  relative  because 
of  changes  in  the  digital  findings  produced  by  the  dilatation  of  the  uterus — for  ex- 
ample, a  marginalis,  after  the  cervix  is  open,  may  become  a  lateralis,  and  a  placenta 
that  seemed  to  cover  all  the  c(!rvix  with  two  fingers'  dilatation  subsequently  may 
cover  only  half  of  the  opening. 


0: 


(^ 


(^ 


PLACENTA    rii^VIA 


447 


Causation. — PUiconta  praovia  is  said  to  occur  ton  times  as  frffjuontly  in  multi- 
para; as  in  ])rimi|)aric,  and  in  f^cncral  once  in  1000  cases,  l)ut  wo  wciglit  is  to  be 
placed  on  tlu;  statistics,  sinc(^  the  figures  given  Ijy  various  authors  vary  from  1  to 
1500  to  1  to  300.  Central  placenta  pra^via  occurs  in  less  than  one-fifth  of  the  cases, 
and  multiparae  are  especially  prone  to  the  deeper  varieties,  and  the  tendency  to  the 
low  insertion  increases  with  nuiltiparity  and  age. 

PredisiK)sing  causes  are  chronic  endometritis,  multiparity,  espcciull}^  when 
the  children  come  in  rapid  succession,  subinvolution,  and  twin  pregnancies. 
These  conditions  are  likely  to  be  associated.  The  author  in  nearly  all  his  cases 
of  placenta  pricvia  has  obtained  a  history  of  abortion,  of  slow  recovery  from 
previous  confinement,  of  manual  removal  of  the  placenta  in  previous  labor,  of 
recurrent  placenta  prievia  and  other  evidences  of  a  diseased  endometrium,  and 
the  findings  on  the  placenta  often  confirm  the  endometritis  as  the  predisposing 
factor — for  example,  white  infarcts,  very  thick  serotina,  adherent  placenta. 

The  acting  causes  are — (a)  Primary  low  insertion  of  the  ovum  near  the  internal 
OS  or  on  its  edge;    (6)  the  development  of  placenta  in  the  refiexa  and  its  coming  to 


Fig.  409.  Fig.  410. 

Figs.  409  and  410. — Ovum  Splitting  Decidua  (Hofmeier), 

lie  over  the  os  (Hofmeier  and  Kaltenbach).  Owing,  perhaps,  to  an  endometritis, 
to  lack  of  the  cilia,  or  to  some  unknowai  anomaly  of  the  ovum  itself,  the  egg  slips 
do\vn  the  uterine  cavity  and  does  not  succeed  in  attaching  itself  until  it  reaches  the 
neighborhood  of  the  internal  os. 

How  the  placenta  grows  over  the  internal  os  has  given  rise  to  much  discussion. 
All  investigators  agree  that  the  ovum  must  be  inserted  low  in  the  uterus.  Since 
the  ovum  burrow^s  into  the  mucosa  and  then,  in  its  gro'^i:h,  splits  the  decidua  in  all 
directions,  it  is  easy  to  see  how  part  of  the  placenta  could  come  to  cover  the  internal 
OS  (Fig.  410).  The  decidua  vera  and  refiexa  are  carried  across  the  narrow  cerA'ical 
slit  and  come  to  lie  in  apposition  with  the  vera  of  the  opposite  side,  where  fusion  may 
or  may  not  occur.  If  the  ovum  splits  the  decidual  membrane  circularly  around  the 
OS,  the  remaining  minute  hole  is  easily  l^ridged  over,  and  a  horseshoe-shaped  or  a 
placenta  fenestrata  results.  The  downward  splitting  of  the  decidua  may  not  be 
arrested  at  the  internal  os.  In  rare  cases  the  cervical  mucous  membrane  is  capable 
of  forming  decidua,  and  in  this  the  development  of  the  placenta  goes  on,  the  villi 
in  their  growth  reaching  even  to  the  external  os,  as  in  the  author's  case  (Fig.  408) 


448 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


and  in  those  of  von  Weiss  and  Goodman.  There  are  seven  cases  on  record 
(Ahlf eld,  Wyder,  Devraigne) .  The  union  of  placenta  and  cervix  was  very  intimate, 
and  required  actual  digging  out  of  the  placenta  with  the  finger-nail. 

Hofmeier  beheved  many  placentae  prsevise  are  due  to  the  development  of  the 
villi  in  the  reflexa  (Fig.  411).  Owing  to  peculiar  nutritional  conditions,  the  chorion 
Iseve  does  not  atrophy,  but  the  villi  develop  in  the  reflexa  and  this  surface  later  be- 
comes applied  to  the  vera  on  the  opposite  wall  of  the  uterus. 

Placentae  that  have  been  placentae  praeviae  exhibit  great  variety  of  form,  two 
having  already  been  mentioned.  Sometimes  there  is  a  tongue  of  tough,  fibrous 
placental  tissue  which  has  overlaid  the  os ;  sometimes  the  edge  of  the  os  is  encircled 
by  this  placental  tissue,  more  or  less  infarcted.     Occasionally — and  this  in  the  isth- 

mial  variety — ^the  placenta  hangs  across 
the  lower  uterine  segment  like  a  festoon. 
These  are  the  most  serious. 

Symptoms. — Hemorrhage  is  the  first 
and  most  constant  symptom,  occurring  in 
the  last  three  months  of  pregnancy^ — most 
frequently  in  the  eighth.  Usually  no  cause 
is  assignable,  the  patient  waking  from 
sleep  to  find  herself  in  a  lake  of  blood,  or, 
on  arising  from  the  toilet,  sees  fluid  and 
clotted  blood  in  the  vessel.  A  painless, 
causeless,  uterine  hemorrhage  in  the  third 
trimester  of  pregnancy  is  almost  pathogno- 
monic  of  placenta  prcevia.  The  flrst  hemor- 
rhage may  vary  from  a  few  drops,  hardly 
a  stain  on  the  linen,  to  a  profuse  "flood- 
ing," which  may  be  fatal  at  once,  but  usu- 
ally a  few  ounces  are  lost  as  the  initial 
symptom.  Each  succeeding  hemorrhage 
is  greater,  and  unless  treated,  a  high  grade 
of  anemia  is  developed.  The  accoucheur 
must  not  be  misled  by  apparent  recovery : 
this  is  never  complete  during  pregnancy — 
the  blood  is  only  "patched  up";  the  sys- 
tem is  not  in  a  condition  to  withstand  a 
new  drain,  one  that  is  inevitable  at  labor. 
Some  of  the  worst  cases  of  spanemia  are 
produced  by  a  condition  called  stillicidium 
sanguinis,  which  is  a  continuous  but  very  slight  dribbling  of  blood,  hardly  com- 
manding the  notice  of  the  accoucheur,  but  slowly  undermining  the  woman's  con- 
stitution.    Labor  usually  comes  on  after  the  second  or  third  hemorrhage. 

In  central  insertion  of  the  placenta  the  bleeding  usually  occurs  earlier  than  in 
the  other  varieties,  but  exceptions  are  noted,  the  cervix  remaining  closed  and  there 
being  no  hemorrhage  until  full-term  labor  begins.  Such  cases  have  weak  pains 
and  are,  therefore,  unfavorable.  In  partial  placenta  praevia  the  pains  of  pregnancy 
are  usually  present;  hemorrhage  is,  therefore,  more  constant;  the  cervix  softens 
and  dilates,  and  treatment  during  labor  is  facilitated.  Marginal  placenta  praevia 
may  not  cause  hemorrhage  until  the  very  beginning  of  labor,  or  even  toward  the 
end  of  the  first  stage,  and  then  it  is  slight.  One  may  suspect  the  type  of  placenta 
praevia  from  the  above  symptoms,  but  exceptions  to  the  rules  are  very  common,  the 
author  having  met  a  severe  and  almost  fatal  hemorrhage  from  a  marginal  insertion 
and  another  case  of  mild  bleeding  in  a  complete  placenta  praevia.  Ahlfeld  and  Edgar 
lost  patients  from  one  profuse  hemorrhage,  and  only  an  edge  of  the  placenta  pre- 


FiG.  411. — Hofmeier's  Idea  of  Reflexa  Placenta. 


PLACENTA    PKyE\lA  449 

scntod.  Perhaps  the  manner  of  development  of  tlic  phiccnta  pnt'via  may  explain 
these  variations  in  tlie  anunnit  of  heniorrha<;('. 

Tiie  origin  of  tiie  hemorrhage  is  fourfold:  From  the  sinuses  of  the  plaeental 
site;  from  the  intervillous  spaces  of  the  placenta;  from  the  circular  sinus  of  the 
placenta;  rarely,  and  then  only  as  the  result  of  interference,  from  the  villi — that  is, 
the  fetal  blood-vessels.  Owins  to  the  develoi)ment  of  the  isthnuis  uteri  and  the 
lower  uterine  segment,  and  the  constant  upward  retraction  of  the  fibers  of  the  lower 
portion  of  the  uterus,  the  area  occupied  l)y  the  placenta  is  enlarged,  but  the  pla- 
cental growth  is  not  in  proportion.  During  the  painless  uterine  contractions  of 
pregnancy  the  lower  edge  of  the  placenta,  therefore,  is  likely  to  be  disunited  from 
the  wall  of  the  uterus,  opening  the  sinuses  and  allowing  maternal  blood  to  escape. 
It  is  easy  to  see  why  such  liemorrhage  is  called  unavoidable. 

Other  symptoms  of  placenta  prsevia  are  l)oth  inconstant  and  equivocal,  as 
pain,  pressure,  and  throbbing  in  the  lower  abdomen,  frequent  urination,  leukor- 
rhea,  and  "carrying  the  child  differently." 

Placenta  prnevia  affects  the  course  of  pregnancy,  labor,  and  the  puerperium. 
Abortion  is  not  seldom  the  result  of  it,  though  Hofmeier,  in  sixteen  years'  experi- 
ence, could  not  find  one.  In  several  abortions  the  author  found  indubitable 
evidences  of  low  implantation  of  the  ovum.  Many  cases  of  placenta  praevia  give  a 
history  of  threatened  abortion  in  the  early  months.  Premature  rupture  of  the  ])ag 
of  waters  is  another  sign  of  low  insertion,  usually  the  marginal,  and  is  due  to  the 
adherence  of  the  membranes  around  the  os,  from  catarrhal  endometritis  or  abnormal 
placentation.  Premature  labor  is,  therefore,  common.  Doranth  found  full-term 
labor  in  only  32  per  cent.  Some  authors  mention  that  pregnancy  may  go  beyond 
term  in  placenta  prajvia  centralis,  but  I  have  had  contrar}^  experience. 

During  lal^or  the  low  implantation  of  the  l^ulky  placenta  causes  malpositions 
and  malpresentations,  for  example,  breech  and  shoulder;  delayed  engagement  of 
the  head;  abnormalities  of  rotation;  prolapsus  funis;  weak  pains^all  these  plus 
the  inevitable  hemorrhage  and  the  injuries  so  commonly  inflicted  by  operative  de- 
livery. Air-embolism  because  the  uterine  sinuses  are  so  near  the  external  air,  and 
rupture  of  the  uterus,  because  the  musculature  is  w^eakened  by  the  ingroMih  of  the 
placenta,  are  commoner  than  usual. 

Postpartum  hemorrhage  is  very  frequent,  because  the  uterine  wall  is  thin  and 
weak  in  muscle,  which  contracts  tardily,  and  closes  imperfectly  the  large  venous 
sinuses,  also  often  being  unable  to  separate  the  placenta.  Further,  the  placenta  is 
likely  to  be  adherent  because  of  endometritis,  infarction,  ingroT\i:h  of  villi  (placenta 
accreta,  Fig.  704),  or  from  infection  during  pregnancy,  the  placenta  being  so  near 
the  septic  vagina.  Did  not  the  uterine  arteries  enter  the  uterus  higher  up  and, 
therefore,  in  the  zone  of  contraction,  many  women  would  l^leed  to  death,  because 
the  clotting  in  the  vessels  is  not  sufficient  to  procure  hemostasis.  Xo  doul^t  many 
cases  of  postpartum  hemorrhage  are  clue  to  low  implantation. 

In  the  puerperium  placenta  prsevia  also  makes  trouble:  (o)  Bits  of  placenta 
may  remain  adherent  and  become  infected;  {h)  from  the  close  proximity  of  the 
placental  site  to  the  septic  vagina,  infection — and  that  of  the  most  dangerous  kind, 
metrophleliitis — is  invited;  (c)  subinvolution,  and  (d)  finally  the  woman  has  the 
profound  anemia  to  contend  with. 

These  dangers  beset  the  child:  prematurity  and  atelectasis  pulmonum;  a 
much  infarcted  or  ill-developed  placenta  causes  the  infant  to  l^e  pun}-;  prolapse  of  the 
cord;  compression  of  the  insertion  of  same,  and  dislocation  of  the  placenta  during 
delivery,  may  cause  asphj-xia;  injury  of  the  placenta  causes  fetal  hemorrhage;  and 
the  infant  may  suffer  from  the  forceps  or  version,  but  especially  from  the  use  of  its 
body  as  a  tampon  to  stop  hemorrhage — the  Braxton-Hicks  method. 

Diagnosis. — A  painless,  causeless,  uterine  hemorrhage  n  the  last  three  months 
of  pregnancy  usualh'  ena])les  a  direct  diagnosis  of  placenta  prsevia  to  be  made,  but 
29 


450      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

the  conclusion  must  be  certified  by  vaginal  examination  and  the  finding  of  placental 
tissue  over  the  internal  os. 

Before  making  the  internal  examination  everything  must  be  prepared  as  for 
operation,  and  great  gentleness  is  to  be  practised  to  avoid  separating  and  tearing 
the  placenta,  the  dangers  being  maternal  and  fetal  bleeding.  It  has  happened  that 
the  mere  insertion  of  the  finger  into  the  cervix  has  provoked  such  alarming  hemor- 
rhage that  treatment  had  to  be  instituted  there  and  then. 

The  pecuUar  spongy,  fibrous  feel  of  the  placental  tissue  may  be  simulated  by  a 
firm  coagulum,  by  thick  vernix  caseosa  in  matted  hair,  by  a  monstrosity  with  ex- 
posed viscera, — for  example,  anenccphalus, — by  hemorrhage  into  the  fetal  mem- 
branes (which  may  indicate  a  placenta  located  near  by),  and  by  thickened  mem- 
branes. Bogginess  in  the  fornices,  the  sensation  of  a  flat  sponge  between  the  head 
and  the  fingers,  pulsating  arteries,  excessive  vascularity,  and  a  low  and  pronounced 
uterine  souffle  are  all  equivocal  signs  of  placenta  prsevia. 

In  the  differential  diagnosis  bleeding  from  varicose  veins,  hemorrhoids,  etc., 
are  easily  excluded,  but  ruptura  uteri,  ectopic  gestation,  and  abruptio  placentae 
need  more  care.  (See  p.  441  for  a  table  which  gives  the  differential  points  con- 
cerning the  last  mentioned.)  It  must  be  remembered  that  a  placenta  situated  low 
in  the  uterus  without  being  actually  a  prsevia  may  become  partly  detached  at  its 
lower  pole,  and  the  point  of  bleeding  being  near  the  os,  the  blood  escapes  readily, 
not  increasing  intra-uterine  tension  and  not  separating  the  placenta  entirely.  In 
such  instances  the  signs  of  abruptio  may  be  wanting.  Then,  too,,  in  the  severest 
cases  of  abruptio  placentae  the  organ  may  prolapse  and  come  to  lie  over  the  os. 

Rupture  of  the  uterus  is  easily  shut  out,  but  one  must  remember  the  tendency 
of  the  uterus  to  rupture  when  the  placenta  is  low. 

Bleeding  from  a  vessel  passing  over  the  os  from  a  velamentous  insertion  of  the 
cord  must  also  be  thought  of,  and  also  laceration  of  the  circular  sinus. 

Another  point  to  be  determined  by  the  internal  examination  is  whether  the 
pre  vial  portion  of  the  placenta  is  central,  lateral,  or  only  marginal — which  is  not 
always  easy.  Sweeping  the  finger  delicately  around  the  internal  os,  the  accoucheur 
notes  where  the  thin  membranes  become  thicker,  then  passing  into  the  thick  pla- 
cental margin.  If  the  student  will  lay  a  placenta  over  a  ring  made  by  his  fingers, 
he  can  practise  the  diagnosis  of  placenta  praevia  as  on  the  living. 

Prognosis. — Placenta  praevia  is  a  formidable  complication,  and  annually  sacri- 
fices more  mothers  and  children  than  appear  in  statistics.  These  figures,  collected 
from  many  sources,  will  give  an  idea  of  the  mortality  of  mothers  and  children. 

Author.                           Number  of  Cases.  Died,  Mothers.  Died,  Infants. 

Strassman 229  22,  or    9.60  per  cent.  61.22  per  cent. 

Pohl 467  18,  or    4.00        "  60.00        " 

Doranth 216  20,  or    9.20        "  60.40 

Hantel 12.3  12,  or  10.00        "  78.00 

Boss 13.3  8,  or    6.70        "  53.00 

Hannes 119  6,  or    .5.00        "  49.00 

Hammerschlag 191  7,  or    6..30        "  84.00        " 

Treub 120  14,  or  11.70        "  55.00 

Moskow  Maternity 480  56,  or  11.25        "  58.00 

Author 75  3,  or    4.00        "  56.00 

2153  166,  or    7.70        "  61.46        " 

This  table  shows  that,  of  21.5.3  women  with  placenta  praevia,  166  died,  a  per- 
centage of  7.7,  which  is  very  much  better  than  fifty  years  ago,  by  grace  of  asepsis 
and  better  obstetric  practice.  The  Berlin  Frauenklinik  showed  3.8  per  cent,  of 
deaths  in  467  cases,  and  Schauta's  Vienna  clinic,  5.85  per  cent,  in  342  cases.  Kronig 
collected  6569  cases  which  showed  mortalities  of  9.3  per  cent,  and  58.7  per  cent, 
respectively  for  mothers  and  children.  Fiith  collected  726  cases  from  private 
practice  near  Koblenz,  and  found  143  deaths,  19.7  per  cent.,  with  an  infant  mor- 


PLACENTA    PREVIA  451 

tality  of  48  per  cent.  McPhcrsoii,  in  250  cases  in  tlu;  New  York  Lying-in  Hospital, 
found  18  p(!r  cent,  and  57  per  cent.,  l)ut  in  this  arc  included  the  moribund  cases. 
McDonald  collected  reports  of  8025  cases,  and  found  7.22  per  cent,  and  55.5  per 
cent,  mortalities  for  mothers  and  children  respectively. 

All  these  figures  require  careful  study  before  being  applied  to  any  purpose, 
especially  for  deciding  on  methods  of  treatment,  because  the  condition  of  the  pa- 
tient, whether  she  was  infected  before  admission  to  treatment,  the  degree  of  the 
praevia,  total  or  partial,  the  period  of  gestation,  the  amount  of  blood  lost  previously, 
the  manner  of  treatment,  etc.,  must  all  be  properly  cvaluated^which  is  impossible. 
One  man's  opinion,  if  he  is  qualified  by  general  mental  ability  and  clinical  experience 
to  render  an  opinion,  is,  therefore,  usually  more  useful  in  deciding  on  lines  of  treat- 
ment than  the  largest  statistics.  The  highest  mortality  occurs  in  central  placenta 
praevia;  the  lowest  in  the  marginal  variety,  which  is  true  for  both  mother  and  infant. 

IVIost  of  the  deaths  in  placenta  praevia  come  from  hemorrhage,  sepsis,  rupture 
of  the  uterus,  and  air  embolism,  named  in  the  order  of  frequency.  The  woman 
bleeds  to  death  in  lal)or  usually  l^ecause  her  store  of  blood  has  been  wasted  during 
pregnancy,  or  from  an  injury  inflicted  by  delivery.  Sepsis  is  invited  by  the  proxim- 
ity of  the  susceptible  placental  site  to  the  field  of  operation,  and  the  fact  that  hasty 
and  many  manipulations  are  necessary  in  the  treatment.  Rupture  of  the  uterus 
is  usually  the  result  of  violence  exerted  by  the  accoucheur,  but  may  occur  from 
tumultuous  uterine  action.  Air-embolism  is  rare,  but  does  occur,  experiments  on 
animals  to  the  contrary  notwithstanding.  The  children  die  from  asphjTcia  through 
dislocation  or  compression  of  the  placenta,  tearing  of  the  placenta  and  fetal  hemor- 
rhage, from  being  used  as  a  plug  in  the  Braxton-Hicks  treatment,  further,  from 
prematurity.     Later  methods  of  treatment  have  improved  the  child's  chances. 

The  prognosis  as  to  health  is  also  bad.  Puerperal  infection  is  of  very  frequent 
occurrence,  resulting  in  life-long  invalidism;  the  anemia  may  cause  permanent 
changes  in  the  blood-forming  organs  and  in  the  nervous  system,  and  the  woman 
may  be  damaged  by  the  operations  performed  for  delivery. 

Treatment. — Fortunately,  we  possess  rational  and  certain  methods  of  treat- 
ment for  this  formidable  accident,  which  caimot  be  said  of  most  other  obstetric 
complications.  In  deciding  on  the  course  of  procedure  in  the  individual  case  many 
factors  must  be  considered:  the  surroundings  of  the  patient;  the  condition  of  the 
mother  and  that  of  the  child;  the  necessity  for  preserving  it  (Catholic  family) ;  the 
skill  of  the  accoucheur;  the  degree  of  the  praevia — whether  partial  or  total;  whether 
the  patient  is  in  labor  or  not;  and  the  amount  of  dilatation  of  the  cer\'ix.  From 
his  own  experience,  and  from  thoughtful  consideration  of  the  published  experience 
of  others,  the  author  would  lay  down  these  axioms: 

1.  A  woman  with  placenta  praevia  should  not  die,  except  in  the  very  rare  in- 
stances of  air-embolism,  hemorrhagic  diathesis,  or  spontaneous  rupture  of  the  uterus. 

2.  Every  woman  with  placenta  praevia  should  be  sent  to  a  well-equipped  ma- 
ternity hospital  unless  she  is  aljle  and  willing  to  j^rovide  the  several  physicians  and 
nurses  necessary  in  her  0A\ai  home.  It  is  otherwise  impossible  to  give  the  patient 
all  the  benefits  of  our  art. 

3.  With  two  exceptions  every  pregnancy  complicated  vrith  placenta  prae\ia 
should  be  terminated  as  soon  as  the  diagnosis  is  made.  "When  the  bleeding  is  in- 
deed slight,  and  when  the  child  is  very  near  the  border  of  viability,  one  may  tem- 
porize a  few  weeks,  providing  the  'patient  will  remain  in  bed  in  a  good  maternity  hos- 
pital. Should  the  woman  refuse  to  go  to  the  hospital,  and  also  to  allow  the  ac- 
coucheur to  induce  lal^or  at  her  home,  the  attendant  had  better  drop  the  case  and 
•let  the  patient  employ  a  physician  in  whom  the  gaml^ling  instinct  is  better  developed. 
A  "flooding"  may  occur  during  the  night,  and  the  woman  lose  a  fatal  amount  of 
blood  before  aid  can  reach  her.  Dr.  W.  W.  Jaggard  said,  "there  is  no  expectant 
plan  of  treatment  for  placenta  praevia." 


452      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

4.  One  must  distinguish  sharply  between  maternity  and  private  practice, 
measures  which  are  safe  in  the  former  being  impossible  in  the  latter.  In  the  ma- 
ternity hospital  one  may  make  a  consistent  effort  to  save  the  life  of  the  child,  but 
at  the  home  one  must  use  that  method  which  will  put  an  immediate  stop  to  the 
hemorrhage,  with,  if  necessary,  less  regard  to  the  child.  Also  the  accoucheur  will 
select  the  procedure  which  he  is  best  able  to  carry  out,  and  must  know  all  methods 
of  delivery,  as  well  as  be  able  to  suture  the  cervix  and  perform  vaginal  and  abdom- 
inal hysterectomy,  etc. 

5.  When  labor  has  begun  in  a  case  of  placenta  prsevia,  the  accoucheur  must 
remain  by  the  patient  until  she  is  delivered  and  out  of  danger. 

6.  At  all  times  in  the  treatment  of  these  cases  the  accoucheur  should  heed  this 
warning,  save  hlood!  One  can  never  foretell  how  much  of  the  vital  fluid  the  woman 
will  lose  in  the  successive  stages  of  treatment,  nor  does  one  know  what  is  the  par- 
ticular woman's  ability  to  withstand  bleeding.  A  loss  of  a  pint  will  kill  one  woman, 
while  another  will  recover  from  the  loss  of  three  quarts.  Be  not  extravagant  with 
her  supply  during  the  first  and  second  stages  of  labor,  because  the  normal  flow  in 
the  third  stage  may  be  a  fatal  drain.  Therefore  if,  on  arrival  at  the  bedside,  the 
accoucheur  finds  the  woman  already  anemic,  it  is  unwise  to  use  uncertain  methods, 
but,  regardless  of  all  else,  the  hemorrhage  must  be  arrested  at  once  and  every 
possible  drop  of  blood  spared. 

During  -pregnancy,  before  labor-pains  have  begun,  if  one  has  decided  to  assume 
the  risk  and  to  temporize,  the  woman  should  be  put  to  bed  at  the  first  indication 
of  hemorrhage,  and  she  should  be  in  a  perfectly  appointed  maternity  hospital.  If 
the  hemorrhage  is  free,  a  firm  vaginal  tampon  is  to  be  applied.  In  all  cases  of 
hemorrhage  during  pregnancy  a  firm  tampon  is  indicated,  in  order  to  limit  the  loss 
of  blood  to  a  minimum.  If  the  woman  is  to  be  transported  to  a  hospital,  a  provi- 
sional tampon  is  to  be  applied,  as  the  unavoidable  jolting  on  the  way  will  increase 
or  incite  the  bleeding.  The  application  of  a  tampon  to  control  hemorrhage  is  by 
no  means  a  simple  matter.  Unless  the  head  is  engaged  in  the  pelvis,  it  is  impossible 
to  apply  the  tampon  so  firmly  that  all  bleeding  will  be  stopped,  and  since  the  head 
rarely  has  sunk  so  low,  one  must  be  content  with  checking  the  flow.  Dry  sterile 
cotton  is  best  for  the  purpose,  and  the  rules  of  asepsis  must  be  especially  strict. 
Counterpressure  is  to  be  applied  with  a  firm  abdominal  binder,  as  in  Fig,  403. 
Even  an  aseptic  tampon  aseptically  applied  becomes  a  source  of  danger  very  soon, 
and  for  this  reason  it  should  be  removed  in  twelve  hours  and  not  renewed  unless 
absolutely  necessary.  On  the  appearance  of  another  hemorrhage  action  is  de- 
manded— there  is  no  "udsdom  in  waiting  longer.  It  is  a  wanton  exposure  of  the 
mother  to  immediate  and  future  danger  for  the  sake  of  an  infant  which  will  prob- 
ably succumb  during  delivery  or  shortly  after. 

If  the  patient  is  near  the  ninth  month,  the  child  is  viable  and  well  developed, 
and  on  its  account  there  is  no  reason  for  waiting. 

During  labor  we  have  four  objects  to  accomplish:  First  and  most  urgent,  to 
stop  the  hemorrhage;  second,  to  empty  the  uterus;  third,  to  insure  hemostasis; 
fourth,  to  combat  the  anemia. 

We  must  stop  the  hemorrhage,  then,  first  of  all,  and  it  matters  a  great  deal 
whether  the  patient  has  already  lost  much  or  little  blood  when  it  comes  to  the  selec- 
tion of  the  method  of  stanching  the  flow. 

In  cases  of  marginal  placenta  praevia  the  hemorrhage  usually  begins  toward  the 
end  of  the  second  stage  of  labor  and  is  very  slight.  The  proper  treatment  is  to 
puncture  the  bag  of  waters.  This  method  is  named  after  Puzos,  who  mentioned  it 
flToO),  but  Puzos  knew  nothing  of  the  nature  of  placenta  prsevia,  and,  further, 
Mauriceau  ruptured  the  membranes  to  stop  hemorrhage  in  1688.  Both  considered 
detachment  of  the  placenta  the  cause  of  all  the  hemorrhages  during  pregnancy. 

The  puncture  of  the  membranes  allows  the  placenta  to  retract  with  the  receding 


PLACEXTA    PRyEVIA 


453 


lower  uterine  sc.uinciit,  to  lieroine,  as  it  were,  l)art  of  the  uterine  wall,  thus  arresting 
the  process  of  separation,  and  the  head  may  ikav  enter  the  lower  uterine  segment 
and  iipply  itself  against  the  i)iaeenta,  thus  aiding  in  stoi)ping  the  hemorrhage,  lint 
rarely  a  case  will  occui'  In  whirh,  even  in  a  marginal  ])ra'via,  ])Uiieture  of  the  hag 


Fig.  412. — Puncturing  Membr.4.nes  at  Edge  of  Placenta. 
It  mav  be  necessary  to  use  a  long  scissors  to  get  through  tough  membranes. 


Fig.  413. — Compression  of  Placent.a.  for  Temporary  Hemostasis. 
Rubber  gloves,  omitted  for  artistic  reasons  in  the  illustrations,  are  used  throughout. 


454      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

of  waters  vnll  fail  to  arrest  the  flow.  Such  cases  are  treated  hke  central  and  lateral 
implantation. 

The  usual  condition  met  is  a  more  or  less  severe  hemorrhage,  with  the  os  ad- 
mitting two  or  more  fingers.  Pains  may  or  may  not  be  present,  but  some  uterine 
action  must  have  taken  place  or  the  hemorrhage  and  dilatation  could  not  have 
occurred. 

There  are  now  two  methods  of  treatment — Braxton-Hicks'  version  and  met- 
reurysis. Which  one  should  be  selected  depends  on  several  conditions.  If  the  woman 
has  lost  much  blood;  if  the  babe  is  dead  or  dying,  or  if  it  is  very  premature,  so 
that  its  chances  are  very  slim;  if  one  has  had  little  experience  with  placenta  prsevia — ■ 
Braxton-Hicks'  version  is  preferable.     Bring  down  one  foot,  make  slight  traction  on 


Fig.  414. — Br.\xton'  Hicks'  Version  Completed. 

Breech  acts  as  tampon  and  squeezes  placenta  against  bleeding  vessels.     It  is  essential  for  success  to  be  certain  that 

the  placenta  lies  flat  against  the  uterine  wall,  and  is  not  bent  back  on  itself,  exposing  uterine  ve.ssels. 

it,  so  that  the  infant's  thigh  compresses  the  placenta  against  the  cervix,  thus  stop- 
ping the  hemorrhage.  Then  leave  the  case  to  nature.  Do  not  extract  the  child;  do 
not  put  traction  on  the  leg  unless  bleeding  recurs.  If  oozing  commences,  pull 
lightly  on  the  leg.  The  object  of  this  method  is  to  use  the  child's  body  as  a  cer- 
vical tampon  to  stop  hemorrhage,  and  to  stimulate  pains  until  the  cervix  is  ready 
for  safe  delivery.  Neglect  of  the  al)Ove  advice  and  rapid  extraction  have  cost  many 
mothers  their  lives,  and  the  object  sought,  the  saving  of  the  child,  has  usually  been 
frustrated  by  the  attempt  itself. 

In  pcrforminp;  Braxton-Hicks'  version  these  points  are  to  be  noted.  Puncture  the  mem- 
branes at  the  side  of  the  cervix  as  far  from  the  edge  of  the  placenta  as  possible  (Fig.  412).  Then, 
disregarding  the  bleeding,  which  now  commences  and  is  sometimes  furious,  pass  the  hand  into  the 
vagina, the  two  fingers  through  the  rent  in  the  membranes  alongside  the  head.  The  head  is  gently 
pushed  to  one  side,  while  the  outside  hand  presses  first  the  breech,  then  the  foot,  down  in  the  direc- 
tion of  the  inside  fingers.  The  fingers  seek  the  foot,  and  as  soon  as  this  is  grasped,  it  is  led  down 
into  the  vagina.  It  is  then  very  gently  drawn  out,  the  other  hand  outside  pressing  the  head  up- 
ward toward  the  fundus.     The  secret  in  the  performance  of  Braxton  Hicks'  version  is  complete 


PLACENTA    PILEVIA 


455 


nshixat/ujii  of  the  ahdoincii  and  utorus,  and  dcxlrous  aid  by  the  outside  luuid  in  jjn'.ssinK  the  foot 
into  tli(!  {i;rasp  of  tiii'  inside  fingers.  Tiie  f(jot  may  be  seized  with  a  long  placenta  forceps.  An 
anesthetic  may  be  necessary  for  a  few  moments,  but  as  soon  as  th(!  foot  is  secured  the  mask  should 
be  removed,  because  anemic  jjatients  d(j  not  do  well  with  anesthetics. 

If  (lie  placenta  covers  the  entire  os,  it  is  not  advi-sable  to  waste  valuable  seconds  in  seeking 
its  edge.     It  is  better  to  bore  through  the  most  accessible  portion. 

It  ha|)pens  occasionally  (hat  delay  is  caused  in  performing  the  version  after  the  membranes 
have  been  punctured.  Perhaps  the  ])atient  is  unruly  or  rigid,  or  the  bleeding  may  become  so 
great  (ha(  one  fears  for  (he  modier's  life.  In  such  ca.ses  (he  bleeding  may  be  temporarily  checked 
l)v  grasi)iiig  (he  placenta  and  uterine  wall,  as  in  Fig.  41;*.  "^I'his  will  give  the  operator  time  to 
collect  himself.  .Knot her  way  is  to  grasp  the  whole  cervix  with  the  inside  hand,  press  it  against 
the  head,  while  the  outside  hand  forces  the  whole  uterus  down  into  the  pelvis.  We  must  strive  to 
save  blood  every  inch  of  the  way. 


Fig.  41.5. — P.\ssixg  Colpeuryxter  into  Uterus. 


After  the  version  the  case  is  absolutely  under  control  (Fig.  414).  If  the  pla- 
centa is  pressed  fiat  against  the  uterine  wall,  the  woman  can  bleed  no  more,  and 
measures  may  be  instituted  to  replace  the  blood  she  has  lost.  Salt  solution  is 
administered  intravenously  or  hjqDodermicall}',  not  per  rectmii,  using  judgtnent  as 
to  the  proper  amount. 

Unfortunatel}',  this  method  sacrifices  a  large  number  of  children,  and  to  re- 
move this  opprobrium  Maurer  introduced,  and  Dlihrssen  urged,  the  second  method, 
metreurysis.  This,  in  brief,  is  the  use  of  a  rubber  balloon  to  take  the  place  of  the 
breech  in  tamponing  the  cer\'ix  and  lower  uterine  segment.  ^liiurer,  in  1887, 
described  this  manoeuver,  but  it  is  due  to  the  labors  of  Diihrssen  that  it  has  been 
generalized,  though  even  now  few  accoucheurs  are  aware  of  its  immense  advantages. 


456 


THE    PATHOLOGY   OF    PREGNANCY,    LABOR,    AND    THE    PUERPERIUM 


It  is  applicable  at  all  stages  of  cervical  dilatation,  before  the  os  is  sufficiently  open 
to  permit  delivery.  It  may  be  used  to  induce  labor,  or  it  may  be  used  when  version 
has  been  tried  and  has  failed.  One  may  dilate  the  cervix  sufficiently  to  proceed 
with  immediate  delivery,  or  one  may  dilate  sufficiently  for  the  performance  of 
version,  after  which  the  case  may  be  treated  according  to  conditions  as  they 
arise.  The  colpeurynter  (or  metreurjaiter)  marks  nearly  as  great  an  advance 
in  the  treatment  of  placenta  prsevia  as  chd  the  introduction  of  Braxton-Hicks' 
version.  JNIetreurysis  is  used  in  cases  where  the  condition  of  the  mother  and  child 
is  good.  When  the  mother  has  lost  little  blood  and  the  child  is  viable,  we  may 
take  a  reasonable  chance  on  a  little  greater  hemorrhage  for  the  sake  of  the  infant. 


Fig.  416. — Filling  Colpeurynter.     (Some  operators  prefer  a  piston  syringe.) 


Several  bags  are  on  the  market.  The  original,  Carl  Braun  colpeurynter,  is  as  good  as  any 
of  the  later  modifications,  and  I  use  it  considerably  (Fig.  795,  p.  911).  Voorhees,  of  New  York, 
made  a  modification  of  the  Champetier  de  Ribes'  inelastic  conic  balloon,  which  is  very  service- 
able, and  sizes  may  bo  gotten  large  enough  to  secure  complete  dilatation.  I  use  it  in  cases  in  wliich 
the  head  is  low  in  the  pelvis,  as  its  flat  top  does  not  displace  the  head  much. 

All  preparations  are  made  beforehand.  The  bag  and  the  bulb  syringe  for  filling  are  sterilized 
by  boiling  twenty  minutes  in  plain  water.  The  colpeurynter  is  emptied  of  air  first.  This  is 
accomplished  by  filling  it  with  0.5  per  cent,  lysol  solution,  then  inverting  it  so  that  all  this  fluid 
runs  out.  A  clamp  is  now  affixed  four  inches  from  the  end  of  the  tube.  The  air  is  all  pumped 
out  of  the  bulb  syringe  and  the  nozle  fitted  into  the  end  of  the  tube  of  the  colpeurynter.  For 
greater  security  this  tube  may  be  tied  on  with  tape.  The  bag  is  now  folded  lengthwise  into  as 
narrow  a  compass  as  possible,  and  then  grasped  by  the  long  uterine  packing  forceps.  The 
whole  apparatus  lies  in  a  basin  of  0.5  per  cent,  lysol  solution,  from  which  it  is  to  be  filled. 

The  membranes  are  now  punctured  as  for  the  performance  of  version,  and,  operating  quickly, 
guided  by  the  two  fingers  in  the  cervix,  the  bag  (Fig.  415)  is  placed  inside  the  uterus  on  top  of  the 


PLACENTA    PILEVIA 


457 


placenta.  He  careful  not  to  push  up  the  cdin'  of  the  placenta  so  that  it  douWes  up  under  the 
coli)eurynter.  Tiiis  would  allow  iiitra-uteriiie  heni(jrrliaK<'-  The  clanip  is  now  removed  from  the 
tube,  and  steadying  the  (•(jlpeurynter  on  the  placenta,  the;  (jther  hand,  by  slow  firessures  on  the  bulb 
of  the  syringe,  injects  the  re(|uired  amount  (jf  lysol  solution  (I'iM:.  JKi).  Fourteen  to  20  ounces  are 
required,  varying:  in  individual  cases.  Each  full  compression  of  the  bulb  of  the  syringe  is  about 
one  oimcc,  and  in  this  way  the  amount  may  be  estimated.  If  the  child  is  small,  the  bafz;  need  not 
be  fully  distended;  if  the  jjatient  is  at  term,  IS  to  20  ounces  aic  needed.  If  1o(j  much  solution  is 
injeete(|,  the  b.iji;  will  not  api)ly  it.self  to  the  placenta,  and  hemorrhage  will  continue,  upon  seeing 
which  one  will  alh^wa  few  ounces  to  escape  through  the  tui)e.  If  too  lit  I  le  is  injected,  thecoli)eurynter 
will  fall  out  before  the  os  is  sulhciently  dilated.  One  must  inject  slowly  in  order  not  to  overdistend, 
and  too  rapidly  stretch,  the  lower  uterine  segiment.  The  head,  of  cour.se,  is  disi)laced  b}'  the  col- 
peurynter,  but  this  cannot  be  avoided.  Since,  when  the  bag  is  expelled,  delivery  is  consunmiatod, 
little  harm  results  from  displacing  the  head.  After  the  bag  is  in  position  one  reassures  him.self  that 
the  placenta  is  underneath  it,  and  not  doubled  upon  itself,  and  withdraws  the  hand  from  the  vagina. 
Now  the  tube  is  clamix'd  with  an  artery  forceps  and  slight  traction  exerted  on  it  (Fig-.  417).  Only 
sufficient  pressure  is  brought  to  bear  on  the  placenta  and  cervix  as  will  stop  the  hemorrhage. 
This  accomi)lished,  the  accouch(nir  seats  himself  at  the  bedside  and  maintains  sliglit  traction  on 
the  tube  of  the  colpeurynter.     One  or  at  most  two  pounds  will  be  required,  and  to  determine  this 


flG.    417. COLPEUEYNTER    IN    PlACE. 

It  acts  like  the  breech  in  compressing  the  placental  site. 


one  may  insert  a  scale  in  the  line  of  traction,  or  fasten,  by  means  of  a  tape,  a  bottle  containing 
the  proper  amount  of  water,  and  hang  it  over  the  foot-board  of  the  bed. 

I  prefer  to  hook  the  ordinary  baby  scale  into  the  artery  forceps,  or  pull  on  it  myself,  and  thus 
personally  watch  the  traction.  Every  three  'or  four  minutes  one  should  relax  the  pull  to  allow 
blood  to  get  into  the  cervix.     An  anemic  cervix  will  tear  more  readily  than  one  properly  nourished. 

Pains  usually  come  on  within  an  hour,  and,  while  they  are  irregular,  they  accomplish  the 
effacement  and  dilatation  of  the  cervix.  After  an  hour  or  so  the  pains  become  more  regular. 
One  relaxes  the  pull  on  the  bag  during  the  pain,  resuming  it  when  the  contraction  is  over.  Aroid 
too  powerful  traction  on  the  bag.  This  may  rupture  the  cervix  and  lower  uterine  segment  directly, 
or  it  may  excite  such  powerful  uterine  action  that  this  ruptures  the  uterus.  I  have  had  one  such 
accident.  Indeed,  the  pains  must  not  be  allowed  to  become  too  strong  in  placenta  pra^via.  If 
such  a  danger  threatens,  stop  pulling  on  the  bag,  and  if  this  does  not  produce  the  desired  effect, 
allow  several  ounces  of  fluid  to  escai)e  from  the  bag. 

The  obstetrician  must  possess  a  large  fund  of  patience,  as  he  may  be  required  to  hold  onto 
the  colpeur>Titer  for  from  three  to  twelve  hours. 

The  next  point  of  imjiortance  in  the  treatment  is  to  determine  the  exact  moment  when  the 
colpemynter  passes  through  the  ccr\-ix.  If  one  neglects  to  note  this,  ])ulling  on  the  tube  brings 
the  bag"^  down  onto  the  perineum  and  a  large  quantity  of  blood  accumulates  between  it  and  the 


458      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

child  (Fig.  41S).  It  is  a  very  serious  loss,  because  one  cannot  control  the  hemorrhage  so  well 
after  dilatation  of  the  cervix  as  before,  unless  it  is  possible  to  dehver  at  once.  Sometimes  the  head 
follows  down  and  takes  the  place  of  the  colpeiuynter,  tamponing  the  cervix  securely.  These  are 
fortunate  cases,  and  one  has  nothing  to  do  but  watch  and  let  nature  take  the  lead.  It  is  advisable, 
as  soon  as  the  head  has  passed  the  cerAdx,  to  deliver,  because  the  child's  life  is  in  a  rather  precarious 
position,  and,  second,  the  placenta  may  separate  and  blood  may  accumulate  in  the  uterine  cavity. 

The  accouchem-  determines  that  the  colpeurynter  is  passing  the  cervix,  first,  by  noting  the 
steady  advancement  of  the  tube;  bj^  occasional  direct  internal  examination  one  feels  the  cervix 
slipping  oA-er  the  greatest  circumference  of  the  bag;  third,  the  patient  begins  to  bear  down,  and 
the  pain  has  a  sharp,  cutting  character;  fourth,  after  the  bag  has  passed  through,  the  pains  cease 
or  are  milder;  fifth,  the  bag  is  ex-pelled — but  the  two  latter  signs  show  dehnquency  on  the  part  of 
the  accoucheur.  By  the  time  the  bag  comes  to  pass  through  the  cervix,  the  attendant  must  be 
ready  to  dehver  or  to  do  a  version,  as  indicated.  The  time  consumed  in  getting  ready,  after  the 
bag  has  shpped  through  the  os,  may  mean  a  fatal  loss  of  blood. 

If  the  head  does  not  follow  the  metreurynter  into  the  pelvis,  the  operator  withdraws  the  bag 
quickly  from  the  vagina,  emptying  it,  if  necessary,  as  quickly  inserts  his  whole  hand,  and  grasps 
the  cervix  and  placenta  until  he  can  determine  on  the  course  of  procedure.     If  the  head  is  still 


Fig.  41S. — Bag  has  Passed  the  Cervix  and  Blood  has  Accumttlated  Behind  It. 

high,  he  tries  to  force  it  down  into  the  pelvis.  Tliis  will  stop  the  hemorrhage  and  allow  the  forceps 
to  be  applied.  If  the  head  does  not  go  into  the  pelvis,  podalic  version  is  to  be  performed.  If 
the  cervix  is  not  sufficiently  dilated  by  the  first  attempt  with  the  colpeurynter,  one  may  reinsert 
it  and  fill  it  with  a  still  larger  amount  of  water, — 20  to  24  ounces, — which  will  dilate  the  os  to  the 
size  of  the  fetal  head. 

The  heart-tones  of  the  child  must  be  carefully  noted  after  the  version  is  done 
and  during  the  time  the  colpeurynter  is  in  place.  If  the  cord  is  in  the  area  of  the 
placenta  compressed  by  the  breech  or  colpeurynter,  some  asphyxia  of  the  infant  is 
unavoidalile.  This  may  not  be  fatal,  but  is  very  unwelcome,  the  more  so  because 
we  are  practically  powerless  to  extract  the  child  until  the  cervix  is  dilated.  The 
most  we  can  do  is  to  try,  if  safe,  to  hasten  the  dilatation  of  the  cervix  somewhat. 
This  is  done  by  exerting  a  little  more  traction  on  the  breech  or  bag,  say  23^  pounds — 
with,  of  course,  the  precautions  already  emphasized.  If  an  urgent  indication  on 
the  part  of  the  child  for  delivery  should  arise  before  the  cervix  is  sufficiently  dilated, 
it  A\ill  have  to  be  disregarded.  The  danger  of  haste  is  too  great  for  the  mother. 
An  indication  for  delivery  will  not  arise  on  the  part  of  the  mother,  because  we  can 


PLACENTA    PILEVIA  459 

control  the  hemorrhage  by  the  colpeurynter  or  the  breech.  Great  hemorrhage  and 
collapse  do  not  indicate  rapid  delivery;  on  the  contrary,  the  sudden  emptying  of 
the  uterus  may  add  to  the  shock  and  turn  the  delicat(;  balance  against  th(j  woman. 
In  suchcasesof  severe  hemorrhage  and  slujck  the  (luickest  and  most  definitive  means 
of  stopping  the  hemorrhage  is  by  version  and  tamponing  the  lower  uterine  segment 
l>y  the  breech.  One  then  has  the  case  absolutely  under  control,  and  now  the  pa- 
tient may  })e  stimulated  and  her  blood-loss  replaced  with  saline  solution. 

Sine  e  there  is  no  hemorrhage,  there  is  not  tlu^  shadow  of  a  reason  for  hurry. 
Theses  hours  nui}^  be  employed  in  supplying  th(^  woman  with  fluids,  as  saline  solution 
hypodermically,  food,  etc.  The  woman  recovers  from  the  shock  of  her  first  hem- 
orrhage. The  hours  are  also  useful  for  the  preparations  for  delivery.  No  detail 
should  1)e  omitted,  and  everything  must  be  gotten  ready  and  rehearsed  before- 
hand, so  that  when  the  delivery  is  to  be  made,  not  an  instant's  delay  need  be 
tolerated.  A  complete  set  of  obstetric  instruments  should  be  sterilized,  especial 
jirovision  being  made  for  the  treatment  of  postpartum  hemorrhage.  Needles,  long 
needle-holder,  vulsella,  specula,  etc.,  for  sewing  lacerations  of  the  cervix  may  be 
needed,  as  well  as  gauze  and  long  uterine  packing  forceps  for  tamponing  the  uterus, 
(lood  light  and  a  tal)le  on  which  to  place  the  patient  for  delivery  should  be  gotten 
ready,  and  provision  made  for  the  resuscitation  of  the  child — tracheal  catheter, 
hot  bath,  hot  towels,  etc,  should  be  at  hand. 

The  nurse  prepares  the  douche-bag  for  giving  a  hot  (120°  F.)  injection  of  sterile 
water,  and  sees  that  there  is  a  supply  of  sterile  solutions,  sponges,  towels,  etc.  As 
a  rule,  the  cervix  may  be  sufficiently  prepared  to  permit  deliverj^  but  let  me  again 
sound  the  warning — Beware  of  too  hasty  extraction  through  a  poorly  dilated  cervix! 
The  laceration  of  the  highly  vascularized  cervix  is  one  of  the  most  formidable  acci- 
dents the  accoucheur  could  meet.  The  uteroplacental  sinuses  are  so  superficial  that 
a  tear  3  s  ii"icb  deep  may  lay  one  open.  The  contraction  and  retraction  of  the  lower 
uterine  segment  are  poor  at  best,  and  poorest  in  placenta  prsevia,  and  this  means  of 
hemostasis  is  not  strong,  so  that  the  cases  of  fatal  hemorrhage  from  even  tiny  tears 
of  the  placental  site  are  easily  explained.  Slowest  possible  delivery  is  to  be  prac- 
tised. If  the  head  is  restrained  by  a  tight  cervix,  the  accoucheur  must  not  use  force 
to  extract  it,  but  must  courageously  allow  the  infant  to  die.  The  child  is  so  often 
already  lost  that  this  painful  advice  is  seldom  needed.  An  attempt  to  let  air  into 
the  child's  lungs  must  be  made  by  pulling  the  vagina  back  with  a  speculum,  and, 
after  cleansing  the  fauces,  depressing  the  jaw  with  the  fingers,  an  expedient  which 
was  recommended  by  Pugh,  in  1754,  though  not  in  such  cases. 

Should  placenta  prsevia  occur  in  a  primipara  or  in  others,  and  the  cer\dx  be 
closed  so  that  one  finger  may  not  be  introduced,  the  case  becomes  more  formidable 
still.  For  such  patients  the  vaginal  tampon  and  the  colpeurjiiter  have  been  recom- 
mended. There  are  real  objections  to  both  on  the  score  of  sepsis  and  inefficiency. 
Unless  the  head  is  firmly  engaged  in  the  pelvis,  the  tampon  "will  not  exert  sufficient 
compression  on  the  cervix  and  placenta  against  the  head  to  check  bleeding  in  this 
manner.  Then  the  external  is  converted  into  an  internal  hemorrhage.  The  same 
is  true  of  the  colpeurynter.  I  have  never  failed  to  pass  the  colpeurjTiter  into  the 
uterus,  and  I  never  use  the  tampon  except  provisionally,  during  the  transportation 
of  the  patient,  or  wdiile  other  preparations  are  being  completed.  It  is  for  these 
cases  that  cesarean  section  has  been  recommended. 

Treatment  During  the  Third  Stage. — ^lany  patients  have  l^een  lost  at  this  point, 
ha\'ing  l^een  skilfully  carried  through  the  two  other  stages.  It  is  necessary  to  save 
blood  ^\^th  every  move.  As  soon  as  the  child  is  delivered,  as  in  cesarean  section, 
it  is  handed  to  a  competent  assistant,  the  operator  devoting  all  his  attention  to  the 
mother.  Even  a  moderate  hemorrhage  now  demands  the  immediate  removal  of  the 
placenta.  Since  contraction  and  retraction  of  the  bed  of  the  placenta  are  imperfect, 
and  especially  since  its  structure  may  be  pathologically  altered,  the  delivery  of  the 


460      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

placenta  is  slow  and  adherences  may  be  met  with,  some  of  which  are  so  tough  that 
the  finger  cannot  l^reak  them.  As  soon  as  the  placenta  is  removed  the  uterus  usually 
contracts  strongly  and  bleeding  ceases.  Watch  closely,  pulling  open  the  vagina  with 
a  speculum  to  see  if  blood  continues  to  escape  from  the  cervix,  and  if  it  does,  tampon  the 
whole  uterovaginal  tract  firmly.  Waste  no  precious  seconds  on  uncertain  methods 
of  hemostasis,  but  in  the  presence  of  such  urgent  symptoms  use  the  most  radical  and 
definitive  means  we  have.  During  the  ten  to  twenty  seconds  while  waiting  for  the 
gauze  hold  the  uterus  securely  in  forced  anteflexion  (Fig.  718).  (See  Treatment  of 
Postpartum  Hemorrhage,  p.  775.) 

In  placenta  prsevia  a  tiny  laceration  may  give  rise  to  a  fatal  bleeding.  The 
soft,  vascularized  cervix  is  difficult  to  hold  for  suturing,  and  it  may  be  impossible 
to  sew  up  a  laceration  or  to  sew  it  up  quickly  enough  to  save  an  already  exsangui- 
nated woman.  In  suturing  a  laceration  of  the  cervix  it  is  necessary  to  expose  the 
field  thoroughly  by  broad  retractors  (Fig.  689).  The  lips  are  grasped  with  the 
vulsellum  forceps,  and  the  tear  brought  within  reach  of  the  needle.  Usually  the 
field  is  so  flooded  with  blood  that  it  is  impossible  to  see  where  to  sew.  A  bullet 
forceps  may  l^e  laid  temporarily  on  each  side  of  the  uterus,  seeking  to  secure  the 
uterine  arteries  in  the  bases  of  the  broad  ligaments  (Henkel) .  In  one  such  case  I 
packed  the  uterus  and  the  rent  in  the  broad  ligament  firmly  with  gauze,  thus  stop- 
ping the  furious  flow,  after  which  the  lips  of  the  cervix  were  united  over  the  tampon, 
thus  closing  up  the  uterus  entirely  (Fig.  725).  The  vagina  was  snugly  packed  with 
drj^  cotton,  to  exert  counterpressure.  The  sutures  were  removed  the  next  day  and 
the  gauze  two  clays  later.     The  patient  recovered. 

Before,  during,  and  after  delivery  in  cases  of  placenta  prsevia  it  is  often  neces- 
sary to  treat  the  anemia.  If  the  mother  has  lost  much  blood,  give  her  saline  solu- 
tion under  the  skin,  not  per  rectum,  as  this  interferes  with  the  asepsis  of  the  local 
treatment.  When  the  bowels  are  moving  over  the  field  of  operation,  it  may  be  im- 
possible to  avoid  carrying  the  discharges  into  the  uterus.  Saline  solution  is  to  be 
given  even  if  the  hemorrhage  is  going  on,  as  then  the  patient  does  not  lose  pure 
blood,  but  blood  mixed  with  salt  solution.  We  do  not  wait  for  fainting  to  stop  the 
hemorrhage  in  placenta  prsevia.  The  author  has  administered  a  gallon  of  saline 
solution  under  the  skin  and  it  was  absorbed  as  fast  as  it  could  be  injected,  and,  after 
the  local  treatment  of  the  case  was  completed,  two  quarts  more  per  rectum,  with 
success.     Such  large  amounts  are  seldom  required. 

Other  Methods  of  Treatment. — Accouchement  force,  the  rapid  dilatation  of  the 
cervix,  tearing  and  cutting  it,  if  necessary,  followed  by  the  immediate  delivery  of  the 
child,  has  no  place  in  the  treatment  of  placenta  prsevia.  The  author  believes  it  is 
almost  criminal,  and  it  is  opposed  to  all  recognized  principles  of  treatment.  The 
results  condemn  it,  and  Kerr  says,  judging  from  mortalities,  it  is  the  worst  of  all 
methods.  Treul)  retracts  his  recommendation  of  it,  saying  that  his  mortality  was 
18.25  per  cent,  for  the  mothers  and  48  per  cent,  for  the  children.  Miiller  showed 
44  per  cent,  maternal  mortality  and  62.7  per  cent,  for  the  children.  Gentle  dilata- 
tion is  wanted,  for  even  the  soft-rubber  bag  may  rupture  the  cervix  unless  properly 
handled. 

The  same  may  be  said  of  Bossi's  branched  powerful  steel  dilator  and  of  the 
others  of  the  class. 

Separation  of  the  placenta,  or  its  removal  })efore  delivery  of  the  child  (Simpson, 
1840),  is  obsolete.  Miller,  of  Pitts) )urgh,  ligated  the  uterine  arteries  in  11  cases, 
saving  the  first  and  last  eight  of  them. 

Cesarean  section,  first  performed  by  Tait,  is  gradually  gaining  reluctant  recog- 
nition. Especially  favored  by  American  surgeons  and  gynecologists,  it  was  con- 
demned by  American  and  European  obstetricians, — Ehrenfest,  Hirst,  Holmes, 
Schauta,  Hofmeier,  Ahlfeld, — but  very  recently  the  operation  has  begun  to  enjoy 
more,  and  I  think  just,  popularity.     Williams  and  Edgar  give  it  qualified  approval, 


PLACENTA    PREVIA  461 

Sellhoim,  Kniiiip;,  Pankov,  P.  Dudley,  Fry,  Donoghuo,  Zinke,  Kerr,  Laptliorn 
Smith,  Bar,  Rccasons  (Madrid)  recommend  it — of  course,  in  well-chosen  cases.  At 
the  meeting  of  the  American  (lynecologic  Society,  Ajjril,  1009,  the  subject  was 
thoroughly  iiandled,  and  wiiile  the  opinions  were  divided,  a  perusal  oi  the  transac- 
tions is  ciMU'incing  that  cesarean  section,  in  tlu;  hands  of  the  expert  abdominal 
operator,  is  a  valuable  addition  to  our  treatment.  Cesarean  section  has  a  general 
mortality  of  4  per  cent,  in  favorable  cases;  it  should  be  no  more  than  this  in  favor- 
able cases  of  placenta  previa,  and  tliere  is,  in  addition,  the  reduction  of  the  infant 
mortality  from  50  to  5  per  cent.  Placenta  ])ripvia,  under  the  usual  methods,  shows 
at  best  4  per  cent,  mortality,  and  its  treatment  entails  great  anxiety,  much  loss  of 
time,  and  requires  exceptional  obstetric  skill  to  save  both  mother  and  child.  In 
the  isthmial  variety,  where  tiie  placenta  is  implanted  squarely  over  the  internal  os 
antlhanjijslike  a  festoon  al)oveit,thomaternalniortalityis  so  high  that  the  abdominal 
delivery  is  strongly  the  method  of  choice.  Without  going  further  into  the  discus- 
sion, I  will  state  my  position:  an  indication  for  cesarean  section  will  arise  in  cases 
of  central  and  of  partial  placenta  praivia,  when  the  pregnancy  is  at  or  near  term, 
with  a  living  child,  the  mother  in  good  condition,  the  cervix  being  closed  or  promis- 
ing difficulty  in  dilatation,  conditions  most  common  in  primiparae.  A  necessary 
requirement  also  is  that  the  aseptic  facilities  of  a  good  maternity  can  be  had,  or 
improvised  at  home,  and  a  man  capable  of  his  task  is  obtainable.  The  opportuni- 
ties for  performing  the  abdominal  delivery  with  all  these  conditions  filled  will  be 
quite  rare. 

In  the  exigencies  of  general  practice,  and  in  the  usual  bad  surroundings  in 
which  these  cases  come  to  the  accoucheur,  it  is  found  that  the  best  method  of  treat- 
ment is  Braxton-Hicks'  version  and  very  slow  spontaneous  delivery.  Next  comes 
the  metreurynter. 

Vaginal  cesarean  section  was  performed  by  Dlihrssen  and  is  recommended  by 
Bumni  for  placenta  prsevia.  It  is  condemned  by  most  writers,  among  whom  are 
Kerr,  Spencer,  Peterson,  Newell,  Hofmeier,  Hannes.  I  have  done  it  once  with,  suc- 
cess, when  the  placenta  was  low  in  the  uterus  and  had  partly  separated,  but  believe 
that  the  operation  is  not  to  be  recommended  in  the  treatment  of  placenta  prsevia. 

Very  recently  extraperitoneal,  suprasyraphyseal  cesarean  section  has  been  ad- 
vocated for  these  cases  (Sellheim).  The  author  has  no  experience  with  the  opera- 
tion, liut  from  published  reports  believes  that  the  indication  will  receive  scant 
recognition. 

Literature 

Bar:  L'Obstetrique,  September,  1909. — Devraigne:  L'Obstetrique,  November,  1911,  p.  9G1. — Doranth:  Chrobak's  Be- 
richte  und  Arbeiten,  Wien,  1S97. — Fry:  Amer.  Jour.  Obstet.,  June,  1909. — Goodman:  "Cervical  Placenta  Praevia," 
Jour.  Amer.  Med.  Assoc,  October  14,  l<dl\.—Henkel:  Arch.  f.  Gyn.,  190S,  vol.  lxxx\-i.  Heft  3,  p.  703.— Hof- 
meier: Hand.  d.  Geb.  v.  Winckol,  vol.  ii,  H.  2,  p.  12S5. — Kerr:  Operative  Midwifery,  p.  591. — Kronirj:  Cent, 
f.  Gyn.,  1909,  No.  3-1.— McDonald:  Surg.,  Gyn.  and  Obst.,  June,  1911,  also  July.  Literature. — Miller:  Amer. 
Jour.  Surg.,  January,  1909. — Mullcr:  Handbuch  d.  Geb.,  vol.  ii,  2,  p.  V251.^Puoh:  Treatise  on  Midwifery, 
1754,  p.  -iQ.—Ramsbolham:  1S65,  p.  S72.— Sellheim:  Centralbl.  f.  Gyn.,  190S,  No.  ■iO.—Smellie:  Treatise  of 
Midwifery,  1779,  pp.  1 1.3  and  120,  note. — Treub:  Centralbl.  f.  Gyn.,  1908,  p.  142S.— ».  Weiss:  Centralbl.  f. 
Gyn.,  1897,  No.  22,  p.  041. 


CHAPTER  XXXV 
MULTIPLE  PREGNANCY 


Placing  this  subject  in  the  pathology  of  pregnancy  might  ehcit  comment,  but 
the  succeeding  pages,  sho'wdng  the  frequency  of  maternal  disease  and  of  fetal  death, 
will  prove  that,  in  the  human  female,  having  more  than  one  offspring  at  a  time  is 
distinctly  abnormal.  It  is  an  atavistic  reversion,  and,  in  general,  such  reversions 
are  abnormal.  Tmns  occur,  according  to  Guzzoni,  who  studied  over  50,000,000 
births,  once  in  87  cases,  triplets  once  in  7103;  quadruplets  once  in  757,000;  quin- 
tuplets once  in  41,600,000  births.  Over  30  cases  of  quintuplets  have  been  reported. 
Yassali  reports  an  authentic  case  of  sextuplets,  at  Lake  Lugano,  there  being  de- 
livered at  the  fourth  month  two 
female  and  four  male  children 
with  a  total  weight  of  1730  gm. 

The  frequency  of  multiple 
pregnancy  varies  with  the  fertil- 
ity of  the  people  (Peuch,  1873), 
and  the  fertility  varies  in  different 
countries  and  at  different  periods ; 
thus  in  Ireland  and  Russia  twin 
births  are  commoner  than  in 
France,  where  the  birth-rate  is 
low. 

Multiparse,  especially  those 
giving  birth  frequently,  are  more 
likely  to  have  twins,  and  the  prob- 
ability increases  after  the  age  of 
thirty-three  years  in  both  par- 
ents. A  hereditary  disposition 
is  certain,  and  the  tendency, 
while  usually  transmitted  by 
the  mother,  may  also  be  given 
through  the  father.  It  is  also 
noted  in  the  lower  uniparous  ani- 
mals, for  example,  the  cow  (Dun- 
can) .  Marriage  of  twins  increases 
the  potency  of  the  hereditary  im- 
pulse. Twins  and  triplets  are 
likely  to  be  repeated  in  the  same 
family.  Cases  of  unusual  fertility  are  not  rare.  Geisler  tells  of  a  woman  physician 
(Mary  Austin)  who,  in  thirt^^-three  years'  wedlock,  had  13  twin  and  6  triplet  births, 
a  total  of  44  children,  her  sisters  having  41  and  20  children  respectively  (Strassman). 
Sue  tells  of  a  Parisian  whose  wife  bore  him  21  children  in  seven  years,  and  who 
seduced  a  servant  who  then  delivered  triplets. 

Causation. — Generally,  two  kinds  of  twins  are  distinguished,  those  coming 
from  separate  and  distinct  ova  and  those  from  one  ovum.  Two  eggs  escaping  from 
an  ovary  at  the  same  time  may  he  fertilized  and  develop  synchronously  in  the  uterus. 
These  eggs  may  even  come  out  of  the  same  Graafian  follicle,  since  such  follicles, 

462 


Fig.  419. — Double  Ovum  Twins. 
Black  lines  are  decidua;   red,  the  chorion;    blue,  the  amnion. 


MULTIPLE    PREGNANCY 


463 


and  ovon  some  containing  tlin-c  <'fi;}i;.s,  have  frcfiucntly  l)oon  soon.  Each  ovary  may 
furnLsli  on(>  of  tlic  (n-a.  Wlicn  t\v(j  or  more  separate;  (jva  Icjcatc  in  the  uterus,  wo 
have  (Hstinct  ovular  formations  (h'veloping  side  by  side  (Fig.  419).  If  the  ova  locate 
far  from  each  other,  two  distinct  plac(!ntas  develop;  if  near  each  other,  the  two  pla- 
centas fuse,  but  their  circulations  do  not  (Schatz).  Since  in  such  cases  each  cliild 
has  its  own  anmion  and  chorion,  where  the  membranes  lie  ai)i)osed  a  septum  will 
be  iound  made  up  of  four  lasers — an  amnion  and  a  chori(jn  for  each  fetus.  (Occa- 
sionally (l((i(lu;il  remnants  will  be  found  in  the  septum,  the  relics  of  the  deciduae 
capsulares  or  rellexa)  of  the  early  stages  of  the  development  of  the  ova.  Theoreti- 
cally, one  might  insist  on  hnding  six  layers  in  the  sej)tum  of  double  ovum  twins — 
two  decidua',  two  chorions,  and  two  amnions. 

The  etiology  of  twins  from  one  ovum,  called  homologous,  or  monochorionic, 
is  still  a  mystery.  Aristotle  knew  that  two  embryos  could  come  from  an  egg  with 
two  ycjlks,  and  three  embryos 
have  been  found  in  one  egg.  Two 
nuclei  have  l)een  found  in  one 
3'olk,  and  Kolliker,  Stockel,  and 
von  Franque  found  double  ger- 
minal vesicles  in  the  human  egg. 
If  such  an  ovum  is  to  be  fertil- 
ized, two  polar  bodies  must  first 
be  extruded,  and  two  spermato- 
zoids  are  needed  for  fertilization, 
which  theoretically  is  not  impos- 
sible, l)ut  then  Ave  would  have 
two  chorions  developed  and  the 
findings  would  be  the  same  as  if 
two  different  eggs  had  been  im- 
pregnated. Perhaps  we  shall 
learn  hereafter  that  such  an  oc- 
currence has  been  proved.  An- 
other theory  is  that  on  one 
germinal  vesicle  two  primitive 
streaks  develop,  that  is,  double 
gastrulation  occurs.  Two  sper- 
matozoids  entering  the  ovum 
probably  cannot  produce  this 
condition,  because  ova  fertilized 
in  this  way  usually  die. 

If  the  two  embryonal  spots 
develop  close  to  each  other,  it 
is  possible  that  one  amnion  will 

inclose  the  two  fetuses;  if  far  from  each  other,  each  fetus  will  have  a  separate 
amnion  (Fig.  420).  The  older  writers  held  that  always  two  amnions  developed, 
but  that  the  septum  atrophied  and  disappeared.  Only  about  40  cases  are  on 
record  of  twins  \vithout  a  septum  between  the  two  sacs,  that  is,  lying  in  one 
amniotic  cavity.  Should  the  separation  of  the  two  embryonal  areas  be  incomplete, 
a  double  monster  will  result  (Sobotta);  therefore,  according  to  the  theory  that 
homologous  twins  are  the  result  of  the  fission  of  the  embryonal  area  into  two  parts, 
and  their  separate  development  into  fully  formed  fetuses,  we  must  conclude  that 
double  monsters,  like  the  Siamese  twins,  are  the  result  of  incomplete  fission  and  not 
of  fusion.  A  monster  with  four  legs  would  mean  fission  at  the  lower  ]:)ole,  and  one 
with  two  heads  fission  at  the  cephalic  pole  of  the  embryonal  area.  It  is  regretable 
that  we  have  little  scientific  foundation  for  these  plausible  theories. 


Fig.  420. — Homologous  or  Single  Twins. 
Black  lines  are  decidua;   red,  the  chorion;   blue,  the  amnion. 


464 


THE    PATHOLOGY    OF    PREGNANCY,    LABOR,    AND    THE   PUERPERIUM 


Characteristics. — The  placenta  in  unioval  twins  is  always  single;  there  are 
usually  two  cords,  but  rarely  only  one  which  bifurcates  near  the  fetuses,  and  these 
are  monoamniotic  ova;  the  blood-vessels  anastomose  on  the  surface  of  the  placenta, 
and  also  in  the  villi  themselves,  producing  a  third  or  intermediate  circulation  be- 
tween the  twins.  The  septum  of  the  placenta  never  shows  traces  of  decidua,  and 
only  two  layers,  the  two  amnions,  can  be  found  in  it.  The  children  are  said  to  be 
very  much  alike  in  size  and  in  mental  and  physical  characteristics,  but  the  author 
has  not  found  this  to  be  constant.  Unioval  twins  are  rare,  Ahlfeld  in  1157  cases 
finding  only  15.55  per  cent. 

Triplets  and  even  quadruplets  may  come  all  from  one  ovum,  but  usually  two 
ova  are  concerned,  one  of  which  may  bring  forth  two  fetuses. 

In  length  and  weight  twins  usually  differ  more  or  less,  4  cm.  and  2200  gm. 


Fig.  421. — Acardiacus  Amorphuij.     (Northwestern  University  Medical  School  specimen.) 


being  the  limits  respectively.  Twins  are  usually  smaller  than  single  children,  but 
the  combined  weight  is  greater.  The  same  proportion  of  boys  and  girls  obtains 
with  twins  as  in  general.  Twins  from  one  ovum  are  smaller  than  those  from  two, 
and  the  difference  in  weight  is  not  so  great;  also  they  have  a  higher  mortality  and 
are  more  often  deformed.  The  same  deformity  often  exists  in  both  twins,  as  in 
one  of  the  author's  cases,  double  harelip,  and  one  of  C.  E.  Black,  rudimentary  colon. 
It  is  said  the  tendency  to  this  form  of  twins  is  not  hereditary  (Strassman) .  Eclamp- 
sia is  more  common  with  unioval  twins.  Homologous  twins  are  always  of  the  same 
sex.  The  two  circulations  anastomose  in  the  common  placenta,  artery  to  artery, 
vein  to  vein,  and  artery  to  vein  through  the  third  circulation,  the  intercommunicat- 
ing villus  tree.  The  anastomosis  of  the  two  blood  systems  was  known  to  Portal, 
who,  therefore,  advised  the  tying  of  the  cord  of  the  first  child  delivered  to  prevent 
the  other  from  bleeding  through  the  open  vessels.     As  a  result  of  this  arrangement 


MULTIPLE    PREGNANCY 


465 


many  anomalies  arise  out  of  the  imociuul  (listri]>ution  and  size  of  tlu^  placental 
vessels  and  unequal  nutritional  conditions.  The  heart  of  one  child,  because  of  its 
l)(>tter  nourishment,  iiia>-  overpower  that  of  th(^  other  throuf^'h  the  anastomotic 
vessels.  If  this  occurs  at  an  early  j^eriod,  tlu^  weaker  heart  dilates  into  a  tortu(jus 
vessel,  the  fetus  remains  undeveloped  and  becomes  a  parasite  on  its  stronger  brother 
(Fig.  421),  It  is  called  an  acardiacus.  If  one  fetus  dies  after  being  fully  developed 
and  is  long  retained  in  the  uterus,  it  is  changed  into  a  ftt'tus  compressus  (Fig.  422). 
Sometimes  th(>  stronger  fetus  causes  a  jjolyhydranmion,  according  to  Strassman, 
l)ecause  its  hy])ertroi)hied  heart  and  kidneys  produce  more  urine,  while  the  weaker 
suffers  from  oligohydramnion.  Polyhydramnion  is  so  common  with  twins  that 
when  it  is  discovered,  the  existence  of  the  latter  is  to  be  suspected.  If  the  twins  lie 
in  one  amniotic  cavity,  the  two  umbilical  cords  may  be  twisted,  causing  the  death 
of  one  or  l)oth  fetuses. 

Dichorionic  or  dou])le-ovum  twins  are  also  subject  to  abnormalities.  One 
fetus  may  die  and  be  expelled,  the  other  going  normally  to  term.  The  author  de- 
livered a  woman  at  term  of  twins,  and  she  stated  that  five  months  previously  she 
had  had,  in  New  York  city,  an 
abortion  of  four  months.  Again 
the  dead  fetus  may  be  retained, 
and  the  liquor  amnii  being  ab- 
sorbed, it  is  flattened  against 
the  wall  of  the  uterus,  a  dry, 
shrunken  mass  (Fig.  422).  It 
may  present  before  the  normal 
fetus,  giving  rise  to  diagnostic 
errors,  and  it  may  be  lost  in  the 
uterus  after  delivery  of  the  pla- 
centa and  cause  puerperal  infec- 
tion and  late  hemorrhages.  The 
placenta  of  the  compressed  fetus 
is  white,  hard,  fibrous,  infarcted, 

and  demarked  sharply  from  that  of  the  normal  fetus,  and  this  finding  on  the 
placenta  will  arouse  the  suspicion  of  the  accoucheur  that  another  fetus  has  been 
retained  in  utero. 

Superfetation  is  the  nesting  of  a  second  fetus  in  the  uterus  aheady  occupied  b}'  one  in  the 
process  of  development.  Its  occurrence  has  been  held  possible  by  American  and  French  authors, 
while  the  English  and  German  writers  usually  deny  it.  A  double  uterus  may  carry  a  child  in 
each  compartment,  as  in  the  cases  quoted  bj'  Ramsbotham — one,  where  a  woman,  five  months 
and  sixteen  days  after  the  delivery  of  a  living  seven  months'  child,  delivered  another  of  full 
development,  and  another  where  two  well-formed,  fully  developed  boys  were  born  three  months 
apart.  These  cases  should  not  be  called  superfetation.  Since  the  decidua  reflexa  does  not 
unite  with  the  vera  until  the  middle  of  the  fourth  month,  and  since  ovulation  occurs  during 
pregnancy,  theoretically  superfetation  is  possible,  but  in  most  instances  cannot  be  proved.  Dif- 
ferences in  the  size  of  the  fetuses  may  be  explained  by  unequal  development,  but  F.  T.  .\ndrews, 
Barry,  and  the  author  have  seen  specimens  which  prove  the  occurrence  of  superfetation  in  the 
human  female.  Dr.  Zinnnerman,  of  Cameron,  Illinois,  found  a  healthy  o^'^ml  of  four  weeks, 
together  with  a  healthy  fetus  of  ten  weeks,  in  an  aborted  mass.  A  specimen  was  shown  to  the 
Gynecologic  Society  of  Chicago  of  two  extra-uterine  pregnancies  of  different  dates  which  had  been 
removed  at  operation. 

Suj)rrJ'ccuii(lation  is  the  impregnation  of  two  different  ova,  about  the  same  time,  by  sperma 
from  dttt'erent  fathers.  Its  occurrence  in  animals  is  ])rov<'d,  but  though  doubted  for  the  human, 
is  possible.  A  negro  woman  gave  birth  to  a  black  and  a  nmlatto  child,  after  intercourse  with  a 
black  and  a  white  man.  A  white  woman  gave  birth  to  a  white  and  a  negro  child,  but  both  these 
may  occur  with  only  one  father.  To  prove  superfecundation  we  must  ask,  with  Schultze,  that  a 
woman  after  intercourse  with  two  men  of  different  races  and  other  than  her  own  bear  twins 
showing  the  characteristics  of  both  sires. 

Clinical  Course. — Plural  pregnancy  always  gives  rise  to  disturbances  on  the 
part  of  both  mother  and  child.     The  s\mipathetic  symptoms,  nausea,  and  vomiting, 
are  usually  exaggerated;  toxemia,  varices,  and  edema  are  more  marked;  the  great 
30*^ 


Fig.  422. — Two  Views  of  a  Fcetus  Papyraceus  or  Compressus. 
The  head  of  the  second,  well-developed  child  lay  in  the  hoUowed- 
out  chest  of  the  first  one,  the  fcetus  compressus. 


466 


THE    PATHOLOGY    OF   PEEGNANCY,    LABOR,    AND    THE    PUERPERIUM 


34.2 
per 

cent 


distention  of  the  abdomen  interferes  with  the  bowels,  urination,  and  respiration, 

especially  if  hydramnion  complicates  the  condition. 
Softening  and  relaxation  of  the  pelvic  joints  are  some- 
times extreme,  which,  added  to  the  great  abdominal 
distention  and  the  weight  of  the  large  uterus,  make 
locomotion  difficult  or  impossible.  Either  because  the 
several  fetuses  produce  too  much  toxin  or  because  the 
kidneys  are  laboring  under  mechanical  difficulties  the 
kidney  of  pregnancy,  nephritis,  and  eclampsia  are  much 
more  common  than  in  single  pregnancy.  Edema  and 
even  ascites  may  occur;  indeed,  a  pregnancy  without 
edema  is  almost  positively  a  single  one.  The  heart  has 
a  double  burden,  and,  if  already  diseased,  may  fail. 

About  70  per  cent,  of  duplex  pregnancies  termin- 
ate before  term,  and  practically  all  triplet  and  quad- 
ruplet gestations  do  so.  Premature  labor  is  caused  by 
the  overdistention  of  the  uterus,  the  lower  uterine  seg- 
ment and  cervix  being  developed"  earlier  than  usual, 
and  the  presenting  part  engaging  in  the  pelvis.  Ac- 
cording to  the  latest  theory,  labor  comes  on  sooner  be- 
cause of  the  larger  amount  of  ferment  produced  by  the 
two  fetuses,  stimulating  the  uterus  to  action. 

Labor  with  twins  is  often  abnormal.  Owing  to 
the  overstretcliing  of  the  uterine  muscle,  the  pains  are 
weak  and  intermittent,  labor  drags  on,  sometimes  for 
days,  ef^acement  and  dilatation  of  the  cervix  are  slow, 
and  the  parturient  loses  sleep  and  becomes  early  ex- 
hausted. Many  peculiarities  are  noted  in  the  mechan- 
ism of  labor.  Since  the  children  are  small  and  there 
is  usually  much  liquor  amnii,  we  observe  frequent 
changes  of  presentation  and  position  during  pregnancy, 
and  also  during  labor,  sometimes  produced  by  the  de- 
livery of  one  of  the  twins.  For  example,  while  one 
child  comes  through  head  first,  the  second  changes  from 
shoulder  to  breech  presentation.  Werth  gives  the  fol- 
lowing table  of  1688  tmn  births: 

Both  children  in  cephalic  presentation .  .  47.4  per  cent. 

Head  and  breech  presentation 34.2 

Both  breech  presentation 8.4 

Head  and  transverse  presentation 5.8 

Breech  and  transverse  presentation  ....   3.6 
Both  transverse  presentation 0.47 


3.6 
per 
cent. 


Fio.   423. 


Table  of 


The  sacs  occupied  by  the  twins  usually  lie  side  by 
side  (Fig.  425),  but  one  may  lie  in  front  of  the  other 
(Fig.  424)  or  even  on  top  of  the  other.  In  the  last  in- 
stance the  second  child  during  delivery  has  to  pass 
through  the  empty  amniotic  cavity  of  the  first,  and 
the  second  opening  in  the  membranes  will  be  found 
in  the  septum.  The  children  usually  lie  parallel,  one 
on  each  side  of  the  spinal  column,  V:)ut  one  may  lie  an- 
teriorly and  the  other  be  entirely  beyond  the  reach 
of  the  palpating  hand.  Occasionally,  when  the  amount 
of  li(}Uor  amnii  is  small,  the  children  are  dovetailed 
into  each  other,  and,  under  like  conditions,  if  the  two 


MULTII'MO    PREGNANCY 


467 


hoads  are  apposed,  thoy  may  be  faceted.  In  one  of  I  lie  author's  cases  the  flatten- 
ing of  tlie  forelieads  of  tlu^  children  was  noticeabk^  afte-r  several  years. 

If  one  placenta  lies  above  the  other,  it  is  not  rare  to  find  the  1ow(t  edge  of  the 
common  placenta  near  or  over  the  internal  os.  Placenta  praevia  with  twins  en- 
dangers three  lives.  Transverse  and  ])reech  presentations  are  favored  b}'  tin;  low 
implantation  of  the  common  placenta. 

Owing  to  the  shape  of  the  uterus,  the  child  lying  in  its  left  half  usually  is  lower 
and  presents  and  is  delivered  first.  The  uterine  muscle  now  has  a  chance  to  shorten 
and  get  a  better  grip  on  its  contents.  Another  bag  of  waters  forms,  ruptures,  and 
the  second  fetus  is  extruded,  usually  more  fiuickly  than  the  first,  because  the  muscle 
is  stronger  and  there  is  no  resistance  from  the  soft  parts.  The  interval  b(;tween  the 
deliveries  varies  from  a  few  minutes  to  forty-four  days  (Carson).  Reference  has 
already  been  made  to  the  abortion  of  one  twin  w^hile  the  other  was  carried  to  term. 


Fig.  424. — Twins,  Oxe  in  Front  of  the  Other. 


It  is  impossible  to  show  bj'  figures  the  natural  interval  between  the  two  births,  be- 
cause, as  a  rule,  the  accoucheur  hastens  the  second  delivery.  Usually  the  second 
child  follows  the  first  after  thirty  to  forty  minutes.  In  one  of  the  author's  cases 
the  head  of  the  second  followed  the  feet  of  the  first. 

Now,  the  uterus  contracts  firmly  down  on  the  placenta,  and  in  a  small  majority 
of  cases  the  third  stage  is  natural.  Hemorrhage,  however,  is  more  profuse  and  the 
after-pains  are  harder. 

Diagnosis  of  Twins. — Very  rarely  has  the  diagnosis  of  triplets  been  made  before 
delivery.  Pinard,  of  Paris,  and  Fletcher  Bell,  among  others,  did  it.  Twins  may 
almost  always  be  diagnosed  during  pregnancy  if  the  examiner  is  suflBiciently  atten- 
tive. Extremely  large  and  globular  belly,  rapid  growth  of  the  uterus,  marked 
edema,  albuminuria,  motion  felt  all  over  the  abdomen,  excite  the  interest  of  the 
accoucheur  and  warn  to  greater  care.     The  diagnostic  points  are: 


468 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


1.  A  sulcus  felt  in  the  fundus  or  down  the  front  of  the  uterus.  This  may  occur 
in  uterus  arcuatus  or  distorted  uteri,  or  even  in  ordinary  labor,  and  may  be  absent 
in  twins. 

2.  Unusually  large  and  globular  uterus.  Must  eliminate  hydramnion  and 
large  child. 

3.  Palpation  of  three  large  parts — two  heads  and  one  breech  or  two  breeches 
and  one  head.  Make  no  diagnosis  on  the  multiplicity  of  small  parts,— the  extremi- 
ties,— because  the  child  can  place  these  in  many  locations. 

4.  When  one  head  is  in  the  pelvis  and  the  distance  from  this  to  the  other  large 
part  in  the  fundus  is  too  great  to  be  the  length  of  one  fetus,  for  example,  over  30  cm. 


Fig.  425. — Twins  Side  by  Side. 


5.  Auscultation  of  two  sets  of  fetal  heart-tones,  with  these  characteristics: 
(1)  Both  asynchronous  with  the  maternal  pulse;  (2)  they  must  be  asynchronous 
with  each  other,  the  difference  being  more  than  eight  beats;  (3)  there  must  be  a 
free  zone  between  the  two  areas  of  greatest  intensity.  It  is  best  for  two  qualified 
observers  to  listen  at  the  same  time;  in  doubtful  cases  it  is  well  to  use  a  stop-watch 
and  take  the  average  of  many  counts,  and  during  the  examination  the  patient  may 
not  change  her  position  (Fig.  426) . 

If  one  child  is  dead,  this  irictliod  leaves  us  in  doubt;  afiain  the  two  hearts  may  beat  syn- 
chronously for  a  time.  Th(!  autlior  in  one  such  case  irritated  the  infant  until  it  moved,  which 
acc(;lerutcd  the  heart-beat.  A  child  with  straightened  spine,  as  in  the  military  attitude,  may  have 
heart-tones  audible  on  both  sides  of  tlie  uterus,  or  the  placenta  may  divide  the  area  of  audibility. 
Hearing  two  loud  uterine  souffles  is  not  conclusive,  nor  is  h(!aring  one  fetal  souffle  and  one  fetal 
heart-sound.  During  labor  one  may  hear  normal  heart-tones  and  feel  a  pulseless  cord  in  the 
vngina,  but  even  this  is  not  positive,  because  the  cord  may  be  compressed  temporarily  while  the 
heart  goes  on  beating.     Of  course,  such  a  condition  soon  kills  the  infant. 


MULTIPLE   PREGNANCY 


469 


Durinii  labor  all  tli(i  aliovc  si<i;iis  arc  used,  and  in  addition: 
().  Pali)ati()ii  of  two  I)aj>;.s  of  waters  (Dcpaul),  one  of  which  may  contain  a  fetal 
part. 

7.  Palpation  of  a  fetal  pact  in  an  intact  sac  after  one  sac  has  hurst. 

8.  Pali)ati()u  of  two  large  ])arts  hy  the  vaginal  exaniinati(jn. 

9.  The  .r-ray  may  now  be  used,  and  its  demonstration  of  two  fetuses  is  positive. 
Edling,  of  Malmoe,  showed  three  in  one  case. 

If  the  diagnosis  is  made  during  pregnancy,  it  is  best  not  to  tell  the  mother,  but 
to  acquaint  the  father  with  tho  facts,  to  save  the  one  from  fear  and  w^orry  and  yet  to 
protect  the  accoucheur  from  the  imputation  of  ignorance.  After  the  delivery  of 
one  child  the  diagnosis  that  another 
remains  in  the  uterus  is  easily  made 
by  one  grasp  of  the  fundus. 

Differential  Diagnosis. — In  the 
early  months  the  presence  of  twins 
may,  by  distorting  the  uterus,  give 
rise  to  the  suspicion  of  ectopic  gesta- 
tion. The  differential  diagnosis  of 
simultaneous  extra-  and  intra-uter- 
ine  pregnancy  from  ordinary  twins  is 
possible  only  to  a  keen  and  exper- 
ienced obstetric  hand,  and  even  un- 
der most  favoral)le  circumstances  is 
rarely  made  before  operation. 

Polyhydramnion  often  compli- 
cates twins,  and  one  needs  to  shut 
out  ovarian  tumor  in  these  instances. 
(See  p.  562.) 

Fibroid  tumors  complicating 
pregnancy  may  simulate  plural  ges- 
tation to  perfection.  The  absence 
of  two  heart-beats  upon  repeated 
examinations ;  the  immobility  of  the 
supposed  large  and  small  parts;  their 
constancy  of  location;  the  history  of 
fibroid — usually  allow  prompt  differ- 
entiation. After  delivery  the  fibroids 
may  lead  to  error  unless  the  cavity  of 
the  uterus  is  explored. 

Prognosis. — As  was  said  at  the  beginning  of  this  chapter,  plural  gestation  is 
not  normal.  The  disturbances  of  pregnancy  are  more  common,  and  their  fatality 
increased,  this  l^eing  especially  true  of  the  toxemias  resulting  in  eclampsia.  Heart 
chsease  complicating  twin  pregnancy  is  very  serious,  and  usually  indicates  the  induc- 
tion of  premature  labor.  In  one  of  the  author's  cases  the  anasarca  was  tremendous, 
hydropleura  and  hydropericardium  developing,  the  patient  having  hemoptysis  and 
dying  of  acute  edema  of  the  lungs.  O'wing  to  the  longer  labors  and  the  more  fre- 
quent necessity  for  operative  deliveries,  sepsis  is  more  likely  to  occur,  and  the  opera- 
tive tramnatisms  must  also  be  reckoned  in.  Postpartum  hemorrhage  occurs  oftener, 
and  it,  with  the  danger  of  infection  from  the  usual  methods  of  combating  it,  must 
also  be  included. 

For  the  child  the  prognosis  is  serious.  Since  the  majority  of  twin  l^irths  are 
premature,  many  infants  die  of  atelectasis  and  general  debility.  A  certain  number 
of  the  second  children  are  lost  during  the  interval  after  the  first  is  born,  from  abrup- 
tion of  the  common  placenta,  and  not  a  few  die  during  operative  deliveries.     After 


5^-- 

Fetal  heart-tones 

€m  ~ 

Head 

((m  = 

Back 

Fig.  426.- 

—Abdominal 

Findings 

IN 

Tw 

ins 

470      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

birth  the  mother  may  be  too  ill  or  too  weak  properly  to  care  for  them,  or  she  may 
have  insufficient  milk,  and  these,  coupled  with  congenital  debility,  explain  the  high 
mortahty  in  the  first  year  of  life.  Ahlfeld  places  it  at  75  per  cent.,  but  the  author 
thinks  this  is  too  high.  Triplets  and  quadruplets,  of  course,  offer  much  higher 
mortalities. 

IMany  mothers  ask  if  twin  children  are  mentally  and  physically  as  strong  as 
those  of  single  birth.     The  author  has  carefully  studied  his  cases  and  other  twins, 


Fig.  427. — Interlocked  Twins. 

and  finds  that  all  depends  on  the  degree  of  prematurity.     Where  the  children  were 
fully  developed,  no  difference  could  be  noted. 

Treatment. — During  pregnancy,  a  pluriparient  woman  requires  greater  watch- 
fulness, especially  regarding  her  kidneys  and  circulation.  Should  she  abort,  the 
accoucheur  must  see  that  the  uterus  is  empty.  Although  cases  are  on  record  of  the 
successful  carrying  of  the  second  fetus  to  term,  the  frequency  of  infection  of  the 
partially  emptied  uterine  cavity  is  so  great  that  the  danger  should  not  be  assumed 
on  so  slim  a  chance  of  saving  the  child.  During  labor  "watchful  expectancy"  is 
practised.  One  must  not  be  deceived  by  the  false  pains  of  the  latter  weeks  into  as- 
suming that  labor  has  actually  begun.  Wait,  if  possible,  for  complete  dilatation 
before  rupturing  the  bag  of  waters.  With  freriuent  auscultation  the  accoucheur 
watches  the  welfare  of  the  two  children.     It  is  wise  not  to  let  the  first  stage  drag  on 


MULTIPLE    PREGNANCY 


471 


too  long,  hccausc  inroads  on  tlic  parturient's  strength  may  ho  regretted  in  the  third 
stage,  wluMi  hcinorrliagc  may  set  in.  Preparations  for  operative  delivery  and  for 
the  treatment  of  a  pathologic  third  stage  nmst  l)e  complete. 

After  the  first  infant  is  delivered  a  careful  external  and  internal  examination 
will  enable  the  accoucheur  to  decide  on  the  proper  treatment.  The  cord  should  be 
clamped  or  tied  on  its  placental  end.  Should  th(i  cord  of  th(!  second  child  i)rolapse — 
should  the  siiouldcr  ])rescnt,  inuncdiate  action  is  reriuired — in  short,  any  abnor- 
mality is  to  be  r('ctific<l.  The  delivery  of  the  second  twin  by  version  and  extraction 
or  forcei)s,  or  even  bimijle  Kristeller  expression,  is  usually  easy,  because  the  soft 


FiOi  428. — Interlocked  T^-ins. 


parts  have  been  prepared  by  the  transit  of  the  first  infant.  If  the  heart-tones  are 
normal, — and  one  should  listen  constantly, — if  there  is  neither  external  nor  internal 
hemorrhage,  one  may  safely  wait  for  twenty  minutes  before  rupturing  the  second  bag 
of  waters.  This  interval  allows  the  uterus  to  gather  strength  for  the  ex-jDulsion  of 
the  second  child,  and  is  also  a  safeguard  against  postpartum  hemorrhage. 

Owing  to  the  overdistention  of  the  uterus,  contraction  and  retraction  of  its 
muscle  are  poor  and  the  tendency  to  postpartum  hemorrhage  is  augmented.  Accu- 
rate control  of  the  fundus  and  gentle  massage  are  indicated,  and  exi^ression  of  the 
placenta  is  usually  needed  earlier  than  in  single  labors.  Ergot  should  be  given  as  soon 
as  the  placentas  are  born,  and  repeated  in  smaller  doses  for  a  week  or  more,  because 


472      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

involution  of  the  uterus  is  slower.  The  accoucheur  should  remain  in  the  house 
several  hours  to  be  certain  that  no  relaxation  of  the  uterus  may  occur,  and  to  dis- 
cover any  tendency  to  postpartum  eclampsia. 

Anomalies  of  Plural  Births. — (1)  Pathologic  presentations — shoulder,  breech,  brow,  face, 
anterior  parietal  bone,  etc. — occur  in  a  goodly  percentage  of  cases,  and  are  treated  on  general 
principles. 

(2)  The  part  presenting  may  change  several  times  before  one  finally  engages  and  is  delivered. 
"Watch  for  pathogenic  delay,  then  interfere. 

(3)  The  bag  of  waters  of  the  second  child  may  rupture  before  that  of  the  first,  or  the  two 
maj'  rupture  at  one  time.  No  treatment  is  necessary  in  the  first  instance  unless  the  cord  of  the 
second  child  prolapses  before  the  presenting  part  of  the  second  is  delivered.  If  conditions  for 
extraction  are  filled,  deliver  both  children,  otherwise  replace  the  cord. 

(4)  Rarely  the  placenta  of  the  first  twin  is  delivered  before  the  second  is  born.  If  the 
placenta  is  independent  of  the  other,  no  harm  results  from  this,  but  if  the  two  are  united,  the 
necessary  abruption  of  the  placenta  of  the  second  child  will  be  fatal  to  it  unless  it  is  delivered 
at  once.  The  signs  of  asphy.xia  and  external  hemorrhage  apprise  the  accoucheur  as  to  what  is 
going  on.     Rapid  deUvery  of  the  second  child  will  save  it,  and  also  preserve  the  mother. 

(.5)  The  transit  of  the  first  child  may  alter  the  position  of  the  second,  for  example,  from 
longitudinal  to  transverse,  from  vertex  to  face.     Treatment  is  on  general  lines. 

(6)  Interlocking  or  collision  may  occur.  The  two  heads  may  try  to  enter  the  pelvis  at  the 
same  time,  or  one  head  enters,  while  the  second  head,  caught  in  the  neck  of  the  first  twin, 
attempts  to  enter  with  it  (Fig.  427).  If  the  children  are  small,  such  a  mechanism  is  possible. 
Or  the  head  of  the  second  fetus  enters  the  pelvis  after  the  first  one,  presenting  by  the  breech,  has 
been  deUvered  as  far  as  the  neck  (Fig.  428).  The  second  child,  coming  as  a  breech,  may  straddle 
the  first  in  shoulder  presentation,  or  four  extremities  may  present,  the  two  breeches  entering  the 
inlet  at  once. 

Delay  in  the  delivery  of  twins  should  always  excite  the  suspicion  of  locking, 
and  an  examination  with  the  whole  hand,  in  narcosis,  if  needed,  is  to  be  made. 
]Much  can  be  accomplished  by  manipulation,  especially  if  the  uterus  is  paralyzed 
Ijy  deep  anesthesia,  and  the  children  may  be  disentangled,  one  of  them  being  led 
into  the  pelvis.  Should  interlocking,  as  in  Fig.  428,  occur,  a  deep  episiotomy  is 
done,  to  avoid  complete  laceration  of  the  perineum,  the  whole  hand  inserted,  and 
the  second  head  pushed  up  and  out  of  the  pelvis.  If  the  heads  are  small,  such  a 
procedure  is  possible ;  if  not,  one  should  decapitate  the  first  child  quickly  and  push 
its  head  up  into  the  uterus,  then  deliver  the  second  with  forceps.  In  such  a  case 
Lobenstine  did  a  cesarean  section  and  saved  both  twins  and  mother.  Forceps  or 
the  cranioclast  may  be  applied  to  the  second  child,  delivering  it  first,  but  one  should 
attempt  to  save  at  least  one  of  the  children  by  disentangling  them  under  deep 
anesthesia.     If  the  first  one  is  dead,  there  is  no  occasion  for  hurry. 

Literature 

Barry:  N.  Y.  Med.  Jour.,  1896. — Carson:  Centralbl.  f.  Gyn.,  1880. — Geisler:  Allg.  statistische  Archiv  von  G.  v.  Mayr, 
1900,  p.  544. — Guzzoni:  Rassegna  de  scienze  med.,  1889,  p.  19. — Helliu:  Multiparitat,  Munich,  1895. — Pinard 
(of  Paris):  "Des  Grossesses  Triples,"  Annales  de  Gyn.,  1889. — Schatz:  Arch.  f.  Gyn.,  vols,  xix,  xxiv,  xxvii,  xxix, 
XXX,  liii,  Iv,  Iviii,  Ix. — Strassman:   Handbuch  f.  Geb.,  vol.  i,  p.  742. — Sue:   Ibid. 


CHAPTER  XXXVI 
PROLONGED  PREGNANCY  AND  MISSED  LABOR 

REFEREXtH  lias  1)0011  iiiailo  to  ])rolunged  ])ro};nuncy  (p.  112j,  and  hero  will 
be  considered  tho  pathologic  side.  Labor  occasionally  begins  at  the  proper  period, 
some  degree  of  dilatation  is  attained,  but  for  some  reason  the  pains  cease  and  ges- 
tation continues  for  from  two  to  four  weeks,  when  the  uterus  again  is  set  in  action 
and  delivery  is  accomplished.  This  occurrence  must  not  be  confounded  with  the 
])ains  and  ohang(>s  in  the  cervix  which  sometimes  occur  at  "lightening."  When 
tho  child  is  thus  carried  over  term,  it  undergoes  certain  alterations;  the  length  in- 
creases disproportionately  to  the  weight,  the  head  enlarges,  and  the  bones  harden, 
the  parietal  bosses  becoming  prominent  and  pointed.  The  body  is  less  fat  and  is 
firmer  in  consistence;  the  spinal  column  is  harder  and  less  flexil^le.  In  some  cases 
the  fetus  is  overgrown  in  every  way.  Oligohydramnion,  with  its  consequences,  may 
occur.  The  child  may  die  without  other  cause  apparently  than  being  overripe, 
and  this  fact  is  knowTi  and  appreciated  even  by  the  laity. 

During  labor  I  have  observed  these  anomalies: 

1.  Lack  of  cephalic  molding,  from  the  extreme  ossification;  high  arrest  of  head; 
prolonged  and  fruitless  labor;  forceps — hard  extraction;  extensive  injuries;  still- 
births. 

2.  Occipitoposterior  positions,  absent  rotation,  etc. 

3.  Deflexion  attitudes — military  attitude,  forehead,  brow,  and  even  face  pres- 
entations and  their  sequelae. 

4.  More  or  less  disproportion  between  the  size  of  the  passage  and  the  passenger, 
prolonged  labor,  and  operative  interference. 

]\Iany  irregularities  in  the  labor  apart  from  the  above  have  been  observed. 
Some  of  these  are  indirectly  caused  by,  or  indirectly  influence,  the  mechanical 
factors  in  labor.  The  pains  are  apt  to  be  irregular,  intermittent,  and  ineffectual. 
Occasionally,  on  the  other  hand,  they  are  tumultuous  and  quickly  deliver  the  child, 
perhaps  precipitately,  injuring  it  or  the  mother.  The  writer  had  one  case  of  com- 
plete spontaneous  rupture  of  the  uterus  where  the  pregnancy  was  prolonged  and 
labor  rapid.  This  is  the  exception.  AVeak  pains  are  the  rule.  It  is  possible  that 
a  fatty  degeneration  of  the  uterine  muscle  occurs  in  these  weeks  of  prolonged  preg- 
nancy (Bossi).  This  invites  traumatic  rupture  or  produces  inertia,  necessitating  the 
use  of  forceps.  The  lack  of  strong  uterine  contractions  leaves  the  cervix  and 
vagina  "without  the  softening  and  succulence  necessary  for  the  safe  dilatation,  and, 
therefore,  lacerations  of  the  parts  are  frequent  and  all  operative  intervention  is 
rendered  laborious.  The  same  inertia  is  carried  over  into  the  third  stage,  and 
postpartum  hemorrhage  caps  the  chmax  to  the  succession  of  complications. 

While  these  accidents  are  by  no  means  the  rule  in  women  going  over  time,  they 
occur  so  often  that  the  question  of  methodically  inducing  labor  at  the  normal  end 
of  gestation  deserves  grave  consideration. 

Prolonged  labor  is  a  peculiar  condition.  Pains  begin,  the  cer\-ix  becomes  ef- 
faced and  opens,  the  show  appears,  even  the  bag  of  waters  may  rupture,  but  dehvery 
does  not  occur.  I  have  seen  the  os  open  to  the  size  of  the  palm,  but  retract  and 
pregnancy  continue.  However,  intermittent  pains  declare  that  the  woman  is  in 
labor.  In  a  case  sent  to  the  author  from  South  Dakota  the  woman  had  ])een  in 
actual  labor  for  eight  weeks  and  came  to  the  maternity  in  a  tjiDhoidal  condition. 

473 


474      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

Dilatation  with  the  colpeurynter,  cervical  incisions,  and  forceps  procured  a  43^ 
pound  emaciated  infant  which  survived.  The  process  was  repeated  in  a  subse- 
quent pregnancy.  Occasionally  labor  may  be  completely  interrupted  and  resumed 
at  a  later  period — perhaps  at  the  end  of  a  menstrual  cycle. 

The  causes  for  these  conditions  are  unknown — perhaps  some  disease  of  the 
uterine  muscle  or  of  the  nerves  of  the  uterus  should  be  invoked.  I  have  noticed 
that  my  cases  go  over  term  in  groups,  and  that  other  practitioners  are  having  the 
same  trouble  about  the  same  time.  This  fact  Bossi  also  mentions,  and  he  found 
that  the  condition  recurred  and  was  hereditary.  Old  primiparse,.  women  who  have 
had  dysmenorrhea,  and  in  whom  the  pelvis  is  of  masculine  tj'pe,  seem  oftenest 
affected.  Fibroids  have  been  noted  in  several  cases.  A  peculiar  circumstance  in 
these  patients  is  that,  when  fever  begins,  which  is  not  unusual,  especially  if  the  bag 
of  waters  is  ruptured  and  the  vaginal  bacteria  have  gained  access  to  the  uterus,  the 
pains  begin  or  become  stronger,  and  delivery  is  completed  rapidly.  After  delivery 
the  temperature  rapidly  becomes  normal. 

Treatment. — The  author  does  not  consider  it  good  practice  to  allow  gestation 
to  continue  long  after  its  natural  term  has  passed,  and,  likewise,  it  is  not  safe  to 
permit  a  protracted  labor  to  wear  out  the  woman's  strength,  as  it  is  bound  to  do  in 
time,  through  loss  of  sleep,  much  suffering,  and  anxiety.  If  labor  does  not  set  in 
on  the  da}^  which,  after  careful  computation,  has  been  set  for  it,  the  accoucheur 
makes  a  careful  examination  of  the  gravida.  Since  the  fingers  are  to  be  passed  into 
the  uterus,  the  preparations  of  the  patient  and  for  the  patient  should  be  identical 
with  those  of  actual  labor,  that  is,  shaving,  disinfection,  rubber  gloves,  etc.  The 
accoucheur  determines  the  size  of  the  infant,  using  cephalometry,  the  degree  of 
engagement  of  the  presenting  part,  and  the  state  of  the  cervix.  When  convinced 
that  the  end  of  normal  pregnancy  is  reached,  he  informs  the  woman  that  unless 
pains  begin  within  a  week  it  will  be  deemed  wise  to  inaugurate  labor.  This  is  best 
done  by  packing  the  lower  uterine  segment  and  the  cervix  with  gauze  (p.  1016). 
Pains  are  usually  easily  set  up,  because  the  irritability  of  the  uterus  has  been  de- 
veloped; indeed,  the  ease  with  which  uterine  contractions  are  elicited  indicates  the 
nearness  of  the  gestation  to  term.  Very  often  just  sweeping  the  fingers  around  the 
internal  os  and  slightly  separating  the  membranes  set  labor  in  progress.  Gill 
Wylie  recommended  a  dose  of  castor  oil  and  10  grains  of  quinin.  Pituitrin  has 
recently  been  used,  10  minims  ,h3''podermically  every  four  hours.  The  injection 
of  the  blood-serum  of  new-born  infants  for  inducing  labor  is  now  being  experimented 
with.     The  serology  of  pregnancy  deserves  further  study. 

Missed  Labor. — This  is  a  term  applied  by  Oldham  to  the  retention  of  a  fetus, 
dead,  near  term,  in  the  uterus.  Missed  labor  often  occurs  in  cows  and  sheep. 
An  attempt  may  or  may  not  have  been  made  by  the  uterus  to  expel  its  contents. 
The  condition  is  similar  to  the  one  just  considered,  except  in  the  death  of  the  child, 
which  is  often  inexpHcal^le,  and  is  the  same  as  "missed  abortion"  (p.  435),  only  oc- 
curring later  in  pregnancy.  The  reason  for  the  failure  of  the  uterus  to  expel  the 
dead  product  of  conception  has  been  placed  in  a  rigid  cervix,  for  example,  cancer, 
scars,  hj-pertrophy,  a  diseased  uterus,  myomata,  muscular  degeneration,  cornual 
pregnancy,  peritonitis  "with  adhesions,  and  nervous  disease.  After  the  fetus  dies 
it  mummifies  and  shrinks  up,  its  liquor  is  absorbed,  and  the  uterus  applies  itself 
closely  to  the  body.  A  lithopedion  may  form,  as  in  extra-uterine  gestation,  or  in- 
fection, A\dth  purulent  disintegration  and  extrusion  of  the  })ones  of  the  skeleton 
through  the  cervix,  or  by  ulceration  through  neighboring  cavities — a  termination 
which  is  excessively  rare.  Usually  art  interferes  and  empties  the  uterus.  In 
Menzies'  case  the  dead  ovum  was  carried  to  the  seventeenth  month,  and  in  Hening's 
case,  eight  months  after  term. 

Symptoms. — One  finds  the  same  symptoms  here  as  in  missed  abortion  {q.  v.), 
but  exaggerated.     The  woman  complains  of  the  feeling  of  a  dead  and  heavy  mass 


PROLOXGED  PREGNANCY  AND  MISSED  LABOR  475 

in  tlic  Ix'lly,  and  notes  the  absence  of  fetal  movements.  Pains  of  a  parturient 
character  occasionally  occur,  commonly  at  the  time  of  the  customary  menstrual 
periods,  and  it  is  at  such  times  that  labor  often  sets  in. 

Examination  shows  a  closed  cervix,  and  a  thin-walled,  torpid  uterus,  of  hard 
consistence,  entirely  lacking  the  sponj^y  s(jftn('ss  characteristic  of  normal  preg- 
nancy. The  diagnosis  is  easy.  Since  the  (juestion  of  pregnancy  is  seldom  uncer- 
tain, all  that  is  needed  is  to  prove  that  the  symmetric  tumor  is  the  uterus  and  that 
it  does  not  grow.  On  p.  205  are  the  i^oints  for  the  determination  of  the  life  or  death 
of  the  fetus. 

Treatment. — If  the  child  is  dead,  the  bag  of  waters  intact,  and  the  patient  not 
ill,  it  is  advised  to  wait  for  the  time  of  a  monthly  period  or  two  to  see  if  nature  will 
not  start  the  pains  and  empty  the  uterus.  In  the  interval  the  woman  must  be 
enjoin(Hl  not  to  have  intercourse  nor  to  take  douches.  Some  authors  advise  the 
emptying  of  the  uterus  when  the  diagnosis  of  missed  laljor  is  positive,  and  with  these 
I  agree,  because  the  uterine  contents  may  become  infected  while  waiting  and  this 
renders  an  otherwise  safe  operation  extremely  hazardous.  The  torpidity  of  the 
uterine  muscle  in  these  cases  is  sometimes  astonishing — one  may  use  all  sorts  of 
local  irritants — gauze,  colpeurynters,  etc. — for  days  without  evoking  pains.  It  is, 
therefore,  the  author's  practice  to  incise  the  cervix  or  do  vaginal  cesarean  section 
if  the  uterus  proves  refractory  after  fortj^-eight  hours'  trial.  Since  the  fetus  is 
dead,  craniotomy  and  morcellation  are  indicated  to  save  the  maternal  soft  parts 
from  injur3^  If  the  mass  is  already  infected,  the  case  is  treated  as  a  septic  abortion, 
with  tampon  and  morcellation.  If  the  fetus  is  of  considerable  bulk,  laparotomy 
and  complete  extirpation  of  the  uterus  might  be  simpler  than  the  attempt  to  remove 
the  mass  from  below.  If  the  vaginal  route  seems  better,  one  should  not  try  to  re- 
move ever^-thing  at  one  sitting,  but  by  means  of  tamponing  and  morcellation  the 
cervix  is  kept  open,  drainage  provided,  and  the  fetus  and  the  secundines  gotten  rid 
of  safely  and  Avithout  injury  to  the  uterus. 

Graviditas  Exochorialis. — Among  the  rare  conditions  met  with  is  the  develop- 
ment of  the  fetus  in  the  uterus,  but  outside  of  the  amniotic  cavity.  In  such  cases 
the  membranes  shrink  up,  the  liquor  amnii  continually  escapes,  sometimes  in  large 
amounts,  and  the  fetus  may  show  the  results  of  oligohydramnion — contractures, 
club-feet  and  arms,  decubitus,  etc.  The  differential  diagnosis  must  be  made  from 
hydrorrhcea  gravidarum  (q.  v.).     Abortion  is  frequent. 

Literature 

Bar,  P.:  Bull,  de  la  Soc.  d'Obstetrique,  Paris,  1S9S. — Bos^i:  Gynak.  Rundschau,  Wien,  vol.  i,  No.  i,  p.  30. — DeLee: 
"The  Induction  of  Labor  at  Term,"  Surg.,  Gyn.,  and  Obstet.,  July,  1907. — Khinerlz:  Centralbl.  f.  Gyn.,  1901, 
No.  28,  p.  809. — Krevet:  Arch.  f.  Gyn.,  vol.  Ixi,  p.  438. — Luther:  "Mis.sed  Labor,"  Amer.  Gyn.  and  Obstet. 
Jour.,  February,  1899. — MenHes:  Glasgow  Med.  Jour.,  July,  1843,  p.  229. — Oldham:  Guy's  Hospital  Reports, 
1847,  vol.  V,  pp.  105-112. — Schenck:  "Missed  Labour"  and  "Ubertragung,"  Inaug.  Diss.,  M.arburg,  1903. 


CHAPTER  XXXVII 

DISEASES  ACCIDENTAL  TO  PREGNANCY 

A  PEEGNANT  woman  is  not  immune  to  any  disease  which  may  affect  her  in  the 
non-pregnant  state,  and,  contrary  to  the  old  notion,  she  is  more  susceptible  to  some. 
Pregnancy  in  general  aggravates  the  diseases  which  occur,  and  in  turn  the  gesta- 
tion is  endangered  by  them.  Abortion  or  premature  labor  occurs  with  varying 
frequency  in  all  the  infectious  diseases,  and  also  often  complicates  the  course  of 
constitutional,  circulatory^,  respiratory,  alimentary,  and  kidney  affections.  It  is 
obviously  impossible,  in  a  book  of  this  size,  thoroughly  to  consider  all  the  maladies 
from  which  a  pregnant  woman  might  suffer.  Only  the  salient  points  of  large  groups, 
and  especially  important  features  of  individual  diseases,  will  receive  mention. 
The  reciprocal  influences  of  pregnancy  upon  the  disease  and  of  the  disease  upon 
pregnancy  will  be  studied  in  turn. 

THE  ACUTE  INFECTIOUS  DISEASES 

Typhoid,  typhus,  measles,  scarlatina,  variola,  erysipelas,  diphtheria,  cholera, 
malaria,  influenza,  pneumonia — all  occur  in  pregnancy,  and  most  of  them  have  a 
very  deleterious  effect  on  both  mother  and  fetus.  The  action  of  these  diseases  is 
twofold:  first,  they  endanger  the  woman  through  hyperpyrexia,  increased  toxemia, 
the  accompanying  nephritis,  and  through  the  tendency  to  become  hemorrhagic. 
Profuse  menorrhagias  are  often  noted,  some  of  which  may  be  early  abortions,  and 
a  differential  diagnosis  may  have  to  be  made  from  several  conditions.  For  ex- 
ample, a  young  woman  was  sent  to  the  author  with  a  diagnosis  of  septic  abortion 
with  profuse  hemorrhage.  She  was  in  the  first  week  of  typhoid,  with  epistaxis 
uterina,  and  was  a  "virgo  intacta." 

Women  who  have  had  an  exhaustive  siege  of  disease  are  in  poor  condition  to 
withstand  the  pain,  shock,  and  hemorrhage  of  abortion  or  labor,  and  collapse  may 
come  on  in  the  third  stage.  This  is  especially  true  when  the  lungs  or  heart  are  much 
involved.  Finally,  some  of  the  above-mentioned  diseases  lead  directly  to  puerperal 
sepsis,  either  by  blood  or  regional  transmission  of  the  bacteria,  or  by  so  reducing  the 
immunities  of  the  patient  that  infection  easily  gains  foothold.  Examples  of  these 
are  variola  (infection  from  the  pustules),  typhoid  (the  streptococci  from  Peyer's 
patches,  and  even  the  typhoid  bacilli  themselves),  influenza  (direct),  erysipelas 
(direct),  scarlatina  (from  the  throat),  pneumonia  (direct),  diphtheria  (direct),  etc. 

Second,  these  diseases  interrupt  pregnancy,  which  is  due  to  a  not  infrequently 
accompanying  hemorrhagic  endometritis  and  to  the  death  of  the  fetus.  Fetal 
death  is  brought  about  in  various  ways: 

(a)  The  fetus  may  die  from  insolation.  Normally,  the  temperature  of  the  fetus  is  one- 
half  a  degree  higher  than  that  of  the  mother,  and  since  it  has  its  own  heat-regulating  system, 
it  can  take  care  of  the  ordinary  changes,  but  when  the  mother  is  hyperpyretic,  the  child  cannot 
do  so  because  it  has  not  the  means  to  discharge  heat,  as  by  evaporation,  for  example.  High 
temperature,  especially  a  sudden  rise,  is,  therefore,  less  well  borne.  Itunge  and  Dore  showed  that 
a  gradual  rise  to  104°  F.  is  fairly  well  borne,  and  unless  continued  thus  for  a  long  period,  is  usually 
survived  by  the  infant.  The  movements  and  the  heart-tones  are  at  first  increased,  later  slowed, 
and  death  occurs.  Rabbits  will  stand  a  very  gradual  rise  to  109°  F.,  but  if  it  is  sudden,  it  is 
always  fatal.  Krummaker  reported  a  case  of  hysteric  fever  with  sudden  rises  of  109.4°  F.  at 
intervals  for  .seven  daJ^s  without  effect  on  the  child. 

(fj)  Pregnancy  is  interrupted  by  the  hot  blood  circulating  through  the  uterus.  This  is 
not  improbable,  because  heat  applied  to  the  abdomen  and  by  hot  douches  causes  the  uterus  to 
contract,  and  clinical  experience  in  delayed  labors  shows  that  when  the  temperature  rises,  as 
from  sepsis,  the  pains  grow  stronger. 

476 


DISEASES   ACCIDENTAL   TO    PREGNAN'CY  477 

(c)  Tlic  fetus  (lies  from  asph/jxia,  hrouii}\i  nhout — (1)  By  low  blood-pressure  of  the  mother 
;in(l  cotiscfiuciit  stagnation  of  the  cirfulation  in  the  uterine  sinuses;  (2)  the  same,  because  f)f 
profuse  licMiorriiages;  (li)  from  ]iy[)en-arbonization  and  deoxidation  of  the  mother's  blood,  the 
direct  resuH  of  tlie  disease,  for  exanii)le,  pneumonia;  (-4)  from  a  hemorrhaK<'  in  the  [)laeenta 
with  separation  of  the  organ;  and  (5)  because  of  fatty  degeneration  of  the  f(!tal  villi,  whieh 
renders  tiie  resjjiratory  exchange  of  gases  in  them  impossible. 

{(I)  The  child  may  acfiuire  the  disease  from  which  the  mother  is  suffering  or  it  may  di(!  from 
the  toxins  which  it  receives  from  the  maternal  circulation.  The;  villus-wall  ofTers  no  hindrance 
to  the  pa.s.sage  of  the  toxins,  which,  like  other  poi.sons,  strychnin  and  pota.ssium  iodid,  are  known 
to  go  through,  as  also  do  antiicjxins,  i'or  example,  dip!  it  her!  a.  '^I'lie  \i!  his  is  no  barrier  to  the  passage 
of  the  bacteria — they  either  jjass  through  directly  or  after  destroying  the  wall,  and  lesions  of  the 
latter  are  not  hai'd  to  [find.  These  infections  ha\'e  been  demonstrated  in  the  fetus:  variola, 
measles,  scarlatina,  tyi)hoid  (the  author  in  ISOlj,  cholera,  pneumonia,  bubonic  plague,  erysipelas, 
pus  infections,  anthrax,  tubercuhjsis,  sj'philis,  febris  recurrens,  malaria.  It  is  remarkable  that 
in  some  of  the  diseases  the  chikl  is  not  at  all  afTected,  and  the  author  has  had  cases  where  the  child 
alone  was  ill,  the  mother  remaining  free.     Others  have  noted  such  an  occurrence  in  smallpox. 

Typhoid. — It  is  said  that  typhoid  is  rare  in  pregnancy,  Freund  found  42  cases 
in  3272  ly])hoids,  which  is  not  excessively  rare  when  all  the  facts  are  con.sidered. 
The  Eb(>i-ti>  bacillus  and  the  Widal  reaction  have  been  found  in  the  fetal  blood, 
especiall}'  in  the  latter  months  of  gestation.  Preg-nancy  is  interrupted  in  two-thirds 
of  the  cases,  especially  in  the  early  months.  Children  of  the  later  months  almo.st 
always  die  after  birth.  Hemorrhage  is  usually  not  profuse,  but  the  accoucheur  is 
warned  to  prevent  all  bleeding  because  of  the  exhaustion  of  the  patient.  The  soft 
parts  are  very  easily  torn,  but  bleed  little.  Union  was  good  in  the  author's  three 
cases.  The  mortality  is  higher  than  in  uncomplicated  typhoid.  In  the  puerperium 
the  differential  diagnosis  is  most  important,  since  the  fever  is  usually  ascribed  to 
puerperal  sepsis.  The  gradual  rise  of  fever,  the  absence  of  chills,  the  slow  pulse, 
the  tendency  to  apathy,  not  excitement,  the  early  splenic  tumor,  the  stool,  the  rose- 
ola, and  the  negative  findings  on  the  genitalia  usually  enable  the  proper  course  to  be 
taken,  but  one  should  always  try  the  Widal  reaction,  and,  if  necessary,  make  a 
culture  from  the  blood.  A  tj-phoid  puerperal  infection  is  not  impossible,  and  t\'- 
])h()i(l  nia>'  be  combined  with  putrefactive  and  purulent  infections. 

Variola. — In  the  majority  of  cases  of  smallpox  abortion  or  premature  labor 
occurs,  and  the  child  almost  always  dies.  It  may  be  born  pock-marked,  as  was  the 
accoucheur  Mauriceau,  or  in  the  eruptive  stage.  Confluent  and  hemorrhagic 
variola  are  more  common  in  gravidse,  and  the  mortality  is,  therefore,  much  higher 
(Mnay,  36  ])er  cent.).  Sepsis  may  arise  from  the  pustules,  and  after  recovery  from 
the  smallpox  a  recrudescence  of  the  feyer  may  occur  from  the  resorption  of  toxic 
material  from  the  fetus,  which  disappears  when  the  uterus  is  emptied.  Hemorrhage 
during  labor  is  greater.  Vaginal  examination  and  intra-uterine  manijmlations  are 
to  be  avoided,  as  far  as  possible,  because  of  the  danger  of  introducing  infection. 

Vaccination  during  the  disease  not  always  protects  the  child,  which  may  be 
infected  during  delivery  or  afterward  (isolation  for  the  healthy  child).  Vaccination 
of  the  child  should  be  done  immediately  on  delivery,  but  it  usually  does  not  protect. 
"Women  who  have  been  vaccinated  or  who  have  had  variola  during  pregnancy  give 
birth  to  children  which  later  are  immune  to  vaccination  and  smallpox  (Kollock  and 
Sawyer).  On  the  other  hand,  vaccination  of  the  mother  sometimes  has  no  protec- 
tive influence  on  the  child.  Franklin  reports  a  case  where  the  father  had  smallpox; 
the  mother,  vaccinated,  remained  well,  but  the  child  was  born  dead. of  smallpox, 
whieh  shows  that  the  child  received  the  contagion  through  its  healthy  mother. 

Scarlatina. — Pregnant  women  seldom  get  real  scarlatina  (Ballantyne),  but 
erj-themata  which  resemble  it,  due  to  sepsis,  are  not  uncommon,  especially  in  the 
puerperium.  The  relations  of  scarlet  fever  to  sepsis  are  not  yet  decided  upon,  and 
will  not  be  until  the  exciting  cause  of  scarlatina  is  known,  but  probably  the  strepto- 
coccus has  something  to  do  ^^^th  }:)oth  diseases  when  a  connection  between  the  two 
is  suspected.  The  author  knows  of  many  instances  of  labor  occurring  in  the  same 
room  A\-ith  children  suffering  from  scarlet  fever  and  has  seen  no  trouble  arise  there- 
from.    Of  course,  precautions  were  taken,  but  these  could  not  always  be  complete, 


478  THE    PATHOLOGY   OF    PREGNANCY,    LABOR,    AND    THE    PUERPERIUM 

and  often  were  largely  neglected.  The  mortality  of  scarlatina  in  the  puerperium  is 
given  as  from  5  to  52  per  cent.,  and  the  frequency  of  puerperal  ulcers,  parametritis, 
and  puerperal  infection  in  general  as  complications  is  emphasized  (Tornery). 

In  the  puerperium,  unless  an  epidemic  of  scarlet  fever  is  raging,  it  is  best  to 
consider  the  scarlatiniform  eruption  as  due  to  infection,  unless  the  other  character- 
istics of  the  case  stamp  it  distinctly  as  scarlet  fever. 

Measles. — Fellner  collected  30  cases  from  the  literature.  Measles  is  a  serious 
complication  of  pregnancy,  as  it  generally  is  in  adults.  Gestation  was  interrupted 
in  55  per  cent. ;  the  general  mortality  was  15  per  cent. ;  during  the  puerperium  two 
of  three  women  died.  Sepsis  explains  the  high  mortality.  The  children  are  usually 
affected  by  the  disease  and  show  the  eruption,  as  the  one  of  Clarus  did  when  re- 
moved by  cesarean  section  from  the  dead  body  of  its  mother.  In  the  serviice  of  the 
Chicago  Lying-in  Hospital  Dispensary  many  of  the  puerperse  are  exposed  to  this 
contagion  from  their  sick  children,  but  in  no  case  has  measles  developed,  which 
shows  that  even  the  imperfect  isolation  possible  in  the  homes  of  the  poor  will  suffice 
to  protect.  In  one  of  my  cases  the  child  developed  typical  measles  on  the  tenth 
clay,  the  mother  being  free. 

Cholera. — In  the  Hamburg  epidemic  of  1892,  57  per  cent,  of  pregnant  women 
affected  by  cholera  asiatica  died*(Schiitz).  Abortion  was  very  frequent  because  of 
hemorrhagic  endometritis.  The  disease  usually  is  not,  but  may  be,  transmitted  to 
the  child. 

Erysipelas.^ — When  this  disease  attacks  any  other  portion  of  the  body  than  the 
genitalia,  it  seems  to  be  less  dangerous,  but  many  records  are  at  hand  to  show  that 
puerperal  infection  may  result  in  such  cases.  The  author  delivered  a  woman  suffer- 
ing from  facial  erysipelas;  shortly  after  birth  the  vulva  became  red,  and  she  died 
under  the  picture  of  acute  sepsis.  At  the  autopsy,  from  the  very  little  clear  peri- 
toneal fluid,  a  pure  culture  of  Streptococcus  pyogenes  was  recovered.  The  identity 
of  the  Streptococcus  erysipelatis  of  Fehleisen  with  the  streptococcus  of  pus  is  under 
discussion.  (See  Puerperal  Sepsis.)  Pregnancy  is  not  often  interrupted  by  ery- 
sipelas, and  frequently  the  children  are  delivered  alive,  but"  they  may  have  the  dis- 
ease.  The  mortality  is  increased.    Late  literature  on  the  subject  is  scarce  (Lebedeff ) . 

Sepsis. — Under  puerperal  infections  the  usual  forms  of  sepsis  will  be  considered 
at  length.  Here  might  briefly  be  mentioned  infections  of  distant  portions  of  the 
body,  for  example,  mastoiditis,  frontal  and  other  sinusitis,  tonsillitis,  abscesses, 
cellulitis,  anthrax,  and  tetanus.  These  diseases  are  usually  aggravated  by  preg- 
nancy, and  their  bacteria  may  be  transmitted  by  way  of  the  blood-stream  to  the 
uterus  and  the  fetus.  It  is  possible,  too,  that  direct  transference  of  the  virus  may  be 
effected  by  the  woman  herself  with  her  fingers.  A  local  infection  of  the  uterus  and 
fetus  may  occur  at  any  period  of  gestation  and  cause  abortion.  The  author  is 
convinced  that  coitus  in  the  latter  weeks  often  causes  labor  to  set  in,  and  may  be 
followed  by  serious  puerperal  infection. 

Malaria. — Mild  cases  of  malaria  exert  little  influence  on  gestation.  Severe 
cases  may  interrupt  pregnancy  through  fever  or  cachexia.  Labor  may  change  the 
type  from  tertian  to  quotidian.  Williams  could  not  find  the  plasmodium  in  15  in- 
fants when  it  had  been  demonstrated  in  their  mothers,  yet  Bodenhauser  reports  a 
case  of  such  transmission,  and  fetuses  have  been  delivered  with  enlarged  spleen  and 
pigmentation.  During  labor  an  attack  may  occur.  Uterine  action  is  torpid. 
Hemorrhages  have  been  noted  postpartum.  The  author  had  a  case  of  hemophilia 
which  seemed  to  be  malarial  in  origin.  Lardier  speaks  of  hemorrhage  in  labor,  and 
Legeois  and  Barker  of  bleeding  later  in  the  puerperium.  Postpartum  malaria 
seems  to  be  a  little  more  serious  than  usual,  Ijut  its  chief  interest  is  in  the  diagnosis. 
Practitioners  in  malarious  regions  find  many  times  that  an  outbreak  of  malaria 
occurs  in  the  puerperium  in  a  manner  similar  to  that  of  a  fresh  attack  after  an 
operation.  In  such  cases  puerperal  infection  is  to  be  excluded  and  the  plasmodium 
demonstrated.     Quinin  is  to  be  administered  whenever  indicated  (Fry,  Deale). 


DISEASES   ACCIDENTAL   TO    PREGNANCY  479 

Influenza. — ( )\viii,<j;  to  the  vuriiitions  in  the  severity  of  influenzal  epidemics  and 
pandcniics,  and  the  difficulty  of  differentiating^  the  milder  cases  from  ordinary 
catarrhal  affections, the  reports  of  observers  differ  as  totlu;  effect  of  la  grippeon  preg- 
nancy. The  gastro-intestinal  form  of  la  grijipe  in  [)regnancy  is  not  always  attended 
by  hyperi)yrexia.  The  excessive  vomiting  may  raise  the  suspicion  of  hyperemesis 
gravidarum.  In  the  nervous  forms  eclampsia  should  be  thought  of,  though  these 
varieties  are  very  unusual  ingravid  women.  The  respiratory  grip  is  themost  serious 
in  ])regnancy,  and  if  attended  with  marked  toxemia,  may  lead  to  its  interruption, 
usually  through  uterine  hemorrhage  and  endometritis.  The  severe  cough,  dyspnea, 
and  insonmia  are  exhausting.  During  la])or  the  uterus  is  tender  and  inactive,  and 
operative  interference  oftener  indicated.  In  the  puerperium  influenza  is  not  rarely 
the  cause  of  fever,  and  it  is  frequently  difficult  to  decide  if  there  is  not,  in  addition, 
a  puerperal  infection.  Streptococcic  invasion  of  tlie  uterus  after  la  grippe  is  not 
unknown.  Stoltz  found  decomposition  of  the  lochia  in  50  per  cent.  Subinvolution 
is  common,  and  lactation  retarded.  Pneumonia,  pleurisy,  meningitis,  and  sinus 
suppurations  occur  wdth  double  the  frequency  of  the  normal  state.  Rarely  is  the 
fetus  affected,  excepting  in  those  epidemics  attended  by  high  mortality  and  a  large 
percentage  of  al)ortions.  The  treatment  is  along  general  lines.  Labor  is  not  to  be 
induced  unless  cyanosis,  dyspnea,  or  threatening  respiratory  or  cardiac  failure  indi- 
cate it.  The  bag  of  waters  is  to  be  ruptured,  a  colpeurjaiter  to  be  applied,  and  as 
soon  as  the  cervix  \vi\\  permit  it,  extraction  is  to  be  effected.  The  patient  should  not 
lie  allowed  to  labor  long  nor  to  bear  down  much — both  are  exhausting.  Prepara- 
tions similar  to  those  for  treating  heart  disease  are  to  be  made  (Aloller). 

Pneumonia. — Pneumonia  must  be  considered  one  of  the  specific  infections, 
with  localization  in  the  lungs,  and  it  acts  in  many  ways  like  most  of  the  diseases 
described  in  this  chapter.  Pregnancy  is  interrupted  in  more  than  half  of  the  cases, 
especially  if  it  already  is  in  the  latter  months.  Cyanosis  and  dyspnea  are  more 
marked,  especially  in  the  last  few  weeks,  when  the  excursions  of  the  diaphragm  are 
restricted  by  the  large  uterus,  and  particularly  if  the  abdomen  is  tympanitic. 
Cardiac  collapse  is  earlier  and  more  freciuent;  indeed,  pregnancy  and  pneumonia 
are  a  dangerous  combination.  Yinay  collected  cases  which  showed  a  maternal 
mortality  of  G8  per  cent,  wdien  pregnancy  w^as  interrupted,  and  of  15  per  cent,  when 
it  went  on  undisturbed.  Pneumonia  may  affect  the  fetus,  and  its  chances  generally 
are  not  good,  though  Fellner  quotes  19  cases  of  Schauta's  clinic,  wdth  onh'  1  death. 
One  should  not  induce  lal^or  except  for  threatening  symptoms  of  cardiac  or  respira- 
tory collapse,  the  same  rules  guiding  here  as  were  mentioned  under  Influenza.  The 
rapid  methods  of  emptying  the  uterus  are  to  be  selected. 

Pneumonia  in  the  puerperium  may  be  due  to  the  pneumococcus,  may  result 
from  the  anesthetic  (bronchopneumonia),  or  be  hypostatic  or  embolic.  The  last  two 
forms  appear  in  septic  cases — the  one  from  cachexia  and  the  other  from  embolism 
from  infected  pelvic  veins  {q.  v.).  Other  manifestations  of  pneumococcus  invasion 
are:-  Pleurisy,  pericarditis,  endocarditis,  meningitis,  otitis  media,  sinus  infections, 
endometritis,  and  ophthalmia  neonatorum,  besides  other  fetal  infections. 

For  further  information  on  all  these  subjects  see  Frankl-Hochwart  and  v. 
Noorden. 

Literature 

Ballantyne:  Trans.  Edinburg.  Obst.  Soc,  vol.  xviii,  p.  177. — Barker:  Amer.  Jour.  Obstet.,  ISSO,  p.  210. — Boden- 
hduser:  N.  Y.  Med.  Jour.,  1893. — Dealc:  Amer.  Jour.  Obstet.,  1S97,  vol.  .xxx\-i. — Fellner:  Innere  Krankhei- 
ten,  Vienna,  1903. — Frankl-Hochwart  and  C.  von  Xoorden:  Erkrank.  des  weibl.  Genitales  and  inn.  Med.,  2 
volumes,  1912. — Freund:  Ergeb.  der  allg.  Path.,  III.  Jahrgang,  1896,  vol.  ii. — Fry:  "Malaria,"  .\mer.  Jour.  Ob- 
stet., 1897,  vol.  XXXV. — Kollock:  .\mer.  Jour.  Obstet.,  1889,  p.  1079. — Krummaker:  Munch,  med.  Woch.,  1907, 
p.  1035. — hardier:  Lyon  M6d.,  July,  1888. — Lchedeff:  Zent.  f.  Gyn.,  1886,  p.  423. — Legeois:  Arch,  de  Tocolo- 
gie,  January,  1891. — Moller:  "Influenza,"  Deutsch.  med.  Woch.,  1900,  Xo.  29. — Miiller,  P.:  Die  Krankheiten 
des  weiblichen  Korpcrs.  Immense  fund  of  information. — Olshatisen:  Arch.  f.  Gyn.,  vol.  ix,  p.  169. — Tornery: 
La  Rougeole  et  la  Scurlatine  dans  la  Grossesse,  1891.  Book  of  362  pages. — Vinay:  Pathologie  de  la  Gross- 
esse. — Wallich:   "Pneumonia,"  .\rch.  de  Gyn.,  1889,  vol.  xxxi,  p.  439. 


CHAPTER  XXXVIII 
THE  CHRONIC  INFECTIOUS  DISEASES 

Pulmonary  tuberculosis  has  a  marked  influence  on  the  woman  during  the  per- 
formance of  the  reproductive  function.  In  the  advanced  cases  menstruation  is 
usually  suppressed,  which  may  be  looked  upon  as  the  conservative  effort  of  nature, 
as  the  result  of  extreme  cachexia  with  atrophy  of  the  ovaries,  or  local  tubercular 
disease  of  the  genitalia.  In  beginning  tuberculosis  amenorrhea  or  scanty  menses 
may  be  noted,  and  since  the  girl  may  be  chlorotic,  a  difficult  diagnostic  problem  may 
present  itself — chlorosis  or  tuberculosis,  or  both.  Every  chlorotic  girl's  lungs  should 
be  carefully  examined.     A  leukorrhea  may  substitute  the  menses  in  such  cases. 

Sterility,  fortunately,  is  not  rare  in  tubercular  men  and  women,  but  only  in  ad- 
vanced cachectic  individuals.  Pregnancy  does  not  confer  immunity  on  women 
against  the  disease,  as  was  once  held;  on  the  contrary,  conception  may  arouse  a 
latent  affection,  or  even  develop  it  in  an  individual  who  only  displayed  a  tendency 
to  become  tubercular.  An  existing  pulmonary  disease  is  apparently  benefited  by 
pregnancy,  the  gravida  developing  red  cheeks,  a  lively  expression  of  countenance, 
vnth  clear  eyes,  and  even  rarely  putting  on  fat,  but,  withal,  the  consolidation  is 
maldng  rapid  progress,  and  after  delivery  caseous  degeneration  will  occur  more 
rapidly  than  before.  Ordinarily,  the  disease  makes  deep  inroads  during  gestation, 
and  the  author  has  noticed  this  occur  especially  if  the  woman  also  suffers  from  hy- 
peremesis.  If  a  dormant  tuberculosis  awakens  in  pregnancy  or  a  new  infection 
occurs,  the  course  of  the  disease  is  apt  to  be  more  rapid,  being  usually  of  the  more 
florid  type,  the  tendency  to  fever  greater,  and  emaciation  more  marked.  Hemop- 
tysis occurs  in  50  per  cent,  of  the  cases.  Tuberculosis  of  the  larynx,  heart  disease, 
and  nephritis  aggravate  the  pulmonary  condition  decidedly.  The  chronic  ulcera- 
tive varieties  of  tuberculosis  do  not  usually  produce  such  marked  symptoms  during 
pregnancy,  the  author  having  seen  such  women  have  children  repeatedly,  without 
greater  aggravation  of  the  disease  than  one  would  expect  under  other  circum- 
stances. 

The  puerperium  also  has  a  deleterious  influence  on  the  disease.  Owing  to  the 
changes  in  the  lungs  and  heart  and  the  drain  on  the  system  caused  by  pregnancy  and 
labor,  especially  if  there  has  been  much  hemorrhage,  the  caseous  deposits  soften 
and  rapidly  break  down,  hectic  develops,  and  the  course  of  the  affection  goes  down- 
ward fast.  If  the  patient  has  tuberculous  laryngitis  in  addition,  she  rarely  survives 
the  puerperium  (Kiittner,  90  per  cent,  mortality). 

Pregnancy  is  rarely  interrupted,  and  then  the  infection  is  usually  very  florid, 
and  resemV^les  a  pneumonia  more  than  a  typical  tuberculosis. 

During  labor  the  degree  of  involvement  of  the  lungs  will  determine  how  much 
trouble  will  be  met.  Mild  cases  go  through  it  without  causing  anxiety.  Advanced 
cases  are  harassed  by  dyspnea,  cough,  occasionally  hemoptysis,  and  threatened  by 
cardiac  collapse,  oedema  pulmonum,  pneumothorax,  and,  rarely,  a  spread  of  the 
infection  into  general  miliary  tuberculosis.  Labor  is  slower,  and  the  second  stage 
is  prolonged  and  critical.  During  the  puerperium  fever  is  common;  a  bronchitis 
is  often  added  to  the  other  troubles,  but,  in  the  author's  experience,  sepsis  has  not 
been  more  frequent.     The  differential  diagnosis  from  sepsis  is  easy. 

Tuljerculosis  has  decided  immediate  and  remote  influence  on  the  child.  Birch- 
Hirschfeld  (1891)  first  demonstrated  tuberculosis  in  the  fetus,  and  Schmorl  showed 

480 


THE    CHRONIC    INFECTIOUS    DISEASES  481 

it  in  the  placenta  in  50  per  cent,  of  the  cases,  though  Hardy,  in  1834,  mentions  it. 
Bar  and  Renon  found  tubercle  bacilli  in  the  }>lood  of  the  umbilical  cord  in  2  of  5 
cases.  Placental  tuberculous  foci  usually  precede;  f(!tal  disease,  but  without  doubt 
the  bacilli  may  pass  directly  to  the  fetus  through  the  walls  of  the  villi.  Congenital 
tuberculosis  was  held  impossible  for  years  and  by  many,  but  it  occurs,  and  probably 
more  frequently  than  is  generally  known.  Friedman  injected  weak  suspensions  of 
tubercle  bacilli  into  the  vaginas  of  rcn-entl}^  impregnatc^l  guinea-pigs  and  produced 
fetal  tuberculosis.  By  men,  through  dirty  habits,  or  from  genital  tubercular  foci, 
the  bacilli  could  be  introduced  with  the  semen.  Baumgarten  held  that  the  disease 
was  inherited,  the  germs  developing  at  a  later  period,  but  probably  a  weakness  of 
the  constitution,  a  tendency  to  the  malady,  is  inherited,  and  the  environment  of  the 
child  and  the  numerous  opportunities  for  infection  are  the  exciting  causes. 

The  children  of  tubercular  w^omen  may  be  large  and  robust,  especially  if  the 
disease  is  of  the  chronic  type.  Puny  children  also  are  born,  and  many  die  in  the 
first  weeks  or  months.  The  author  knew  a  family  in  which  six  children  died  con- 
secutively of  tubercular  meningitis.  It  is  possible  that  the  child  becomes  tuber- 
culous through  the  mother's  milk. 

Treatment. — Women  with  tuberculosis  should  not  marry — first,  because  this 
aggravates  their  own  disease;  second,  they  may  infect  the  husband;  and,  third, 
they  propagate  tuberculous  children.     The  same  is  to  be  said  of  the  husband. 

If  the  tuberculosis  is  latent,  or  if  the  candidates  possess  only  the  hereditary 
taint,  the  question  is  more  difficult,  but  it  is  only  exceptionally  that  the  doctor's 
advice  is  asked.  Knowing  the  tendency  for  a  latent  tuberculosis  to  break  out  in 
pregnancy,  marriage  is  to  be  forbidden.  If  the  woman  marries,  she  should  avoid 
conception.  Finally,  if  she  conceives,  she  should  not  nurse  the  baby.  The  disease 
makes  great  progress  during  the  puerperium,  especially  if  the  woman  nurses.  The 
tuberculin  tests  may  be  made  on  gravidse. 

During  pregnancy  the  recognized  medical  treatment  is  carried  out.  Should 
the  pregnancy  be  interrupted  because  the  mother  has  pulmonary  tuberculosis? 
Opinions  differ,  three  positions  being  held:  one,  that  pregnancy  be  always  inter- 
rupted as  a  curative  measure;  another,  that  it  be  never  interrupted,  and  the  third, 
that  the  cases  be  individually  treated  and  the  gestation  brought  to  an  end  only 
when  certain  symptoms  indicate  it.  I  am  inclined  to  a  more  active  treatment.  If 
tuberculosis  of  the  lungs  is  manifest  in  early  pregnancy;  if  there  are  fever,  w^asting, 
hemoptysis,  and  advancing  consolidation, — that  is,  the  process  seems  to  be  florid, — 
abortion  should  be  induced  without  delay.  Trembley,  of  Saranac  Lake,  induces 
abortion  in  the  early  months  in  all  cases,  and  says  that  the  mortality  and  percentage 
of  relapses  are  practically  nil  w^hen  abortion  is  induced  before  the  end  of  the  third 
month.  If  the  process  seems  very  chronic,  especially  if  the  patient  comes  in  the 
second  half  of  pregnancy,  it  is  justifiable  to  wait  and  watch  closely.  If  the  preg- 
nancy is  near  the  period  of  viability,  one  may  tide  the  woman  over  a  few  weeks  for 
the  sake  of  the  child,  or  even  allow  her  to  go  to  term,  depending  on  her  condition. 
Urgent  symptoms  of  cardiac  nature,  persistent  hemoptysis,  and  dyspnea  may  re- 
quire the  emptying  of  the  uterus.  Complicating  nephritis,  heart  disease,  and  con- 
tracted pelvis,  which  is  said  to  be  more  frequent  in  the  tuberculous,  will  give  earlier 
indication  for  interference.  Tuberculosis  with  h}T:)eremesis  makes  the  indication  for 
immediate  abortion. 

Larjmgeal  tuberculosis  in  the  early  months  is  a  positive  indication  for  abortion; 
in  the  later  months  one  may  temporize,  unless  obstructed  breathing  forces  the 
hand.  Be  ready  to  do  tracheotomy.  In  tuberculous  cases  anesthetics  are  used 
only  wdien  very  necessary.  Abortion  may  be  done  in  two  sittings:  the  first, 
for  pacldng  the  uterine  cavity  with  gauze,  after  opening  the  o^"um,  and  the  sec- 
ond on  the  day  following,  for  removing  the  contents  of  the  uterus,  unless  these 
have  come  away  spontaneously.  Premature  labor  is  performed  by  rupturing  the 
31 


482      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

membranes  and  metreurj^sis,  unless  great  urgency  necessitates  more  rapid  operating, 
when  vaginal  cesarean  section  may  be  done.  Bumm  recommends  extirpation  of  the 
uterus  at  this  opportunity,  and  others  tying  off  the  tubes  to  procure  sterility.  Dur- 
ing labor  the  general  course  is  expectancy,  but  armed  for  all  emergencies.  The 
heart  has  been  poisoned  so  long,  a  subcyanotic  condition  of  the  blood  has  existed  so 
long,  that  the  cardiac  muscle  is  likely  to  be  diseased;  therefore  to  it  we  give  our 
main  attention.  As  soon  as  dilatation  is  complete  and  the  head  on  the  perineum, 
forceps  are  to  be  applied,  unless  the  woman's  condition  is  so  good  that  interference  is 
unnecessary.  The  hemorrhage  of  the  third  stage  is  to  be  limited.  The  author  has 
used  ether  in  these  cases  with  no  worse  effects  than  follow  chloroform.  In  the 
puerperium  one  should  keep  up  the  heart  with  caffein,  strychnin,  and  digitalis, 
but  especiallj^  good  are  fresh  air  and  full  diet.  Lactation  is  forbidden,  and  the  child 
should  be  removed  from  the  environment  in  which  it  was  born  unless  the  parents 
are  intelligent  enough  to  carry  out  the  necessary  precautions  for  its  safety.  The 
woman  should  be  instructed  how  to  avoid  pregnancy  in  the  future.  Something 
must  be  clone  until  the  woman  is  cured  of  her  tuberculosis,  so  that  she  may  safely 
go  through  a  confinement,  because  every  accoucheur  recoils  with  horror  from  the 
task  of  repeatedly  doing  abortions  on  these  tuberculous  women.     (See  Bacon.) 

Syphilis. — Obstetricians  should  constantly  be  on  the  alert  for  this  protean 
disease.  Its  baneful  action  is  often  discovered  when  least  expected,  and  it  spreads 
its  blight  on  all  three  individuals  concerned  in  the  propagation  of  the  species,  even 
being  transmitted  to  the  second  generation.  Ricord  says  that  in  Paris  one  in  eight 
is  sj^philitic,  and  while  in  America  the  conditions  are  better,  the  disease  is  not  rare, 
and  in  its  lesser  manifestations  quite  common,  though  often  not  diagnosed.  First 
maternal  syphilis,  then  paternal,  will  be  considered. 

Effects  of  Pregnancy  on  Syphilis. — If  a  woman  acquires  lues  at  the  same  time 
that  she  is  impregnated,  or  if  she  conceives  while  still  in  the  florid  stage,  the  disease 
assumes  graver  forms  than  in  the  non-pregnant.  The  chancre  is  larger  than  usual, 
h^'pertrophies,  is  more  moist,  vascular,  and  soft,  and  shows  a  tendency  to  ulcerate 
or  become  phagedenic.  It  lasts  longer,  and  may  often  be  found  even  after  twelve 
weeks.  Secondaries  develop  sooner  and  are  more  marked,  especially  those  on  the 
genitalia,  because  of  the  natural  succulence  of  the  parts.  The  exanthem  is  very 
wide-spread;  the  papules  are  likely  to  be  large,  and  pustular  forms  are  commoner. 
j\Iore  enlargement  of  the  glands  is  observed,  and  they  tend  more  to  suppuration. 
Eroded  papules  are  very  numerous  on  the  vulva  (Fournier) ;  "they  develop  with  a 
singular  exuberance,  take  on  quickly  a  granulating  condition,  hypertrophy,  and 
often  constitute  veritable  tumors,  which  invade  and  deform  the  entire  vulva. 
Further,  they  are  always  more  rebellious  to  treatment,  being  reabsorbed  slowly  and 
with  difficulty.  The  ulcerating  syphilids  are  very  frequent  in  pregnant  women,  are 
livid,  purple,  and  excavated,  which  condition  is  increased  by  the  general  tumidity 
of  the  parts.     They  persist  longer  and  have  a  tendency  to  become  phagedenic." 

Pregnancy  aggravates  the  general  symptoms  of  syphilis,  the  anemia  is  more 
profound,  fever  more  common  and  a  little  higher,  digestive  troubles  are  marked, 
neuralgias,  headache,  insomnia,  and  bone  pains  all  exaggerated.  Neuralgias  be- 
ginning shortly  after  marriage  may  serve  to  draw  attention  to  the  infection.  Ter- 
tiary syphilis  is  less  affected  by  the  advent  of  pregnancy,  though  sometimes  it  may 
awaken  the  disease  which  was  thought  to  have  been  cured. 

Effects  of  Maternal  Syphilis  on  the  Pregnancy. — Luetic  women  are  often  sterile, 
perhaps  because  the  ovarian  function  is  suspended  in  a  manner  similar  to  that  of  the 
testicle  in  syphilitic  men.  There  is  a  syphilitic  endometritis  which  may  explain 
some  cases.  The  actual  effects  on  the  pregnancy  may  vary  with  the  age  of  the 
syphilis  and  the  success  of  the  treatment,  because  if  the  patient  has  been  success- 
fully treated,  she  may  bear  healthy  children. 

If  the  syphilis  is  more  recent,  the  fetus  dies  and  abortion  occurs.     The  subse- 


THE    CHRONIC    INFECTIOUS    DISEASES  483 

quent  prcftnancios  torminato  tlu^  same  way,  but  each  ono  later,  until  a  living  but 
s>Tohilitic'  fetus  is  born,  and  fiiuiUy  a  living,  ai)par('ntly  well,  child  at  term.  This 
may  develop  syphilis  within  two  months  (lues  conj^enita  tarda)  or  after  years  (lues 
hereditaria  tarda).  This  course  of  events  may  be  interrupted  by  vigorous  treat- 
ment of  both  parents.  Karely  luetic  children  are  born  of  apparently  sound  par- 
ents. I'^ngman  suggests  that  in  such  cases  the  mother  may  be  a  "spirochete 
carrier." 

Still  more  rarely  ai^parentl}'  healthy  children  are  born  of  syphilitic  mothers. 
Why  the  placenta  does  not  allow  the  virus  access  to  the  fetus  is  not  known,  nor  is  the 
manner  of  infection  of  the  fetus  settled — whether  it  is  primarily  ovular  or  later  by 
placental  transmission.  Spirocheta3  have  been  found  in  the  ova  in  the  ovary  of 
the  fetus.  Ruge  says  that  83  per  cent,  of  repeated  abortions  are  due  to  sj^Dhilis. 
Late  abortion — fifth  to  seventh  months — and  early  premature  labor — seventh  to 
eighth  months — are  characteristic  of  syphilis.  Hydrocephalus,  spina  bifida,  de- 
formities in  the  nervous  system,  polydactylia,  etc.,  are  often  due  to  sj'philis 
(Rudaux,  Rosinski). 

If  the  woman  acquires  syphilis  at  the  time  of  conception,  early  abortion  is  the 
rule,  unless  thorough  treatment  is  given  at  the  start,  and  even  then  the  child  is  often 
lost.  If  the  syphilis  is  contracted  during  pregnancy,  both  parents  having  been  well 
at  the  time  of  impregnation,  that  is,  post-conceptional  infection,  abortion  is  the 
rule  in  the  earl}^  months,  but  if  the  disease  was  acquired  in  the  latter  months,  the 
child  may  escape,  the  placenta  offering  a  barrier  to  the  virus.  In  such  instances 
the  child  may  be  immune  (Prof eta's  law).  Later  studies  show  that  these  infants 
have  a  positive  Wassermann  reaction.  In  more  than  half  the  cases  the  fetus  ac- 
quires the  disease  through  the  placenta,  even  in  the  last  month  (Finger) ,  or  even 
during  its  transit  through  the  birth-canal. 

Interruption  of  gestation  is  the  commonest  symptom,  and  von  Winckel  found 
61  per  cent,  fetal  mortahty.  It  is  said  that  eclampsia  is  not  more  common,  but 
the  author  had  three  women  showing  marked  albuminuria  while  carrying  syphilitic 
fetuses.  Labor  may  be  influenced  by  syphihs.  The  pains  maj^  l)e  weak  and  prog- 
ress slow.  Abnormal  presentations  are  common,  because  the  children  are  usually 
macerated.  A  chancre  on  the  cervix  may  impede  delivery,  as  also  may  an  indura- 
tion in  the  secondary  stage  (Blandin),  which  may  necessitate  incisions,  craniot- 
omy, even  cesarean  section.  Friability  of  the  perineum  was  verj^  pronounced  in 
three  of  my  cases,  the  head  bursting  through  the  vulva,  tearing  it  in  all  directions 
like  wet  paper.  Condylomata  lata  vulviB  conduce  to  such  lacerations.  Postpar- 
tum hemorrhage  is  usually  not  greater,  but  the  author  had  one  case  of  hemophilic 
diathesis  in  a  syphilitic  prostitute  which  made  some  such  relation  seem  plausible. 
Ordinaril}^  if  the  fetus  has  been  dead  long,  thrombosis  of  the  placental  site  occurs. 

In  the  puerperium  sepsis  is  not  commoner  than  usual;  the  puerperal  wounds, 
unless  primarily  infected,  heal  nicely,  especially  if  specific  treatment  is  given. 

Paternal  syphilis  has  also  a  bad  effect  on  gestation,  and  its  action  is  hard  to 
understand.  When  the  husband  has  florid  primary  or  secondary  syphilis  and  in- 
fects his  wife  at  the  time  of  impregnation,  it  is  impossible  to  separate  the  results. 
Abortion  is  the  rule.  The  commonest  cases  are  those  where  the  husband  has  been 
treated  more  or  less  successfully  for  sj'philis  before  marriage.  The  limit  of  safety, 
that  is,  the  time  required  before  he  can  procreate  healthy  offspring,  is  variously 
given  as  from  two  to  twelve  years,  but  much  depends  on  the  success  of  the  treat- 
ment. Even  if  at  the  time  of  coitus  he  has  no  infective  lesions,  the  child  is  usually 
syphilitic,  or  it  may  show  signs  of  the  disease  later  in  life.  If  the  father  was  cured, 
it  wdll  remain  well.  If  the  lues  is  more  recent  or  uncured,  the  child  dies,  macerates, 
and  premature  labor  takes  place,  with  a  repetition  of  such  an  occurrence  in  subse- 
quent pregnancies  until  the  virus  is  removed  by  time  or  medicines. 

How  do  the  spirochetae  reach  the  ovum?     They  are  three  times  larger  than  the 


484 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


head  of  the  spermatozoid,  and  surely  this  tiny  organism  could  hardly  carry  such  a 
load;  therefore  they  are  carried  by  the  semen.  Experience  and  experiment  have 
shown  that  syphilis  can  thus  be  conveyed  (Bab),  but  it  is  more  hkely  that  the 
mother  becomes  syphilitic  and  the  spirochetse  settle  in  the  ovum  and    decidua 


"y 


■y'. 


r 


I/' 


0 


r  < 

i) 


} 


-n 


Fig.  429. — Spirochet.b   in  Fetal  Liver   (specimen  of  Professor  Zeit). 


FlO.    430. E.VDAHTERITIB    FROM    SYPHILITIC    PLACENTA. 


TIIE    CHRONIC    INFECTIOUS   DISEASES 


485 


from  the  1j1o(kI.     Nijf^uclii,  \)y  cultivating  the  spirochetic,  has  proved  tho  specificity 
of  tho  organism  for  syphilis. 

A  woman  carrying  a  child  l(>iitic  ex  patre,  as  a  rule,  hecomes  immune  to  syphilis. 
(Abraham  CoUes'  law,  Dublin,  1837.)  Wc;  know  now,  from  the  results  of  the  study 
of  the  women  and  infants  with  the  Wassermann  l^lood-test,  that  the  mothers  are 
immune  l)ecause  they  are  really  syphilitic.  CoUes'  law  is  thus  upset,  and  Wolff's 
dictum  of  1879  confirmetl.  A  mother  carrying  an  ex  patre  syphilitic  fetus  some- 
times develops  actual  k^sions  which  may  be  secondary  and  tertiary,  or  even  only 
tertiary — the  "syphilis  by  conception."  The  virus  has  passed  from  the  fetus 
through  the  placental  wall  to  the  mother.  It  is  certain  that  the  spirillum  of  relaps- 
ing fever  may  pass  the  placenta  and  infect  the  child,  and,  therefore,  it  is  fair  to 
argue  that  the  Spirocha;ta  i^allida  may  infect  the  mother  by  a  reverse  process. 


,  %  ^ 


-»  l^"*^^ 


m 


■9-.  00 


Fig.  431. — Syphilitic  Placenta. 


Syphilitic  Changes  in  the  Fetus. — The  skin,  the  mucous  membranes,  the  viscera,  and  the 
bones  are  moat  often  affected. 

1.  The  Skill. — Bullous  eruptions;  desquamation  of  large  areas  of  epidermis,  leaving  deep- 
red,  macerated  corium  underneath;  papules  and  vesicles,  especially  of  tlie  palms,  soles,  and  face; 
coppery  erythema  of  the  buttocks;   paronychia;   pemphigus;   icterus. 

2.  Mucous  Membranes. — Mucous  patches  in  mouth  and  pharynx,  coryza,  weeping  papules 
around  anus,  fissures  and  ulcerations  of  the  body  orifices. 

5.  Viscera. — The  hver  is  larger,  feels  elastic,  is  granular,  and  almost  always  is  particularly 
full  of  spirochetie  (Fig.  429)  (Lcvaditi).  It  shows  the  antigen  reaction.  Liver  changes  explain 
the  frequency  of  icterus  and  infection  of  the  child,  and  also,  because  its  aid  in  assimilation  is 
reduced,  the  athrepsia  of  the  infant  (Bar).  The  spleen  is  enlarged,  sometimes  to  five  times  its 
normal  size.  The  belly  is  cUstendcd;  there  is  some  fluid  in  the  peritoneum.  The  lungs  ma}-  show 
gummata  or  a  peculiar  interstitial  infiltration  which  is  characteristic  of  lues;  this  is  called  white 
pneumonia,  and  is  incompatible  with  respiration.  The  kidneys  nearly  always  show  an  intersti- 
tial nephritis  and  endarteritis  and  peri-arteritis,  with  cellular  infiltration  of  the  vessel-wall,  which 
may  be  generalized  throughout  the  body,  and  is  also  found  in  the  cord  (Fig.  430).  These  blood- 
vessel changes  are  pathognomonic.  The  placenta  is  large,  heavy  (sometimes  being  over  one-fourth 
the  weight  of  the  fetus),  pale,  soft,  fatty,  edematous,  but  these  changes  are  also  found  in  other 
conditions.     If  the  father  alone  was  sj'philitic,  the  changes  may  be  hmited  to  the  ^•i^i,  which  are 


To  see  the  fine  structure,  the  reader  should  look  at  these  pictures  through  a  hand  magnifying-glass. 


486 


Fig.      -tUS. — Osteochondritis       .Svphilitica      (gross 
snocimi'ii   from   Dr.    Zeit). 


DISEASES    OF    THE    CIRCULATORY    SYSTEM  487 

thickened,  club-shapod  (Fifi;.  4.31),  obliterated  by  overp;rowth  of  white  cells,  fatty  degenerated, 
or  calcareous  ami  soiiictiines  speckled  with  fine  hciiKjrrhanes.  If  the  mother  alone  was  syphilitic, 
the  changes  11U13'  be  restricted  to  [he  endoinetriuiii  and  the  |)urely  maternal  jjcjrtion  of  the  placenta 
— gummatous  growths  which  stretch  up  between  the  cotyledons,  inlih ration  of  the  decidua;,  and 
epithelial  degeneration  of  the  placenta  materna,  but  usually  the  wIkjIc  placenta  is  affected.  The 
arteries,  and  to  a  less  extent  the  umbilical  vein,  are  much  thickened,  even  obliterated,  a  fact 
which  may  be  used  for  diagnosis.  The  si)irooheta)  are  ran;  in  th(!  j)laeenta,  but  havr;  been  found 
in  the  liver,  spleen,  testicle,  ovary,  skin,  (>ye,  etc.  The  fetal  blood  shows  a  mononuclear  lympho- 
cytosis. The  W'assermann  reaction  is  likely  to  be  negative  in  the  f(;lal  blood,  even  though  the 
mother  was  luetic  (liar  and  Daunay),  and  even  doubtful  reactions  may  be  obtained  in  the  absence 
of  syphilis.     From  the  cerebrospinal  fluid  the  best  results  are  obtained. 

4.  The  Hones. — Osteochondritis  syphilitica,  described  by  Wegner  (Fig.  4.3.5),  is  the  most 
constant  and  pathognomonic  autopsy  finding.  The  line  of  o.ssification  is  broader,  with  irregular 
edges  and  points  running  into  the  cartilage.  There  are  small  islands  of  bony  matter  off  to  the 
side  in  the  cartilage,  and  the  whole  epiphysis  is  yellower.  In  advanced  cases  the  part  is  swollen 
and  the  periosteum  thickened.     The  x-ray  shows  a  line  of  bony  thickening  at  this  point. 

The  (liai)hysis  breaks  off  easily.  Similar  changes  occur  in  congenital  rachitis,  but  a  glance 
at  Fig.  435  will  enable  a  differentiation  to  be  made. 

Syphilis  has  been  invoked  to  explain  many  diseases  of  the  new-born,  for  example,  icterus 
gravis,  hemorrhagic  diathesis,  hydrocephalus,  congenital  deformities,  C3^stic  kidnej's,  athrepsia. 
Perhaps  the  discovery  of  the  spirocheta  and  the  various  serum  reactions  may  bring  light  in  these 
and  other  conditions. 

Treatment. — Syphilis  is  to  be  thoroughly  treated  as  soon  as  discovered,  and 
in  the  usual  manner,  regardless  of  pregnancy.  Instituted  early,  abortion  may  be 
prevented.  Salvarsan  and  inunctions  seem  to  give  the  best  results.  Habitual 
abortion  after  the  fifth  month,  or  premature  labor,  when  due  to  syphilis,  indicate 
antisyphilitic  treatment  of  both  parents.  In  doubtful  cases,  too,  this  advice  may 
be  given.  It  is  the  author's  practice  to  give  women  with  such  a  history,  during  preg- 
nancy, mercury  and  iron  as  alterative  tonics.  As  soon  as  it  is  born  the  child  also 
is  to  be  treated,  and  it  must  be  watched  minutely  for  the  appearance  of  rashes, 
coryza,  etc.  Salvarsan  passes  over  to  the  child  through  the  milk,  but  in  small 
amounts.  More  important  are  the  specific  antibodies  developed  by  the  drug, 
which  pass  over  and  are  curative.  The  child,  however,  may  be  given  "606" 
also  (Jesionek).  The  author  still  uses  and  prefers  calomel  and  inunctions  (-jV 
grain  thrice  daily,  unguentum  hydrargyri,  20  grains  daily).  Baths  of  1 :  20,000 
mercury  bichlorid  are  given  daily  when  there  are  profuse  eruptions.  Isolate  the 
child  and  use  rubber  gloves  in  handling  it,  since  the  disease  is  very  infectious. 

Nursing. — Only  its  mother  may  nurse  the  infant,  because  the  child  is  almost 
invariably  diseased,  even  if  it  shows  no  evidences  of  lues.  Latterly  cases  are  being 
published  in  which  a  luetic  mother  infected  her  previously  healthy  child ;  but  these 
cases  are  rare.  The  milk  of  a  luetic  woman  is  infectious.  If  the  child  is  sj'philitic 
but  the  mother  apparently  well,  only  the  mother  may  nurse  the  infant,  because  she 
is  latently  luetic.  Never  put  a  child  of  a  syphilitic  mother  or  father  to  a  healthy  wet- 
nurse.  It  is  criminal,  though  the  law  allows  only  damages  from  a  civil  suit.  In 
hospitals  and  in  maternities  the  authorities  must  be  on  guard  constantly  for  this 
danger.  Only  after  most  careful  investigation,  including  the  serum  reaction,  has 
shown  that  the  baby  and  the  wet-nurse  are  healthy  may  nursing  be  allowed.  In 
general,  in  maternities,  the  physicians  and  nurses  should  constantly  watch  for  the 
first  evidences  of  s^iDhilis,  and  only  after  three  months  may  one  say  that  the  child 
has  escaped  infection  (Zeisler,  Zeit). 

DISEASES  OF  THE  CIRCULATORY  SYSTEM 

The  Heart. — There  is  no  doubt  that  the  heart  regularly  suffers  an  alteration 
as  the  result  of  gestation.  It  hypertrophies,  it  dilates,  or  does  both,  and  Virchow 
found  slight  evidences  of  fatty  degeneration. 

In  the  routine  examination  of  the  hearts  of  pregnant  women  the  author,  in  a 
majority  of  the  cases,  has  found  systolic  murmurs  at  the  base  and  accentuation  of 
the  second  aortic  sound,  occasionally  a  presystoUc  murmur,  and  displacement  of  the 
apex-beat  to  the  left.  It  was  not  alwaj'S  easy  to  eliminate  actual  vitium  cordis. 
Several  real  heart  diseases  were  discovered,  which,  without  such  a  routine  examina- 


488      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

tion,  would  surely  have  passed  through  labor  without  being  noticed,  because  they 
produced  no  trouble  whatever.     Heart  disease  in  labor  is  certainly  often  overlooked. 

The  Effect  of  Pregnancy  on  Heart  Disease. — A  normal  healthy  heart  easily  satis- 
fies all  the  extra  demands  made  on  it  by  gestation  and  labor.  Even  a  diseased  heart, 
if  compensation  is  good,  often  sustains  the  additional  strain  without  laboring  hard. 

Pregnancy ,  therefore,  in  mild  heart  cases,  in  young,  otherwise  healthy  women, 
does  not  seem  to  exert  a  very  harmful  influence  on  the  disease,  but  it  has  seemed  to 
the  author  that  these  women  develop  discompensation  and  die  sooner  than  other 
women,  and  men  with  similar  cardiac  disease.  Naturally,  it  is  hard  to  collect 
statistics  on  this  point.  If  the  disease  is  advanced;  if  the  heart  is  in  unstable 
equihbrium,  and  especially  if  myocarditic  or  fatty  degeneration  has  occurred,  the 
danger  of  broken  compensation  with  its  pernicious  sequelae  is  present.  Pregnancy 
predisposes  to  an  acute  exacerbation  of  chronic  endocarditis,  especially  if  the  latter 
be  not  too  old,  and  ^vith  this  sometimes  a  fatty  degeneration  of  the  papillary  muscles, 
which  has  a  bad  effect  on  the  compensation.  The  congestion  of  the  venous  system 
leads  to  kidney  and  hepatic  disturbances;  the  pulmonary  congestion  leads  to 
dj'spnea  and  carbonic-acid  narcosis,  and  the  high  position  of  the  diaphragm,  with 
the  slight  decrease  of  vital  capacity,  augments  the  respiratory  difficulty  and  cyanosis. 
Transudations  in  the  pleurae  may  cause  compression  of  the  lungs,  hypostatic  pneu- 
monia, and  oedema  pulmonum,  and  hemoptysis  may  also  be  a  complication.  Edema 
of  the  extremities,  ascites,  dyspnea,  attacks  of  suffocation,  dry  cough,  palpitation, 
insomnia,  albuminuria— all  these  show  that  the  compensation  is  broken  and  warn 
the  accoucheur  of  impending  danger. 

During  Labor. — There  is  danger  from  not  fully  compensated  hearts,  and,  too, 
an  apparently  competent  heart  may  suddenly  prove  default.  Without  doubt  some 
of  the  cases  of  sudden  death  during  labor  are  due  to  an  unrecognized  vitium  cordis. 
I  have  seen  two  cases  of  acute  dilatation  of  an  apparently  normal  heart,  but  prob- 
ably unsuspected  myocardial  disease  was  present.  Even  a  strong  heart  may  not 
be  able  to  stand  the  strain  of  an  unduly  prolonged  second  stage. 

Uterine  action  increases  the  arterial  tension,  and  straining — bearing  down — 
increases  both  arterial  and  venous  pressure.  In  themselves  these  are  not  very 
dangerous;  it  is  the  fluctuation  of  the  blood-pressure  incident  to  labor  which  is 
hard  on  the  heart.  Symptoms  of  a  laboring  organ  appear,  or  the  heart  may  sud- 
denly give  way  to  the  strain,  and  cyanosis,  collapse,  oedema  pulmonum,  and  death 
ensue.  If  the  heart  holds  out  until  the  baby  is  born,  the  balance  of  the  circulation 
may  be  established  rapidly,  or,  in  not  a  few  cases,  sudden  death  in  collapse  may 
occur.  In  one  of  the  cases  seen  by  the  author  in  consultation  the  fatal  collapse 
occurred  three  hours  after  delivery. 

In  the  puerperium  some  of  the  patients  that  recover  from  the  strain  of  labor 
grow  worse,  and  die  from  embolism  of  the  brain  or  lungs,  cardiac  thrombosis, 
recurring  endocarditis,  degeneration  of  the  heart  muscle,  and  aggravation  of  the 
existing  disease.  Sepsis  in  the  puerperium  favors  acute  endocarditis,  or  may 
cause  exacerl^ations  of  an  old  affection. 

Valvular  lesions  are  less  affected  by  gestation  than  the  myocardial  diseases,  a 
point  which  Angus  MacDonald,  Berry  Hart,  and  others  have  emphasized.  This 
table  is  compiled  from  statistics  of  Fellner,  Porak,  and  Vinay,  and  shows  the 
relative  frequency  of  the  several  affections. 

Fellner 

Mitral  rogurgitation 37 

Mitral  stenosis 5 

Combined  mitral  disease 34 

Aortic  regurgitation 3 

Aortic  stenosis 

Aortic  and  mitral  disease 10 

Myocarditis 2 

Unknown 3 


Porak 

ViNAT 

22 

6 

13 

11 

22 

7 

9 

1 

2 

22 

3 

DISEASES    OF    THE    CIKCULATOKY    SYSTEM  489 

A  second  class  of  cases  is  composed  of  those  that  dc^velopduririf?  pregnancy  and 
the  puerperiuni.  It  was  once  thouji;ht  that  a  subacute  endocarditis  was  peculiar  to 
pregnancy,  hut  this  is  not  considennl  any  longer.  Acute  endocarchtis  may  occur 
during  i^regnancy.  Acute  myocarditis  and  fatty  degeneration  may  occur  during 
gestation,  but  they  are  more  likely  in  the  puerperium,  as  evidences  of  a  septic  proc- 
ess, though  they  may  occur  alone.  Brown  atrophy  has  been  found  in  many  cases 
of  sepsis.  Fatty  degeneration  of  the  heart  may  follow  severe  hemorrhages,  es- 
pecially if  repeated,  also  ])rolonged  and  hard  labor,  protracted  chloroform  narcosis, 
and  there  has  been  observed  an  acute  general  fatty  degeneration  similar  to  Buhl's 
disease  of  the  new-born.  Heart  cases  are  aggravated  by  the  complications  of  preg- 
nancy, for  exampl(>,  twins,  ])olyhydramnion,  contracted  pelvis,  tuberculosis,  tox- 
emia, nei)hritis,  etc. 

Effects  of  the  Heart  Disease  on  Pregnancy. — Sterility  is  not  common  in  women 
with  cardiac  lesions  unless  in  advanced  stages.  Profuse  menstruation  has  been 
noted.  Abortion  and  premature  labor,  especially  the  latter,  occur  in  cases  of  dis- 
compensation,  in  from  20  to  40  per  cent.,  and  still-births  in  29  to  70  per  cent.,  giving 
the  figures  collected  from  various  sources  by  Fellner.  Labor  is  often  slow,  the  pains 
not  good,  and  operative  interference  commoner.  It  is  said  that  postpartum  hemor- 
rhage is  frequent,  but  I  have  not  found  it  so.  Its  gravity  in  heart  cases  is 
variously  gaged,  some  authors  even  considering  it  beneficial.  Placenta  margin- 
ata  is  common.  Heart  disease  has  no  particular  influence  on  the  puerperal  proc- 
esses.    The  lochia  are  somewhat  profuse  and  prolonged,  and  lactation  is  imperfect. 

Prognosis. — Since  many  women  with  cardiac  disease  pass  through  pregnancy 
and  labor  %vith  the  condition  unknown,  it  is  necessary  to  receive  the  published  ac- 
counts with  caution.  Published  statistics  of  mortality  are,  34,  61,  60,  55,  48,  49, 
12,  6,  31,  and  85  per  cent.,  and  these  surely  present  a  dark  picture  of  the  gravitj^  of 
cardiopathy  in  pregnancy,  but  Fellner,  who  collected  the  above,  calls  attention  to 
the  fact  that  these  are  only  the  bad  cases,  and  that  the  many  mild  ones  are  not  re- 
ported, and  supports  the  statement  with  the  figures  of  Schauta's  clinic,  w^hich  showed 
a  mortality  of  6.3  per  cent.,  and,  if  he  reckoned  in  those  cases  w^here  the  vitium  was 
accidentally  discovered,  it  would  be  only  0.9  per  cent.  Nevertheless,  my  own  ex- 
perience has  taught  me  to  fear  the  complication  of  heart  disease  with  pregnancy,  for 
even  though  one  finally  brings  the  patient  through  alive,  the  dangers  that  threaten 
at  every  step  are  very  disquieting,  and  when  accidents  occur,  they  require  the 
promptest  and  most  skilful  treatment.  Mitral  stenosis  is  generally  considered  the 
worst  of  the  valvular  diseases,  so  far  as  pregnancy  is  concerned,  especially  when 
complicated  by  myodegeneration,  which  makes  all  cases  very  serious.  Everything  ■ 
depends  on  the  compensation.  In  uncompensated  heart  disease  many  children  die 
from  prematurity,  abruptio  placentae,  disease  of  the  placenta,  and  asphjoda,  be- 
cause of  the  imperfectly  aerated  maternal  blood  and  carbonic  acid  narcosis. 

Treatment. — A  woman  with  uncompensated  heart  disease  should  not  marry,  and 
if  married,  should  not  conceive,  and  if  she  has  a  baby,  should  nurse  it  onlj'  in  part. 
If  the  woman  is  otherwise  healthy,  that  is,  has  good  lungs,  liver,  kidnej's,  etc.,  and 
her  heart  is  carrying  its  burden  well,  she  may  marry,  and  if  she  much  desires  it, 
have  children,  but  the  dangers  are  to  be  explained  to  both  husband  and  wife. 
Rarely  is  the  physician  consulted  until  pregnancy  has  occurred.  In  itself,  heart 
disease  is  no  indication  for  abortion,  yet  if  a  woman  with  chronic  discompensation, 
with  myodegeneration,  with  liver  or  Iddney  insufficiency,  becomes  pregnant,  it 
may  be  necessary  to  empty  the  uterus  verj^  earlj^,  because  we  know  she  will  not  be 
able  to  go  through  the  process  safely.  Expectancy'  is  the  rule,  biit  the  woman  must 
be  under  medical  surveillance.  Patients  with  heart  lesions  should  take  a  small 
amount  of  outdoor  exercise  each  day,  should  not  overexert  nor  get  excited,  should 
avoid  crowds,  overeating,  and  alcohol — in  short,  should  pursue  a  quiet,  normal  course 
of  life.     On  the  first  signs  of  discompensation  they  should  rest  in  bed  a  few  days 


490  THE    PATHOLOGY   OF   PREGNANCY,    LABOR,    AND    THE    PUERPERIUM 

under  restricted  fluids  and  simplified  diet.  If  the  heart  needs  help,  digitalis 
in  small  doses  may  be  useful.  For  suffocative  attacks  morphin  hypodermically — 
in  short,  the  usual  treatment — is  to  be  given.  Should  the  symptoms  aggravate 
and  the  heart  begin  to  show  its  overstrain,  labor  is  to  be  induced.  I  am  aware  that 
many  authors  oppose  this  on  the  ground  that  labor  is  usually  the  cause  of  collapse, 
and  that  the  deaths  often  occur  in  the  early  puerperium,  but  this  reasoning  has 
always  seemed  to  me  peculiar.  The  pregnancy  is  evidently  aggravating  the  lesion, 
the  heart  is  proving  default,  the  woman  must  go  through  her  labor  sooner  or  later, 
and  if  she  is  getting  worse  in  spite  of  treatment,  she  will  be  less  and  less  able  to 
withstand  the  strain  the  longer  the  interference  is  delayed.  The  urgency  of  the 
symptoms  will  decide  the  choice  of  method.  In  cases  of  imminent  danger  puncture 
the  bag  of  waters,  and  as  soon  as  preparations  can  be  made,  empty  the  uterus  by 
vaginal  cesarean  section.  If  there  is  no  occasion  for  great  hurry,  pack  the  cervix 
and  lower  uterine  segment  with  gauze.  If  no  pains  are  set  up,  remove  in  twenty- 
four  hours,  puncture  the  membranes,  and  put  in  a  small-sized  colpeurynter.     A 

^  woman  ^vith  heart  disease  should  never  be  allowed  to  go  beyond  term. 

During  labor  all  heart  cases  require  close  scrutiny,  even  if  there  is  good  com- 
pensation. Labor  must  be  so  conducted  that  collapse  in  the  third  stage  and  sudden 
death  later  in  the  puerperium  are  rendered  impossible — a  task  of  no  small  difficulty. 
Preparations  for  all  eventualities  must  be  made  beforehand — plenty  of  assistants, 
oxygen,  salt  solution,  venesection  instruments,  hypodermic  syringe  with  stimu- 
lants— in  short,  the  facilities  of  a  well-equipped  maternity.  All  the  instruments  for 
operative  delivery  are  to  be  held,  sterilized,  ready  for  instant  use.  Watch  the  effect 
of  the  pains  on  the  heart,  such  as  cyanosis,  flagging,  or  irregular  pulse.  Dyspnea 
between  pains  is  suggestive.  Digitalis  may  be  given  during  labor.  When  dilata- 
tion is  complete,  puncture  the  membranes,  but  let  the  water  escape  slowly.  As  the 
head  comes  down  on  the  perineum  watch  the  effect  of  the  bearing-down  efforts  on 
the  heart.  Even  if  the  dyspnea  is  not  very  marked  nor  the  cyanosis  very  deep;  if 
cough  sets  in;  if  the  pulse  begins  to  drop  beats;  if  it  gets  very  rapid — 108  to  130; 
if  the  bearing-down  efforts  do  not  produce  regular  and  decided  advancement  of  the 
child,  extract  at  once.  Do  not  wait  for  actual  edema  of  the  lungs  or  actual  cardiac 
failure  to  spur  you  to  action,  because  in  such  cases,  even  if  you  do  save  the  patient, 
the  time  that  the  circulation  has  been  in  abeyance  has  perhaps  allowed  a  clot  to  form 
in  the  heart,  or  the  overstrain  of  the  muscle  has  caused  a  hemorrhage  in  the  myo- 
cardium, and,  later  in  the  puerperium,  death  may  occur  from  embolism  or  cardiac 
rupture.  Extraction  is  done  by  forceps  or  by  the  breech,  depending  on  conditions, 
but  the  actual  delivery  is  to  be  executed  slowly,  and  two  strong  hands  must  follow 
down  the  uterus,  so  that  the  intra-abdominal  pressure  is  not  reduced  too  quickly, 
since  the  rush  of  blood  into  the  dilated  veins  of  the  abdomen  would  tend  to  leave  the 
enlarged  heart  empty.  Some  authors  recommend  that  the  woman  be  allowed  to 
bleed  freely  in  the  third  stage.  I  do  not  believe  it  is  wise,  and  permit  it  only  in  cases 
of  mitral  stenosis,  and  where  the  pulmonary  circulation  is  evidently  overloaded. 
Delivery  of  the  placenta  should  not  be  hastened.     Ergot  may,  if  necessary,  be 

-  given  after  the  third  stage.  Ether  is  the  anesthetic  of  choice,  a  professional  an- 
esthetizer  being  employed,  if  possible,  since  this  will  enable  the  accoucheur  to  give 
all  his  attention  to  the  delivery  of  the  child.  In  myodegeneratio  cordis  it  is  best 
to  give  no  anesthetic,  and  I  have  been  surprised  to  see  how  much  could  be  accom- 
plished by  encouragement  and  suggestion. 

Should  collapse  occur  at  any  time  during  the  first  stage,  it  must  be  combated 
instantly,  for  reasons  aljove  given,  and  labor  should  be  completed  by  bimanual  dila- 
tation, cervical  incisions,  or  even  the  vaginal  cesarean  section.  When  the  fetus  is 
dead,  craniotomy  is  to  be  done.  While  doing  these,  or  after  delivery,  give  hypo- 
dermically 30  minims  of  camphorated  oil,  then  30  minims  of  tincture  of  digitalis  (or 
1  c.c.  of  digalen  intravenously),  oxygen  by  inhalation,  and  6  ounces  of  strong  black 


DISEASES    OF    THE    C'lltCULATOUY    SVS'JEM  491 

coffee  per  rectum.  A  very  ti^ht  abdominal  hinder  is  applied,  or  a  sand-bap;  laid  on 
the  belly.  For  (edema  pulmouum  the  same  treatment  is  given.  Venesection  may 
be  useful  wluui  the  heart  is  overenj^orged,  8  to  12  ounces  being  withdrawn.  Though 
used  in  other  heart  cases,  I  have  never  found  it  necessary  under  these  circumstances. 
Salt  solution  is  not  to  be  given  in  these  cases  unless  complicated  by  severe  hemor- 
rhage. Since  the  most  critical  period  is  just  after  delivery,  a  physician  should  re- 
main near  the  patient  for  at  least  twelve  hours.  In  the  pueri)erium  absolute  rest, 
with  the  body  horizontal,  the  head  a  little  raised,  and  the  exhibition  of  the  usual 
remedies,  are  advised.  Nursing  is  to  be  prohibited  only  in  bad  cases,  but  it  is 
always  best  to  substitute  part  of  the  feeding  to  prevent  too  great  a  drain  on  the 
woman's  resources. 

Basedow's  Disease. — Palpitation  of  the  heart  is  not  infrequent  during  gesta- 
tion, caused  by  indigestion,  toxemia,  exercise,  or  by  a  pure  neurosis.  I  have  seen 
not  a  few  cases  where,  during  pregnancy,  tachycardia,  nervousness,  struma,  and 
slight  exophthalmos  have  raised  strong  suspicions  of  Basedow's  disease,  but  the 
symptoms  disappeared  later.  These  may  be  toxemic  in  nature.  Indeed,  many 
cases  of  true  Graves'  disease  show  symptoms  which  we  find  in  the  pregnancy  tox- 
emias. On  the  other  hand,  clinically  typical  Graves'  disease  occurs  during  gesta- 
tion, and  perhaps  more  frequently  than  the  literature  would  indicate.  It  seems  to 
the  author  that  pregnancy  brings  out  the  latent  affection,  but  rarely  causes  serious 
aggravation  of  the  symptoms  unless  toxemic  conditions  are  added  as  a  complication. 
Sometimes  pregnancy  ameliorat(3s  the  symptoms,  the  fetus  taking  up  the  excess  of 
thyroid  secretion.  Repeated  pregnancies  usually  have  a  bad  effect.  Hirst  had  a 
patient  in  whom  the  disease  recurred  in  three  successive  pregnancies.  Labor  does 
not  produce  serious  trouble,  exc(?iot  in  the  advanced  cases,  and  then  the  conditions 
are  the  same,  and  one  treats  them  the  same  as  heart  lesions.  The  puerperium  exerts 
no  special  influence,  though  sometimes  the  course  of  the  disease  continues  dowmward 
during  this  time. 

Amenorrhea  and  sterility  are  common  in  women  suffering  from  exophthalmic 
goiter,  because  of  the  atrophy  of  the  uterus  and  ovaries.  Pregnancy,  however,  has 
occurred  during  the  amenorrhea.  Abortion  is  not  usual  unless  the  cardiac  dis- 
compensation  is  marked.  In  bad  cases  death  of  fetus  and  premature  labor  may 
occur.  Labor  is  uninfluenced  by  the  disease,  but  it  is  said  that  abruptio  placentae 
and  postpartum  hemorrhage  are  more  frequent  (White).  Hj^perinvolution  is 
common.  Lactation  is  likely  to  be  imperfect,  and  only  few  cases  show  oversupply 
of  milk.  The  fetus  is  usually  healthy.  Thyroid  secretion  passes  over  to  the  child 
in  the  milk.  Graves'  disease  is  exceedingly  rare  in  infants,  only  one  case  at  four 
weeks  being  on  record. 

The  treatment  of  the  disease  is  the  same  as  if  the  woman  were  not  pregnant,  and, 
in  general,  what  was  said  of  the  care  of  heart  cases  in  pregnancy  applies  here.  Abor- 
tion may  be  required  if  the  heart  proves  default  early,  and  especially  if  toxemic 
symptoms  predominate,  though  perhaps  ligation  of  the  upper  poles  of  the  gland,  or 
partial  removal,  might  hold  the  disease  in  check  until  pregnancy  has  been  com- 
pleted. Late  in  pregnancy  the  symptoms  may  demand  interference,  but  emptying 
the  uterus  does  not  produce  the  same  relief  as  in  pure  heart  cases,  because  the  tox- 
emia and  hyperthyroidism  persist.  The  slower  methods  of  delivery  are  to  be  pre- 
ferred unless  lalwr  drags  on,  when  cervical  incisions  or  vaginal  cesarean  section  may 
be  needed.  Pregnancy  should  never  be  allowed  to  go  beyond  term.  jMorphin,  rest 
in  bed,  and  an  ice-bag  over  the  heart  are  used  to  calm  the  cardiac  action.  Ether  is 
the  best  anesthetic. 

Phlebitis,  periphlebitis,  throml^osis  of  the  heart  and  of  the  veins  of  the  legs,  all 
of  which  may  occur  during  pregnancy,  wall  be  considered  under  the  Puerperal 
Diseases. 


492  THE    PATHOLOGY   OF   PREGNANCY,    LABOR,    AND    THE   PUERPERIUM 


DISEASES  OF  THE  ALIMENTARY  TRACT 

Mild  disturbances  of  the  intestinal  tract  are  very  common  during  gestation. 
Nausea  and  vomiting  have  already  been  chscussed,  and,  under  the  Hygiene  of  Preg- 
nancy, the  treatment  of  constipation  has  been  considered. 

Gastric  and  intestinal  indigestion  are  of  frequent  occurrence,  and  yield  very 
slowly  to  the  usual  remedies.  For  the  acidity  of  the  stomach  soda-mint  tablets, 
milk  of  magTiesia,  or  effervescent  phosphate  of  soda,  may  be  used.  In  a  few  cases 
slowly  sucking  pure  rock-candy  or  chewing  salted  nuts  until  fine  has  been  helpful. 
Sodium  bicarbonate  and  magnesia  usta  are  also  useful  for  the  "heartburn."  For 
the  colicky  pains  a  dose  of  Rochelle  salts  combined  with  proper  dieting  does  the 
most  good,  but  it  may  be  necessary  to  give  a  sedative — sodium  bromid,  15 
grains  thrice  daily  in  syrup  of  red  raspberry,  after  meals.  It  may  not  always  be 
eas3"  to  differentiate  between  intestinal  and  uterine  or  tubal  colic  (ectopic  gestation) . 
Bimanual  examination  will  clear  the  diagnosis.  Colics  due  to  intestinal  adhesions, 
resulting  from  the  so  common  abdominal  operations  of  today,  are  very  rebellious 
to  treatment. 

Flatulence  causes  colic,  and  may  itself  be  very  annoying.  Proper  diet  and 
movement  of  the  bowels,  with  5  grains  of  salol  and  15  grains  of  charcoal  three  times 
a  day,  will  usually  give  relief.  Diarrhea  as  a  special  symptom  is  rare.  I  have  fre- 
quently observed  it  as  a  prodrome  of  labor.     Treat  according  to  cause. 

Toothache  and  dental  caries  are  common,  perhaps  as  the  result  of  a  mild  form 
of  osteomalacia,  to  which  reference  has  already  been  made.  So  common  is  dental 
caries  that  there  is  an  old  saying — ''for  every  child  a  tooth."  Neuralgia  of  the 
teeth  is  also  noted  in  gestation,  and  is  usually  due  to  an  infected  cavity  or  sinus 
disease.  Before  teeth  are  extracted  the  patient  is  to  be  examined  by  a  surgeon 
capable  of  detecting  these  obscure  causes.  Dental  neuralgia  may  indicate  the 
toxemia  of  pregnancy.  Teeth  that  are  hopelessly  diseased  and  infected  are  to  be 
removed,  and  experience  proves  that  nitrous  oxid  gas  may  safely  be  used.  It  is 
more  than  possible  that  some  obscure  puerperal  infections  have  their  ultimate  origin 
in  abscessed  teeth. 

Jaundice.- — Hepatic  insufficiency  is  now  fully  recognized  as  a  cause  of  many  of 
the  disorders  incident  to  pregnancy,  under  which  heading  they  are  considered. 
Icterus  gravis  gravidarum,  or  acute  yellow  atrophy  of  the  liver,  has  been  described. 
Epidemics  of  infectious  jaundice  have  been  observed,  and  when  pregnant  women 
are  affected,  they  show  a  high  mortality.  Catarrhal  jaundice  is  rare  in  gesta- 
tion. In  the  service  of  the  Chicago  Lying-in  Hospital,  now  over  15,000  cases,  it 
occurred  but  five  times.  No  special  significance  attaches  to  catarrhal  jaundice, 
except  to  call  our  attention  to  the  liver  and  to  the  necessity  of  making  sure  that  it  is 
only  a  simple  affair  with  which  we  have  to  deal.  In  ectopic  pregnancy  jaundice 
sometimes  appears.  Jaundice  occurring  just  before  or  during  labor  is  very  signifi- 
cant. (See  Acute  Yellow  Atrophy.)  Jaundice  may  be  observed  after  delivery 
when  general  anesthesia  has  been  used,  especially  after  chloroform.  One  should 
think  of  late  chloroform  poisoning,  that  is,  liver  autolysis.  The  child  delivered 
from  a  jaundiced  mother  is  not  icteric. 

Gall-stones. — It  seems  that  pregnancy  is  a  factor  in  the  development  of  gall- 
stones, and  it  is  not  rare  that  the  gravida  has  attacks  of  biliary  colic.  These  seldom 
occur  before  the  fifth  month,  and  jaundice,  with  chills  and  fever,  is  more  common 
than  in  the  non-pregnant  state.  Labor  may  cause  pain  in  the  full  gall-bladder,  and 
the  latter  may  be  easily  palpated  during  the  third  stage.  In  the  puerperium 
attacks  of  gall-stones  are  infrequent.  I  have  observed  two  cases,  in  one  of  wliich 
the  symptoms  Avere  very  stormy,  with  intense  pain,  collapse  and  vomiting,  so  that 
suspicion  of  the  rupture  of  an  abdominal  viscus  could  well  be  entertained.  Opera- 
tion should  be  postponed,  if  possible,  until  after  delivery,  at   least  as  late  in 


DISEASES    OF    THE    ALIMENTARY    TRACT  493 

progrianoy  as  possible,  bccauso  jx-cinaturc  labor  may  occur  and  the  child  bo  lost. 
However,  the  later  operation  is  made  technically  difficult  by  the  large  uterine 
tumor.  Only  that  operation  should  be  done  which  will  quickest  remove  dangerous 
conditions  (Peterson) . 

Cholecystitis  may  complicate  pregnancy,  labor  (rupture),  and  the  puerperium. 
The  symptoms  are  quite  stormy  and  jaundice  conmion.  It  is  better  to  wait  until 
after  delivery  for  the  operation,  if  possible,  but  in  the  presence  of  a  strict  indication, 
for  example,  a  large  empyema,  one  may  have  to  drain  the  sac  before  labor.  In  one 
case  the  author  luul  to  make  a  differential  diagnosis  ])etween  puerperal  infection 
and  i)us  in  the  gall-bladiler  (c/.  Vineberg).  Absence  of  local  evidences  of  puerperal 
disease,  signs  of  local  peritonitis  in  the  upper  abdomen,  with  appropriate  history, 
usually  indicate  the  exact  source  of  the  trouble. 

Appendicitis. — Many  pregnant  women  complain  of  pain  in  the  region  of  the 
appendix,  and  it  is  possible  that  the  rising  uterus  draws  on  complicating  peritoneal 
adhesions.  Women  who  have  had  appendix  operations  almost  always  complain 
of  dragging  pains,  especially  from  the  fifth  to  the  eighth  months.  Primary  ap- 
pendicitis is  very  rare,  but  recurrent  disease  is  not  rare  during  gestation,  the  latter 
being  usually  the  catarrhal  variety,  and  seldom  causing  real  trouble. 

Perforation  and  suppurative  peritonitis  are  very  much  more  serious  than  out- 
side of  pregnane}^,  because — (1)  Protective  adhesions  are  less  likely  to  be  formed; 

(2)  the  inflammation  is  more  stormy,  owing  to  the  intense  vascularity  of  the  parts; 

(3)  thrombosis  and  phlebitis  are  commoner;  (4)  suppuration  takes  place  higher  in 
the  abdomen  (true  of  late  pregnancy),  which  portion  is  recognized  to  be  less  re- 
sistant; (5)  drainage  is  less  free,  owing  to  the  large  uterus  near  by,  and  the  abscesses 
burrow  deeply  in  all  directions;  (6)  tympany  compromises  the  respiration  sooner, 
and  (7)  obstructive  symptoms  arise  earlier.  The  mortality,  according  to  Schmid, 
who  collected  486  cases,  is  very  high.  Appendicitis  offers  a  better  outlook  the  earlier 
in  pregnancy  it  occurs  and  the  sooner  it  is  recognized.  During  labor  the  contract- 
ing uterus  may  rupture  the  pus-sac  or  tear  an  adherent  or  perforating  appendix, 
with  resulting  general  peritonitis,  which  may  be  mistaken  for  sepsis  subpartu. 
This  danger  is  greatest  during  the  third  stage  and  during  the  first  few  clays  of  the 
puerperium,  at  which  times  the  uterine  fundus  makes  its  greatest  excursions.  In 
the  puerperium  acute  appendicitis  is  easily  mistaken  for  an  infection  of  the  tubes 
or  broad  ligament,  and,  indeed,  they  may  coexist.  The  puerperal  processes  ag- 
gravate the  appendiceal  disease. 

The  effects  of  perforative  appendicitis  on  the  pregnancy  are  also  marked,  abor- 
tion,  premature  labor,  infection  of  the  uterine  contents,  and  death  of  the  new-born 
child  being  noted  in  the  majority  of  cases.  This  might  all  be  forestalled  by  early 
operative  removal  of  the  infective  focus.  Labor  is  very  painful;  the  shock  of  it  is 
greater,  and  because  of  the  diseased  uterine  muscle  (contiguous  to  an  abscess)  weak 
pains  in  all  three  stages  are  observed.  Manual  removal  of  the  placenta  is  more 
often  needed,  and  such  brusk  manipulations  spread  the  pus.  On  the  puerperium 
the  worst  influence  is  shown  when  the  diseased  appendix  forms  adhesions  to  the 
tube  or  the  uterus,  direct  transmission  of  the  infection  being  thus  effected,  either 
through  the  walls  of  tlie  applied  organs  or  along  the  surface — rarely  through  the 
l)lood.  A  parametritis  may  also  be  caused  by  the  infection  creeping  through  Clado's 
ligament.  The  relics  of  appendicitis  may  anchor  the  uterus  in  an  unfavorable 
position,  may  occlude  the  tube,  producing  sterility  or  favoring  ectopic  gestation. 
On  the  other  hand,  I  am  convinced  that  tubal  infections  cause  appendicitis.  The 
frequency  of  appendicitis  in  newly  married  women  is  striking,  and  the  gonococcus 
was  found  by  J.  H.  Hess  in  the  pus  from  an  appendix. 

The  diagnosis  of  appendicitis  should  present  no  special  difficulties  if  only  the 
possibility  of  its  occurrence  be  kept  in  mind.  Ectopic  gestation  {q.  v.)  and  f-^dsted 
ovarian  tumor  come  up  for  consideration,  but  most  mistakes  are  made  with  ure- 


494      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

teritis  and  ureteral  stone  (g.  v.).  In  the  puerperium  sepsis  must  always  be  thought 
of,  and  only  a  laparotomy  may  explain  the  equivocal  symptoms.  A  worse  prog- 
nosis is  to  be  made  than  usual  because  nearly  40  per  cent,  of  perforated  appendix 
peritonitis  cases  die. 

As  yet  it  is  possible  to  lay  down  rules  for  only  a  few  of  the  conditions  pre- 
sented for  treatment.  Recurrent  appendicitis  should  be  cured  before  pregnancy 
occurs.  A  woman  with  only  a  history  of  appendicitis  should  not  be  operated  during 
pregnancy  unless  a  recurrence  takes  place.  A  mild  attack  should  always  indicate 
operation  in  the  first  five  months.  Only  perforative  disease  should  be  operated 
in  the  last  four  months,  and  then  as  soon  as  diagnosed,  but  in  cases  of  doubt  opera- 
tion is  the  safer  course.  The  incision  is  made  a  little  higher  than  ordinarily,  and 
drainage  should  be  liberal.  Every  effort  should  be  made  to  prevent  premature 
labor.  Should  abortion  occur,  it  should  be  allowed  to  run  as  natural  a  course  as 
possible,  the  tampon  and  even  prolonged  expectancy  being  employed.  Manual 
curetage  is  to  be  replaced  by  instrumental  should  the  uterus  not  empty  itself.  The 
reason  for  this  is  evident — the  outside  hand  may  break  the  protective  adhesions 
around  the  abscess.  During  labor  the  same  rule  appHes,  and  if  manual  removal  of 
the  placenta  is  necessary,  the  dangers  of  spreading  the  abdominal  infection  should 
be  borne  in  mind.  No  doubt,  too,  genital  infection  is  favored  by  all  intra-uterine 
manipulations.  If  abortion  is  impending  at  the  time  of  operation,  the  uterus  should 
first  be  emptied,  and  then  drainage  of  the  abdomen  carried  out.  The  question  of 
emptying  the  uterus  artificially  before  operating  on  the  appendix  has  been  raised; 
even  cesarean  section  has  been  proposed  if  the  woman  is  near  term.  When  one  con- 
siders the  high  mortality  of  suppurative  peritonitis  at  or  near  term,  perhaps  it  would 
be  best,  in  the  interests  of  the  two  inchvicluals,  to  remove  the  appendix  and  do  a 
Porro  cesarean  section  at  the  same  time.  I  believe,  in  cases  where  the  uterus  is 
opened  in  the  presence  of  pelvic  infection,  as  from  ruptured  appendix,  pus-tube,  or 
infected  tumors,  it  is  best  to  amputate  the  bulky  organ  and  drain  the  whole  pelvis 
freely  from  below.  If  the  operation  removed  an  acutely  inflamed  appendix  without 
adhesions  or  abscess,  it  is  not  advisable  to  empty  the  uterus  from  below  at  once, 
because  pregnancy  may  go  on  without  further  trouble,  and  if  a  walled-off  abscess 
has  formed,  it  is  dangerous  to  do  so,  because  during  labor  the  adhesions  always 
break.  With  free  drainage  and  the  use  of  opium  one  may  tide  the  woman  along  for 
several  days  and  thus  allow  the  sac  to  get  firm  and  the  amount  of  pus  in  it  to  be  re- 
duced. Obstetric  interference  may  thus  be  delayed  until  the  abscess  cavity  is 
granulating  safely  (Hilton,  Rudaux,  Babler,  Abrahams,  McArthur). 

Ileus,  a  rare  complication,  may  be  due  to  the  same  causes  which  produce  it 
outside  of  pregnancy,  or  may  be  due  to  compression  or  torsion  of  the  gut  by  the 
growing  uterus.  Naturally,  the  gut  must  be  abnormally  adherent  for  this  to  take 
place.  In  one  of  the  author's  cases  an  old  appendicitis  was  responsible  for  the  ad- 
hesions, and  the  uterus  at  term  dragged  on  the  intestine,  producing  severe  pain  in 
the  right  iliac  fossa  and  almost  complete  obstruction — induction  of  labor,  recovery. 
If  the  ileus  is  due  to  a  complicating  suppurative  peritonitis,  premature  labor  is  the 
rule  and  death  very  common  (Gauchery).  Treatment  is  the  same  as  in  surgical 
practice,  except  in  those  cases,  as  the  one  mentioned,  where  it  is  reasonable  to  be- 
lieve that  the  growing  uterus  is  the  acting  cause  of  the  obstruction;  then  the  uterus 
is  to  be  emptied.  Ileus  after  delivery  may  be  due  to  the  trauma  of  labor,  to  ob- 
struction of  the  bowel  by  the  large  uterus  incarcerated  in  the  pelvis. 

Hernia  is  not  seldom  met  by  the  accouch(mr.  Unless  the  gut  is  adherent,  the 
growing  uterus  pushes  the  contents  of  the  sac  out  and  away  from  the  hernial  open- 
ing, and  makes  a  temporary  cure,  but  the  ring  is  enlarged  by  the  distraction  of  its 
pillars,  and  the  hernia  is  worse  in  the  puerperium,  though  incarceration  is  rare. 
Adherent  gut  may  be  incarcerated,  twisted,  or  stretched  even  to  the  production  of 
ileus.     During  labor  the  opening  is  usually  closed  by  the  large  uterus,  and  even  dur- 


DISEASES    OF    THE    ALIMENTARY    TRACT  495 

inp;  strong  l)T>;irinp;-(lowii  ('(Torts  the  rupture  docs  not  enlarge.  I  saw,  liowever,  an 
inguinal  hernia  develop  during  strong  expulsive;  effort.  Treatment  of  hernia  is 
the  same  as  at  any  other  time  when  threatening  .symptoms  occur.  During  labor 
it  is  not  wise  to  allow  too  strong  effort  if  one  sees  the  hernial  tumor  enlarging.  For- 
ceps should  be  applied  soon  after  the  (hlatation  is  complete.  It  is  not  safe  to  hold 
the  gut  back  during  tlu;  strong  expulsive  straining.  Umbilical  and  post-()i)erative 
hernias  are  usually  permanently  enlarged  by  pregnancy,  and  traction  on  adherent 
omentum  often  causes  pain  (Manley). 

Literature 

Abrahams:  Amer.  Jour.  Obstet.,  1897,  vol.  xxxv. — Bab:  Centralbl.  f.  Gyn.,  1909,  p.  527;  ibid.,  "Congenital  Syphilis," 
Zoiitschr.  f.  Gyn.,  190S,  vol.  Ix,  p.  161.— Babler:  Jour.  Amer.  Med.  Assoc,  vol.  li,  October  17,  1908,  p.  1310. — 
Bacon:  Jour.  Amer.  Med.  Assoc,  1912,  vol.  ii. — Baisch:  Munch,  med.  Woch.,  September  21,  1909,  p.  1929. — Bar 
and  Daunay:  L'Obstctrique,  April,  1909,  No.  3. — Bar  and  lienon:  L'Obstetriquo,  vol.  i,  p.  69. — Birch-IIirsch- 
feld:  Arbciteu  d.  Pathol.  Inst,  zu  Leipzig,  Jena,  1891,  p.  428. — Blandin:  L'Obstctrique,  1902,  No.  1,  p.  4.3. 
— Deinclin:  L'Obstct.,  1S9G,  vol.  i. — Edi/ar,  J.  C:  Jour.  Amer.  Med.  Assoc,  April  8,  190.J,  p.  1077. — Enyman: 
Jour.  Amer.  Med.  Assoc,  May  11,  1912,  p.  1415. — Fellner:  Innere  Krankheiten,  p.  70. — Finger:  "Colics'  Law," 
Centralbl.  f.  Gyn.,  1897,  No.  40,  p.  1211. — Fournier:  Syphilis  upd  Ehe,  Hirschwald,  ISSl.—Fraenkel,  E.:  Volk- 
mann's  klin.  Vort.,  1901,  No.  323. — Friedman:  Zeit.  f.  klin.  Med.,  1901,  vol.  xliii,  p.  11. — Gauchery:  Thfise  de 
Paris,  1903.  Literature. — Griifenberg:  Arch.  f.  Gyn.,  1909,  vol.  Ixxxvii,  i. — Hilton:  Surg.,  Gyn.,  and  Obstet.,  Oc- 
tober, 1907. — Jesionek:  Miinch.  med.  Woch.,  May  30,  1911. — Manley:  "Hernia  and  Pregnancy,"  Medical 
News,  1900. — MacDonald:  Obstetric  Journal  of  Great  Britain,  1877. — McArthur:  Amor.  Jour.  Obstet.,  1895, 
No.  31. — Muller,  P.:  Die  Krankheiten  des  weiblichen  Korpers,  p.  85. — Noguchi:  Jour.  Exper.  Med.,  1911, 
No.  14,  p.  99. — Peterson:  Surg.,  Gyn.,  and  Obstet.,  July,  1910.  Full  literature. — Renwall:  Centralbl.  f.  Gyn., 
1910,  p.  955;  288  cases.  "Gall-stones,"  Report  of  Discussion  at  Toulouse,  Annales  de  Gyn.,  December,  1910, 
p.  805. — Rosinski:  Syphihs  in  Pregnancy,  1903. — Rudaux:  Ann.  de  Gyn.,  September,  1911. — Schmid:  Jour. 
Amer.  Med.  Assoc,  July  22,  1911,  p.  349.  Literature. — Schmorl:  Munch,  med.  Woch.,  1904,  vol.  li,  p.  1670. 
— Trembley,  C.  C:  "  Tuberculosis  in  Pregnancy,"  Jour.  Amer.  Med.  Assoc,  1909,  vol.  lii,  p.  989,  with  discus- 
sion by  Jewett,  Edgar,  Cragin,  et  al. — Vinay:  Maladies  de  la  Grossesse,  p.  309;  ibid.,  p.  78. — Vineberg:  Medical 
Record,  April  8,  1905,  p.  532. — Virchow:  Archiv,  1905,  vol.  clxxxi,  p.  150.— White:  Jour.  Obstet.  and  Gyn. 
of  Great  Britain,  September,  1911.  Full  literature. — v.  Winckel:  Handbuch,  vol.  ii,  i,  p.  625. — Zeisler:  Illi- 
nois Med.  Jour.,  October,  1910. — Zeit:  Bulletin  Northwestern  Univ.  Med.  School,  190S.     Literature. 


CHAPTER  XXXIX 
DISEASES  OF  THE  URINARY  SYSTEM 

Nephritis. — Internists  distinguish  the  following  principal  forms  of  renal  dis- 
ease :  Acute  nephritis,  chronic  nephritis,  of  which  there  are  two  grand  divisions,  the 
parenchymatous,  with  its  three  forms,  large  white  kidney,  large  red  kidney,  and  the 
secondar}^  contracted  kidney;  and  the  chronic  interstitial  or  primary  contracted 
kidney,  which  is  accompanied  by  cardiac  hypertrophy  and  a  general  arteriosclero- 
sis. The  accoucheur,  in  addition  to  these,  must  consider  the  kidney  of  pregnancy, 
its  aggravated  form,  the  so-called  pregnancy  nephritis,  and  the  kidney  changes 
which  are  part  of  eclampsia.  Since  even  the  internists  are  not  in  perfect  accord 
regarding  the  classification  of  their  physical  findings  and  admit  that  the  various 
recognized  varieties  of  disease  may  be  associated  or  correlated,  it  is  not  to  be  ex- 
pected that  the  accoucheur  will  be  able  absolutely  to  identify  the  many  conditions 
presented  to  him  for  treatment. 

The  kidney  of  pregnancy  and  the  kidney  in  eclampsia  have  already  been  con- 
sidered in  the  chapters  devoted  to  Incidental  Diseases.  Here  will  be  discussed 
the  accidental  complication  of  pregnancy  with  renal  disease.  Although  only  one- 
quarter  to  one-fifth  of  nephritics  develop  convulsions — ^perhaps  eclampsia — in 
pregnancy,  the  association  of  the  two  conditions  is  always  fraught  with  grave 
dangers  to  mother  and  child. 

Primary  acute  nephritis  may  develop  during  gestation  from  the  same  causes 
which  operate  outside  of  it,  for  example,  exposure  to  cold,  chemical  poisons,  pto- 
mainemia,  scarlatina,  angina,  and  septic  a,ffections.  Antecedent  septic  processes 
make  the  kidney  more  vulnerable,  which  tendency  is  aggravated  by  pregnancy. 
Acute  nephritis  cannot  be  clinically  differentiated  from  the  "pregnancy  nephritis" 
which  often  leads  up  to  eclampsia,  and,  therefore,  will  not  be  further  discussed  here. 
(See  Eclampsia.) 

Chronic  parenchymatous  nephritis  is  always  unfavorably  affected  by  the  advent 
of  gestation,  and  an  acute  exacerbation  is  almost  always  observed.  It  begins  to 
show  in  the  early  months,  contrary  to  the  renal  disease  incidental  to  pregnancy. 
Puffiness  of  the  eyelids  and  of  the  ocular  conjunctiva  and  general  anasarca  are  marked 
and  do  not  disappear  in  the  recumbent  position.  The  edema  affects  the  legs,  which 
may  be  elephantiasic,  and  the  vulva,  which  may  be  transformed  into  two  immense, 
white,  translucent,  watery,  glistening  tumors.  Hydroperitoneum,  hydropleura, 
oedema  pulmonum  may  occur;  pallor,  a  waxy,  pasty  skin,  high  pulse  tension,  even 
in  this  form,  are  to  be  noted.  Headache,  neuralgias,  epigastric  pain,  disorders  of 
the  special  senses,  especially  amaurosis,  nausea,  and  vomiting  are  found,  but  not  so 
marked  nor  so  common  as  in  preeclamptic  toxemia.  Retinitis  albuminurica  is  very 
serious,  and  may  leave  permanent  blindness.  Convulsions  occur,  but  in  less  than 
one-third  of  the  cases.  The  urinary  findings  are  similar  to  those  of  preeclamptic  tox- 
emic nephritis — albumin,  hyaline,  granular,  cellular  casts,  renal  epithelium,  white 
and  finally  red  blood-corpuscles.  Urea  is  diminished,  the  total  solids  reduced, 
the  daily  amount  of  urine  much  less  than  normal. 

Labor  has  a  noxious  influence  on  the  nephritis,  and  often  produces  alarming 
sj^mptoms — oedema  pulmonum,  collapse,  which  may  simulate  pulmonary  or  cere- 
bral embolism,  apoplexy,  and  suppression  of  urine.     Anemia  is  badly  borne  by 

496 


DISEASES   OF   THE    URIXAIIY    SYSTEM  497 

ncphritics.  If  anosthctics  iiro  given,  and  if  the  lahoi-  is  ijrolractcd  and  exhaus- 
ting, real  damage  may  be  done  to  the  kidneys. 

The  puerperal  processes  do  not  exert  a  good  influence  either — sepsis  is  com- 
moner and  ncphritics  do  not  bear  infection  well.  While  the  urine  u.sually  rapidly 
clears  up  after  delivery,  the  restitution  oi  the  kidneys  is  never  complete,  permanent 
structural  damage  having  been  wrought,  and  the  action  of  repeated  pregnancies  is 
so  bad  that  death  is  hastened. 

Chronic  interstitial  nephritis  is  more  fre((uent  than  the  parenchymatous,  and  is 
characterized  by  polyuria  of  low  specific  gravity,  with  little  urea  and  small  anujunt 
of  albumin,  few  casts,  and  these  usually  of  the  hyaline  variety.  It  is  accompanied 
by  high  arterial  tension  (200  to  240  mm.),  thickening  of  the  vessels,  and  hypertro- 
pliy  of  the  heart.  The  effects  of  this  form  usually  appear  later  in  the  pregnancy, 
but  the  symptoms  of  urinemia  already  mentioned  occur  with  almost  equal  fre- 
quency, and  especially  in  the  later  months,  the  distinctions  between  the  various 
forms  become  blurred.  Retinitis,  apoplexy,  and  heart  collapse  are  more  frequent 
with  cirrhotic  kidney,  and  convulsions  less  frequent. 

All  forms  of  nephritis  have  a  very  bad  influence  on  the  pregnancy,  abortion  and 
premature  labor  being  common  (G6  per  cent.,  Hofmeier);  Seitz  found  that  only 
from  20  to  30  per  cent,  of  the  childnni  survived.  One  of  the  causes  of  habitual 
death  of  the  fetus  and  abortion  and  premature  labor  is  chronic  nephritis.  Labor  in 
ncphritics  is  slow:  the  uterus  is  indolent;  the  edema  of  the  vulva  predisposes  to 
perineal  lacerations,  and  in  one  case  of  the  author's  the  edema  of  the  pelvic  struc- 
tures prevented  the  head  from  engaging  in  the  pelvis.  Even  after  the  delivery, 
which  was  very  laborious,  the  cervix  could  not  be  drawai  dowai  to  the  vulva  as  usual, 
because  it  was  anchored  up  high  by  the  infiltrated  broad  ligaments.  Abruptio 
placentas  is  not  infrequent.  Postpartum  hemorrhage  is  common  because  of  atony 
of  the  uterus.  Involution  is  slower.  Many  of  the  children  are  born  dead  and 
more  or  less  macerated.  The  death  of  the  fetus  is  caused  by — (1)  The  hemorrhages, 
the  white  infarcts,  and  the  sclerosis  of  the  blood-vessels  of  the  placenta,  wdiich  cut 
off  the  fetal  circulation  and  are  frequently  found  (80  per  cent.).  Simpson  and 
Fehling  called  attention  to  these  facts,  and  the  French  call  the  condition  "placenta 
albuminurique "  (Fig.  488).  (2)  By  the  frequent  abruption  of  the  placenta  in 
labor.  (3)  By  the  accumulation  of  toxins  in  the  blood  which  alter  the  villi,  making 
them  unfit  for  the  function  of  nourishing  the  child,  or  in  the  deciduffi,  making  their 
blood-vessels  brittle  and  thrombotic,  and  themselves  liable  to  separation  (a  degen- 
erative endometritis);  in  the  first  instance  death  of  the  fetus  occurs;  in  the  latter, 
hemorrhages  into  and  separation  of  the  decidua  with  abortion  result.  (4)  The 
fetus  is  poisoned  by  the  toxins  which  pass  over  from  the  mother.  (5)  Eclampsia 
may  interrupt  the  pregnancy. 

The  children  of  ncphritics  are  usually  puny  and  pale;  they  thrive  poorly  at 
first,  and  may  show  albuminuria  with  casts.  Infarcts  and  hemorrhages  may  so 
reduce  the  functionating  area  of  the  placenta  that  the  fetus  does  not  receive  enough 
food — it  starves  in  utero.     The  placenta  may  be  edematous. 

Diagnosis. — The  discovery  of  albumin  in  the  urine  at  one  of  the  routine  exam- 
inations leads  at  once  to  a  minute  investigation  of  the  cause.  It  is  an  error  of  art 
to  be  surprised  into  making  a  urinah'sis  by  the  symptoms  of  nephritis.  The  author 
is  very  ske])tical  al)out  the  so-called  physiologic  all^uminurias — most  often  a  slum- 
bering disease  is  at  the  bottom.  Before  deciding  that  the  kidneys  are  affected  one 
must  ehminate  cystitis,  ureteritis,  and  congestive  conditions.  It  is  usually  im- 
possible to  differentiate  the  various  forms  of  nephritis  during  gestation,  because  the 
urinary  and  clinical  pictures  are  l^lurred,  but  it  is  not  essential  for  treatment. 

Prognosis. — Both  mother  and  child  are  seriously  jeopardized  by  chronic  neph- 
ritis, the  mortalities  being  about  30  and  70  per  cent,  respectively.  Care  must  be 
exercised  in  promising  a  cure  by  the  induction  of  abortion  or  premature  labor,  be- 
32  .  . 


498      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

cause  the  condition  may  not  be  the  simple  kidney  of  pregnancy,  but  a  real  latent 
nephritis  which  has  l^een  awakened  into  activity.  The  main  dangers  of  nephritis 
are  edema  of  the  lungs,  hydropericardium,  hydropleura,  enormous  anasarca,  retin- 
itis, which  may  lead  to  permanent  blindness,  apoplexy,  eclampsia,  and  acute  heart 
collapse.     A  combination  with  heart  disease  is  very  fatal. 

Treatment. — Women  with  chronic  nephritis  should  not  marry,  and  if  married, 
should  not  conceive.  If  a  woman  had  eclampsia  or  symptoms  of  renal  inefficiency 
in  her  first  pregnancy,  a  second  should  not  be  allowed  until  the  evidences  of  renal 
disease  have  remained  absent  for  at  least  a  year.  Should  pregnancy  occur  with 
diseased  Iddneys,  redoubled  watchfulness  is  required. 

(a)  Nephritis  is  Discovered  After  the  Tiventy-eighth  Week. — ^ While  a  cure  cannot 
be  effected  during  gestation,  most  authors  advise  that  the  patient  be  tided  along  to 
term  if  possible,  but  to  induce  premature  labor  in  the  presence  of  threatening  symp- 
toms. The  details  of  the  medical  treatment  have  been  fully  given  in  the  chapter 
on  Eclampsia,  to  which  the  reader  is  referred.  Here  the  imminence  of  convulsions 
or  coma  decides  the  question  of  the  induction  of  labor,  but  in  nephritis  other  dangers 
may  indicate  interference.  Retinitis  albuminurica  is  a  positive  indication  for  the 
immediate  termination  of  gestation.  Immense  anasarca  and  a  laboring  heart,  which 
do  not  respond  to  treatment,  also  are  good  reasons;  then  the  dangers  which  threaten 
the  child  must  be  considered — abruptio  placentae  and  hemorrhages  into  it,  though 
to  discover  these  accidents  in  time  to  save  the  infant  is  not  always  possible.  For 
this  reason,  and  because  our  knowledge  of  nephritis  is  so  uncertain  and  our  reliance 
on  treatment  so  insecure,  I  usually  interrupt  pregnancy  as  a  matter  of  principle 
when  the  child  has  fully  passed  the  period  of  viability.  The  exceptions,  of  course, 
are  those  cases  where  very  satisfactory  improvement  ensues  under  treatment. 
The  usual  methods  of  inducing  labor  are  employed,  but  in  critical  cases  vaginal 
cesarean  section  may  be  indicated. 

(5)  Nephritis  is  Discovered  Before  the  Child  is  Viable. — Some  authorities  (Schro- 
der, Fehling,  Billings,  Tyson,  Edwards,  Schauta,  and  others)  recommend  the  induc- 
tion of  abortion,  holding  that  the  injury  to  the  kidneys  which  is  inevitable  before 
the  child  becomes  viable,  and,  too,  the  poor  chances  of  the  fetus  in  any  case,  make 
the  continuance  of  the  pregnancy  precarious  and  useless.  With  these  opinions 
mine  agrees,  but  if  the  woman  is  near  the  period  of  viability,  I  try  to  tide  her  along 
a  few  weeks  to  give  the  child  a  better  chance  for  its  life.  Of  course,  the  gravida 
must  stay  in  bed  under  rigid  treatment,  and  a  careful  daily  urinalysis  must  be  made. 
In  the  early  months  the  pregnancy  is  interrupted  on  the  first  indication  of  trouble, 
and,  too,  if  the  disease  of  the  kidneys,  while  not  retrogressing,  remains  stationary 
under  treatment.  Experience  has  shown  that  these  cases  always  grow  worse  and 
require  interference  before  viability  of  the  child,  and  it  is,  therefore,  injudicious  to 
wait,  because  the  kidneys  will  suffer  irreparable  damage  in  the  mean  time. 

During  labor  nephritics  require  special  care.  It  is  wise  to  watch  the  heart 
action  closely  and  be  prepared  for  the  same  emergencies  that  occur  with  heart 
lesions.  It  may  be  necessary  to  puncture  the  swollen  lal^ia  vulvse  (antiseptically, 
of  course)  to  allow  delivery.  In  the  puerperium  the  usual  treatment  is  kept  up. 
Nursing  is  to  be  permitted  only  if  the  puerpera  is  in  good  condition  and  the  renal 
symptoms  disappearing.      (See  Friinkl-Hochwart  and  von  Noorden,  Fellner.) 

Pyelitis  and  Ureteritis. — A  not  infrequent  complication  of  pregnancy  is  in- 
flammation of  the;  kichujy  pelvis  and  the  ureters.  Raycr,  in  1840,  first  described  the 
disease,  and  Reblaub,  in  1893,  reported  several  cases  at  the  Congress  of  the  French 
surgeons.  Bacteriuria  is  foimd  in  about  15  per  cent,  of  pregnant  women.  The 
ureters,  particularly  the  right,  have  been  found  dilated  and  filled  with  urine  in 
about  two-thirds  of  the  gravidse  coming  to  autopsy.  This  is  caused  by  torsion, 
stretching,  or  kinking  of  the  ureters,  due  to  the  enlargement  and  dislocation  of  the 
pelvic  organs,  but  not  to  compression,  since  the  specific  gravity  of  the  pregnant 


DISEASES   OF   THE   URINARY   SYSTEM  499 

uterus  is  a])out  ecjual  to  that  of  the  intestinal  mass.  The  pressure  in  the  pelvis  of 
the  kidney  is  only  10  mm.  Hg,  so  that  slight  causes  may  stop  the  flow  of  the  urine 
in  the  ureter.  Owing  to  the  stasis  of  the  urine  and  the  liacteriuria,  a  pyelo-ureteri- 
tis  is  easily  set  up,  hut  infection  can  reaeh  the  ])arts  also  through  the  blood,  through 
the  lymph-stream  from  contiguous  structures,  for  example,  the  appendix,  the  c(jlon, 
and  by  ascending  from  the  bladder.  The  bacterium  most  often  found  is  the  colon 
l)acillus,but  the  streptococcus,  the  staphylococcus,  the  Proteus  vulgaris,  pneumococ- 
cus,  Bacillus  typhosus,  B.  paratyj^hosus  (Williamson),  and,  frequently,  according 
to  \'ineberg,  tiie  gonococcus,  may  be  associated,  or  even  the  actual  cause.  Preg- 
nancy may  develop  the  disease,  or  may  aggravate  a  preexist(;nt  inflammation  which 
may  have  started  in  childhood  or  at  the  defloration  (Wildbolz).  Two  varieties 
are  found  in  practice — the  acute  and  the  subacute. 

In  the  acute  cases  there  are  chill,  fever,  pain  in  the  back  and  along  the  ureter, 
and  the  symptoms  of  cystitis — dysuria,  frequent  urination,  vesical  tenesmus,  etc. 
Rarely  all  symptoms  are  absent,  the  disease  being  accidentally  discovered  by 
urinalysis.  On  palpation  the  kidney  is  sometimes  enlarged  and  always  tender;  on 
vaginal  examination  the  base  of  the  bladder  is  sensitive,  the  ureter  usually  easily 
palpable,  thickened,  and  acutely  painful  to  touch.  At  first  there  may  be  sup- 
jiression,  but  soon  the  urine  is  increased  in  amount,  is  cloudy,  contains  at  first 
little,  later  much,  pus,  albumin,  characteristic  epithelium,  and  swarms  with  bac- 
teria. If  the  kidney  structure  itself  is  involved, — and  these  cases  are  usually  mixed 
streptococcus  and  Bacterium  coli  infections, — the  general  symptoms  take  on  a 
septic  nature,  such  as  repeated  chills,  with  irregular  high  fever  and  evidences  of 
severe  illness,  while  locally  a  pyonephrosis  may  develop.  One  or  both  ureters  may 
be  involved,  but  the  disease  is  more  frequently  right-sided.  Stone  in  the  kidnej^  or 
ureter  gives  the  same  symptoms  as  occur  outside  of  pregnancy. 

Suppression  of  urine  in  the  course  of  ureteropyelitis  may  be  either  renal  or 
ureteral,  in  the  former  case  due  to  inflammatory  congestion,  in  the  latter  to  block- 
ing of  the  ureter.  The  diagnosis  of  blocking  of  the  ureter  is  not  easy.  Renal  coHc, 
intermittent  polyuria  with  discharges  of  pus  and  relief  of  pain,  the  results  of  cathe- 
terization of  the  ureters,  access  of  fever  at  the  time  pus  is  absent  from  the  urine, 
— all  are  suggestive.  The  phenolsulphophthalein  test  is  more  useful  in  these 
surgical  renal  affections  than  in  nephritis. 

When  the  infection  is  subacute,  the  symptoms  are  milder;  frequent  urination 
and  evidences  of  cystitis  may  exist  for  several  weeks  l^efore  the  pain  in  the  ureter 
and  the  kidney  shows  the  ascending  involvement  of  the  latter.  In  both  cases  the 
tendency  is  toward  cure,  requiring  two  to  eight  weeks,  and  recovery  may  be  com- 
plete during  pregnancy  or  almost  certainly  after  delivery.  Recurrences  are  in- 
frequent. One  observes  the  affection  most  frequently  about  the  fifth  month  and 
again  near  term.  Renal  calculi  may  be  an  additional  complication.  In  the  puer- 
perium  acute  pyelitis  also  occurs,  and  may  give  rise  to  suspicion  of  puerperal  in- 
fection, and  it  is  possible  that  the  infected  urine  fio^nng  over  the  genital  wounds 
may  cause  sepsis.  A  pyeloureteritis  which  apparently  healed  during  pregnancy 
may  light  up  in  the  puerperium. 

Diagnosis. — On  the  direct,  the  symptoms  enumerated  plus  the  urine  findings 
\sill  usually  suffice.  I  have  frequently  noted  the  presence  in  the  urine  of  swollen 
and  transparent  mononuclear  leukocytes,  the  nucleus  hanging  on  the  side  of  the 
clear  protoplasm.  In  the  differential  diagnosis  appendicitis,  calculi,  and  puerperal 
infection  are  to  be  considered. 


500 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


Pyelo-ureteritis  and  Stone 

1.  Pain  goes  from  the  kidney  down  ureter. 

2.  Vomiting  rare — commoner  with  stone. 

3.  Tenderness   in   lumbar   region  and  in  the 

course  of  the  ureter. 

4.  Abdominal  rigidity  not  pronounced. 

5.  Fever  irregular  and  usually  not  high,  unless 

sepsis  present. 

6.  Pulse  slow,  and  even  if  rapid,  not  peritonitic. 

7.  No  tympany  nor  tumor. 

8.  Urination  frequent  and  often  tenesmus. 

9.  Urinalysis — pus,  alwaj^s  bacteria,  some- 
times blood,  tailed  epithelium,  and  find- 
ings of  desquamative  catarrh. 

10.  Cystoscope  shows  ureteral  openings,  swoll- 
en and  inflamed,  with  pus  issuing,  and 
often  cystitis  or  perhaps  a  stone  may 
be  seen.  If  the  bladder  is  normal,  ure- 
teral catheterization  will  show  the  cloudy, 
bacteria-laden  urine. 

1 1 .  May  feel  thickened,  tender  ureter  (Fig.  436) . 


Appendicitis 

1.  Pain  radiates  toward  navel. 

2.  Vomiting  the  rule. 

3.  Tenderness    over   McBurney's   point   and 
lower  abdomen. 

4.  Rigidity  usually  marked. 

5.  Fever  more  constant  and  continuous. 

6.  Pulse  high,  like  peritonitis. 

7.  Both  often. 

8.  Rarely  observed. 

9.  Perhaps  a  little  albumin. 


10.  Negative. 


11.  Negative. 


Fig.  436. — Palpating  Left  Ureter. 


Treatment. — Acute  cases.  Rest  in  bed,  milk,  buttermilk,  and  water  diet; 
hexamethylenamin,  8  grains,  with  methylene-blue,  1  grain,  four  times  daily  until 
the  acute  symptoms  have  subsided,  then  bland  diet,  with  little  meat.  If  the  uro- 
tropin  should  cause  hematuria  or  disturb  the  stomach,  salol  may  be  substituted. 
For  the  suljacute  cases  the  same  treatment  for  a  few  days,  then  more  freedom  and 
food.  The  knee-chest  position,  assumed  thrice  daily,  for  ten  minutes  each  time, 
and  the  elevated  "Sims'  posture  (Fig.  557)  while  in  l^ed,  are  strong  adjuvants,  often 
actually  curative.  To  aid  posture  in  relieving  the  stagnation  of  the  urine  a  balloon 
pessary  may  be  placed  in  the  vagina  to  lift  the  uterus  out  of  the  pelvis,  and  hot 
vaginal  douches  may  be  given.  Water  is  to  be  freely  administered  by  mouth,  per 
rectum,  and  hypodcrmically.  Ureteral  catheterization,  washing  out  the  pelvis  of 
the  kidney,  with  or  \^^thout  the  instillation  of  antiseptics,  has  been  so  successful 
that  it  should  be  given  a  trial  before  radical  measures  are  instituted.     Israel,  Rov- 


DISEASES    OF   THE    URIXARY    SYSTEM  501 

sinj?,  and  others  do  not  fully  approve  of  ureteral  catluiterization.  Vaccine  therapy 
had  better  be  iwstponed  until  after  delivery  unless  the  disease  proves  rebellious. 

It  is  almost  never  necessary  to  incise  the  kidneys  (pyonephrosis),  and  rarely 
needful  to  indu(!e  lal)or.  In  very  bad  cas(!S  tlu;  latt(!r  may  Ik;  done;  Ijecausc;  recovery 
ensues  when  the  uterus  is  em])tied.  A  stone  in  the  ureteral  opening  may  sometimes 
be  seen  and  extractcnl  cystoscopically,  and  such  an  examination  should  ahvaj^s 
precede  any  operative  interference.  Pus  in  and  around  the  kidney  is  to  be  treated 
on  surgical  principles. 

Bacteriuria. — In  LSOo  the  author  found  a  pure  culture  of  Streptococcus  pyo- 
g(>ii('s  lougus  in  the  urine  of  an  ajipareutly  healthy  gravida  of  tin;  ninth  month. 
This  woman  had  an  operative  delivery,  and  developed  double  phlegmasia  alba 
dolens  on  the  tenth  day  of  the  puerperium.  Another  patient  suffering  from  sepsis 
in  1896  showed  enormous  masses  of  a  streptodiplococcus  in  the  urine  and  in  the 
lochia.  Petruschki  in  1898  first  showed  that  living  typhoid  l)acilli  could  be  found 
in  the  urine  months  after  convalescence.  Weichselbaum  (cited  by  Walthard, 
loc.  cit.)  showed  the  streptococcus  in  the  urine  in  a  case  of  sepsis. 

Ahlberg  found  bacteriuria  in  15  per  cent,  of  pregnant  women.  Murray  found 
the  Bacterium  coli  in  the  urine  in  44.5  per  cent,  of  gynecologic  cases  before,  and  in  93 
per  cent,  after,  operation.  It  would  be  interesting  to  discover  what  percentage  of 
eclamptics  and  nephritics  show  bacteria  in  the  urine.  Without  doubt  the  health}- 
kidney  can  and  does  excrete  bacteria,  and  it  is  more  than  probable  that  it  may  suffer 
injury  in  its  task.  Cloudiness  of  the  urine  is  often  due  to  bacteria,  and  it  is  the 
author's  ])ractice  to  give  such  cases  urotropin  or  salol  until  the  condition  is  bet- 
tered. It  is  not  unlikely  that  many  instances  of  puerperal  infection  will  be  trace- 
able to  infected  urine.  During  obstetric  operations  one  should  not  allow^  the  urine 
to  drip  over  the  field,  and  if  it  does,  the  parts  should  be  washed  with  antiseptic 
solutions. 

Cystitis  occurs  as  the  result  of  retroflexio  uteri  gravidi,  but  it  may  appear  alone, 
from  the  usual  causes,  aggravated  by  the  vascularity  of  gestation.  iMild  cystitis 
of  the  trigonum  is  common  and  produces  frequent  urination.  Diagnosis  and  treat- 
ment are  on  general  principles.  Hemorrhage  into  the  bladder  from  vesical  vari- 
cosities, hematuria  from  other  causes,  sometimes  apparently  none  other  than  gesta- 
tion, are  observed  rarely,     (See  Venus,  Burnett,  Kolischer,  Opitz,  Cumston.) 


CHAPTER  XL 

DISEASES  OF  METABOLISM— DISEASES  OF  THE  EYE,  EAR,  NOSE, 

AND  THROAT 

DISEASES  OF  METABOLISM 

Diabetes. — Sugar  is  found  in  the  urine  in  about  5  per  cent,  of  gravidse,  but  it  is 
almost  always  milk-sugar  or  lactose,  and  when  proved  such,  requires  no  further 
attention.  True  glycosuria  is  very  rare,  unless  the  minute  traces  which  are  dis- 
coverable with  fine  reagents  are  considered,  and  when  it  is  found,  is  always  of  serious 
moment.  Alimentary  glycosuria  is  more  easily  produced  in  pregnancy  than  in  the 
normal  state,  a  point  which  must  be  considered  in  evaluating  the  discovery  of 
mellituria.  Transient  glycosuria,  sometimes  to  the  amount  of  2  or  even  3  per  cent., 
may  occur  in  the  latter  weeks  of  gestation,  accompanied  by  mild  symptoms  of 
diabetes.  Many  authors  hold  these  cases  as  of  no  real  significance,  since  recovery 
takes  place  after  delivery,  but  the  author  believes  that  they  are  reallj''  the  first 
warnings  of  underlying  disease,  and  that  the  after-history  of  the  women  will  show 
the  same.  Habitual  death  of  the  child  in  pregnancy  and  after  labor  is  sometimes 
found  in  such  women,  and  in  two  of  my  cases  a  clear  hereditary  tendency  was  proved. 
True  diabetes  is  rare,  for  reasons  soon  to  be  given. 

Effects  of  Diabetes  on  Pregnancy. — Sterility  is  common,  Lecorche,  of  114  cases, 
finding  only  7  gestations.  This  is  clue  to  atrophy  of  the  uterus  and  ovaries,  which 
also  explains  the  frequent  amenorrhea.  Abortion  and  premature  labor  occur  in  33 
per  cent,  of  the  pregnancies,  the  fetuses  usually  being  macerated.  The  children,  if 
the  pregnancy  goes  to  term,  often  die  shortly  after  birth,  the  total  mortality  being 
66  per  cent.  Sugar  is  sometimes  found  in  the  liquor  amnii,  and  if  germs  gain  access 
to  it  during  labor  (Bacterium  coli),  decomposition  sets  in  and  gas  forms — physome- 
tra.  The  infant  may  have  glycosuria.  Polyhydramnion  is  frequent,  and  over- 
growth of  the  child,  perhaps  edema,  has  rarely  been  noted.  Labor  in  diabetics  is 
not  very  different  from  the  normal.  Hemorrhage  is  not  a  prominent  symptom,  nor 
does  the  puerperium  show  anything  unusual.  Sepsis  is  not  more  frequent^ndeed, 
it  seems  as  if  they  are  a  little  more  resistant  to  infection.  ■ 

Effects  of  the  Pregnancy  on  the  Diabetes. — Without  doubt  pregnancy  has  a  bad 
effect  on  the  course  of  the  disease.  It  may  develop  a  latent  diabetes,  there  being 
cases  where  severe  symptoms  appeared  only  during  successive  pregnancies,  and 
others  where  the  disease  grew  progressively  worse  each  time.  Since  the  carbo- 
hydrate metabolism  of  the  liver  is  at  fault  in  diabetes  and  the  liver  is  overburdened 
during  gestation,  acute  hepatic  insufficiency  is  easily  explained.  The  acidosis  of 
hyperemesis  gravidarum — of  eclampsia — is  on  the  same  basis.  Unless  treatment 
is  instituted,  the  sugar  in  the  urine  increases,  the  malnutrition  becomes  marked, 
and  the  nervous  system,  which,  as  usual  in  pregnancy,  suffers  first  from  bad  in- 
fluences, begins  to  show  signs  of  intoxication.  Coma  occurs  in  30  per  cent,  of  the 
cases,  and  is  almost  always  fatal.  It  may  be  brought  on  by  a  very  slight  shock  in 
pregnancy,  but  more  often  during  and  just  after  labor.  Delivery  seems  to  have  even 
a  worse  effect  than  most  surgical  operations,  causing  collapse,  coma,  or  sudden 
death.  Bronchitis  has  been  often  noted  in  the  puerperium,  and  this  has  been  found 
to  eventuate  in  tuberculosis. 

Diagnosis  consists  in  determining  whether  the  case  is  one  of  true  diabetes, 
lactosuria,  alimentary  glycosuria,  or  transient  glycosuria  (always  to  be  viewed  with 

502 


DISEASES    OF    iMETABOLISM  503 

suspicion).  A  real  diabetes  will  l)e  (liaKnose(l  when  the  classic  symptoms  are 
present — grape-sugar  in  the  urine,  pcjlyuria,  thirst,  and  malnutrition,  and  esjoeci- 
ally  if  the  urine  shows  large  amounts  of  sugar,  aeet(jne,  diaeetie  and  heta- 
oxy butyric  acids. 

Prognosis. — True  diabetes  has  a  very  bad  prognosis,  Of'fergeld  finding  (jver  50 
per  cent,  mortality,  of  which  30  per  cent,  died  in  coma,  the  others  of  tuberculosis  or 
coma,  within  two  and  one-half  years.  The  cases  of  glycosuria  (0.5  to  2  per  cent, 
sugar)  without  symptoms  of  malnutrition  or  of  marked  acidosis  offer  a  better  prog- 
nosis, l)ut  must  be  watched.  Albuminuria  is  an  ominous  complication.  Of  the 
children,  51  per  cent,  were  stillborn,  10  per  cent,  died  within  a  few  days  after  Ijirth, 
and  5  i)er  cent,  more  before  six  months,  from  hydroc(>phalus  and  diab(!tes. 

Treatment. — In  all  cases  the  usual  medical  treatment  is  to  be  employed.  Ali- 
mentary and  transient  glycosuria  need  no  other  consideration. 

(a)  Before  the  Child  is  Viable. — If  a  woman  comes  under  treatment  with  a 
history  of  diabetes,  and  the  examination  of  the  urine  in  the  first  months  shows  grape- 
sugar,  it  is  best  to  terminate  the  pregnancy  at  once.  The  attempt  to  carry  the 
patient  up  to  term  or  even  to  viability  of  the  child  is  too  perilous — either  the  shock 
of  delivery  brings  on  coma,  or  some  other  nervous  shock  does  it,  or  the  disease 
aggravates  dangerously,  and,  too  often,  the  child  dies  in  utero.  If  the  pregnancy  is 
near  viability  and  the  symptoms  respond  to  medical  treatment,  one  may  try  to  tide 
the  woman  along  with  a  view  to  improving  the  child's  chances,  even  though  this 
hope  is  only  too  often  illusory — the  child  dies  either  before  or  after  delivery.  Klein- 
wachter  says  we  should  not  consider  the  child  at  all. 

(6)  After  Viability  of  the  Child. — Since  some  cases  of  simple  glycosuria  occur 
at  this  time,  and  since  any  interference  or  even  natural  labor  may  evoke  a  terminal 
complication,  most  authorities  advise  waiting,  with  medical  treatment,  and  the 
induction  of  premature  labor  only  when  threatening  symptoms  arise.  Williams — 
and  in  this  I  agree — advises  the  induction  of  premature  labor  in  all  cases  when  the 
sugar-content  of  the  urine  does  not  diminish  under  appropriate  treatment,  and  es- 
pecially if  ominous  conditions  are  found;  such  are  a  history  of  aggravation  in 
previous  pregnancies,  polyhydramnion,  acidosis,  albuminuria,  acetonuria,  advanc- 
ing malnutrition  (determined  by  the  scale),  and  progressive  weakness.  Coma  in- 
dicates the  emptying  of  the  uterus,  but  the  child  is  almost  always  dead.  If  abor- 
tion or  premature  labor  is  to  be  induced,  no  anesthetic  is  to  be  employed,  and  the 
operation  is  done  with  the  least  possiblephysical  and  psychic  shock.  If  an  anesthetic 
must  be  given,  use  ether.  Ergot  may  be  used  only  if  very  necessary.  Nursing  is 
not  to  be  permitted.     Further  child-bearing  is  prohibited  (Duncan,  Schade). 

Obesity. — Fat  women  are  often  amenorrheic  and  sterile.  Amenorrheic  and 
sterile  women  are  often  fat.  Probably  the  causes  of  the  two  conditions  are  similar, 
being  perhaps  clue  to  anomalies  of  the  ductless  glands.  Pregnancy  usually  causes 
deposition  of  fat  about  the  middle  of  the  body,  and  many  women  put  on  fat  during 
and  after  the  puerperium.  A  coml)ination  of  obesity  with  infantile  pelvis  is  not 
rare.  Obesity,  when  extreme,  may  cause  abortion,  and  in  some  instances  puny  chil- 
dren have  been  noted.  Edema  of  the  feet  and  abdomen  is  often  noted.  Dysp- 
nea is  frequently  a  troublesome  symptom,  and  in  labor  the  heart  must  be  consid- 
ered like  that  of  myocarditis.  Rupture  of  the  uterus  is  favored  by  fatty  infiltration 
of  the  muscle-fil)ers.  Postpartum  hemorrhage  is  a  little  more  frequent,  and 
manual  removal  of  the  placenta  oftener  necessary,  because  the  thick  l^elly-wall 
prevents  a  good  Crede  grasp  for  the  expression.  In  only  one  case  has  the  author 
noticed  that  the  fat  of  the  pelvis  obstructed  the  delivery,  and  this  was  at  the  outlet. 
Perineal  tears  are  more  common,  and,  owingto  the  presence  of  eczema  intertrigo  and 
the  locking  in  of  the  lochia,  the  union  of  the  wound  is  not  so  successful.  Operative 
procedures  are  very  laborious,  and  obesity  complicated  with  a  very  large  fetus  is  a 
formidable  affair.     In  general,  it  is  best  not  to  prescribe  active  antifat  treatment 


504      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

during  pregnancy,  but  where  the  obesity,  or  the  condition  underlying  it,  is  the  cause 
of  frequent  abortion  or  sterihty,  one  should  seek  to  establish  normal  conditions. 

Osteomalacia,  malacosteon,  moUities  ossium,  or  softening  of  the  bones,  is  a  disease 
which  is  A-eiy  rare  in  this  countrj',  being  found  principally  in  Italy,  the  Rhine  Valley,  certain 
places  along  the  Danube  River,  and  in  Flanders,  though  no  country  is  entirely  exempt.  In 
America  but  few  cases  are  reported,  mostly  importations — Hirst,  3;  Williams,  3;  and  the  author 
had  1  case,  an  Italian  woman  who  brought  her  illness  from  Naples.  In  pathology  the  disease 
consists  of  an  osteomyelitis  and  osteitis  progressing  from  the  marrow  along  the  Haversian  canals 
outward,  even  to  the  periosteum.  An  absorption  of  the  lime-salts  of  the  bone  takes  place,  and 
later  the  spaces  are  filled  with  an  osteoid  substance  growing  in  from  the  marrow.  As  a  result  the 
bones  become  yery  much  lighter  in  weight,  softer,  and  sometimes  so  flexible  that  a  pelvis  so 
affected  has  been  called  a  "rubber  pelvis."  The  calcium  and  phosphates  absorbed  from  the  bones 
are  excreted,  probably  through  the  urine  and  feces.  The  bones  themselves  are  very  vascular, 
reddish  yellow  or  brown,  and  in  advanced  cases  the  periosteum  remains  as  a  sac  filled  with  marrow 
and  fat.  If  a  cure  results,  bone  salts  are  again  deposited  in  the  osteoid  substance,  and  the  skeleton 
grows  ^'ery  heaA'j'',  but  the  deformities  remain.  The  pelvis,  the  vertebrae,  the  ribs,  and  lastly 
the  long  bones  are  affected  in  order. 


Fig.  437. — Willard's  Case  of  Osteomalacia.     Porro  Cesarean  'at  Five  Months. 

Osteomalacia  is  a  disease  of  adults,  but  a  case  occurring  in  a  girl  of  eleven  is  on  record.  A 
similar  disease  occurs  in  men  and  in  the  lower  animals.  It  bears  some  resemblance  to  rachitis. 
Multiparse  are  much  oftener  affected  than  primipane,  and  frequent  child-bearing  seems  to  be 
an  active  factor.  It  occurs  mo.st  often  in  women  of  the  lower  classes  of  poor  nutrition  and  unhy- 
gienic mode  of  life.  The  actual  cause  of  the  disease  is  unknown,  only  one  of  the  numerous  theories 
— that  of  Fehling — being  at  all  plausible.  Fehling  holds  that  the  abnormal  metabolism  of  the 
bones  is  due  to  a  trophoneurosis,  a  reflex  from  ovaries  in  a  state  of  hyperactivity,  and  the  almost 
uniform  success  of  castration  as  a  cure  gives  a  strong  basis  for  the  theory,  von  Velitz  found 
hyaline  degeneration  of  the  vessels  of  the  ovaries,  but  this  is  not  pathognomonic.  Since  we  know 
more  about  the  internal  secretions  of  the  ductless  glands,  and  since  the  ovaries  have  been  proved 
to  have  something  to  do  with  the  nutrition  and  growth  of  the  bones,  it  seems  more  probable  that, 
the  cau.se  of  o.stcomalacia  may  be  found  by  search  along  these  lines.  Of  interest  are  the  experi- 
ments of  Sant-Agnese,  who  inserted  bits  of  rib  removed  from  osteomalacic  women  into  rats,  and 
found  bone  changes,  and  constantly  the  Diplococcus  osteomalacia  hominis  of  Morpurgo. 

Symptoms  usually  first  appear  dui-ing  pregnancy — pain  in  the  back  and  legs,  tenderness 
of  the  bones,  difficulty  in  locomotion,  a  wad(lling,  twisting  gait,  intention  tremor,  contracture  of 
the  adductors  of  the  thighs  and  of  llic  levator  ani,  and,  since  the  weight  of  the  trunk  bears  heavily 
on  the  pelvis,  the  sacrum  and  innominates  are  clistortcd,  the;  inlet  narrowed,  and  the  stature  of 
the  woman  shortened.  Encroachment  of  the  bones  on  the  thoracic  cavity  causes  dyspnea  and 
cyanosis.  Softening  and  separation  of  the  joints,  especially  the  pelvic,  have  been  frequently  noted. 
After  delivery,  which  may  be  spontaneous,  recovery  takes  place,  but  since  these  women  are 
remarkably  fertile,  usually  a  new  pregnancy  soon  begins,  and  with  the  recurrence  of  worse  symptoms. 


DISEASES    OF   THE    EYE,    EAR,    NOSE,    AND    TJIROAT  505 

Finally  tho  stature  is  1  to  132  f''<''  sliortcricd,  the  pelvis  hceoinr-s  iinpusHiibh;  to  the  chiM,  loc;o- 
rnolioii  is  impossible,  and  the  univida  becomes  bedridden.  (l'"<jr  details  of  the  cfTeet  of  the  deformed 
pelvis  on  lal)or  see  Chai)ti'r  Lll I,  Contracted  Pelvis. j  Karely  .spontaneous  cure  occurs.  Frac- 
tures of  tlie  bones  are  eonmion  (I'lfS,.  4;i7). 

Many  women — fully  one-third,  in  my  exi)erience — complain  of  symptom.s  durinK  tho  latter 
half  of  i)reti;nancy  which  resemble  very  clo.sely  tho.se  of  mild  decrees  of  oste(jmalacia — pain  in  the 
back  ami  over  the  pelvic  joints,  also,  but  rarely,  in  the  steriumi  and  the  .shoulder-jjirdle,  and 
dilHeulty  and  pain  in  locomotion.  The  .softening  and  looseninfr  of  the  pelvic  articulations  K've 
the  fi;ait  a  waddliiifj;  character,  and  on  vaginal  examination  we  hnd  tlu;  pelvic  bones,  but  especially 
tli(>  joints,  excessively  tender.  It  is  possible,  too,  that  the  osteophytes  of  Rokitansky  have  some 
bcnirinfi;  on  these  two  conditions. 

Trcalnicnl. — Phosphorus,  lime,  cod-liver  oil,  and  abundant  nourishment  arc  always  to  be 
administere<l,  and  if  the  dis"ase  is  rapidly  prof^ressint;,  the  ovaries  m;iy  be  removed,  lio.ss  recom- 
mended the  administration  of  epinephrin,  10  minims  of  the  1:  ]()()()  ,sf)lution  three  times  dailj',  and 
claims  excellent  results.  Very  recently  j)ituitrin  has  been  also  given  (Neu).  If  the  patient  is 
prcfinant,  unless  tho  symptoms  are  very  lU'gent,  wait  until  term  and  do  Porrf)  cesarean  removing 
the  ovaries.  In  my  case  a  cure  was  effected  by  simple  castration  at  cesarean  section.  Clreat 
difficulty  was  experienced  in  stopping  the  hemorrhage  at  the  operation,  an  occurrence  which 
von  Velitz  also  met,  and  which  required  amputation  of  the  uterus  in  two  cases.  For  the  p.seudo- 
osteomalacic  symptoms,  hme  and  phosphates  are  administered  (Schnell). 


DISEASES  OF  THE  EYE,  EAR,  NOSE,  AND  THROAT 

The  Eye. — Even  the  ancients  knew  that  sepsis  and  severe  hemorrhages  in  the 
pucrperiuni  could  produce  bhnchiess  and  strabismus,  and  a  connection  seemed  to 
be  estabhshed  between  the  genitals  and  the  eyes  for  many  affections  of  the  latter, 
l)ut  even  yet  the  exact  mode  of  interaction  is  obscure.  Many  theories  were  in- 
voked, as  reflex  action  from  the  genitalia,  retention  of  poisons  which  should  l)e 
eliminated  in  the  menstrual  blood  (Charrin  and  Roche),  which  is  a  disinterment  of 
the  "purification"  theory  of  menstruation;  hysteria  and  neuroses,  demineraliza- 
tion  of  the  blood,  toxemia,  abnormal  or  insufficient  internal  secretion  of  certain 
organs,  especially  the  ovaries.  It  is  probable  that  several  of  these  hypotheses  may 
explain  the  numerous  ocular  manifestations  which  seem  to  bear  relation  to  gesta- 
tion. 

During  pregnancy  excessive  pigmentation  of  the  eyelids  is  sometimes  noted  in 
neiu'otic  women.  Tanner  speaks  of  a  chromidrosis.  Ulcer  of  the  cornea,  cho- 
roiditis, and  glaucoma  may  begin  or  be  aggravated,  and  a  few  pregnant  women 
complain  of  scotomata  and  dyschromatopsia.  This  may  be  due  to  an  optic  neuritis, 
which  occurs  also  in  the  puerperium,  may  be  associated  with,  and  probably  is 
similar  to,  the  polyneuritis  of  pregnancy.  Since  atrophy  of  the  optic  nerve  may 
result,  the  pregnane}^  should  be  interrupted.  Weakness  of  accommodation  and 
muscular  asthenopia  are  not  very  rare,  and  may  require  temporarj-  treatment. 
Hemeralopia  has  sometimes  been  found  to  precede  the  amaurosis  of  toxemia. 
Retinal  hemorrhage  and  abruptio  retinae  are  serious  complications,  usually  requir- 
ing interference.  Teillas  observed  four  gravidse  recover  completely  from  retinal 
hemorrhages. 

Preeclamptic  toxemia  and  renal  disease  sometimes  produce  an  acute  amauro- 
sis, already  referred  to,  which  usually  is  transitory,  disappearing  more  or  less  com- 
pletely when  the  uterus  is  emptied.  It  may  occur  -Rith  postpartum  eclampsia 
also  or  independently.  The  blindness  often  precedes  the  convulsions  or  coma  for 
several  daj's,  and  is  of  great  prognostic  importance.  Ophthalmoscopically,  nothing 
is  to  be  seen  on  the  retina.  It  lasts  two  to  six  days  after  consciousness  returns,  but 
may  leave  impaired  vision.  It  is  due,  according  to  Berger  and  Loewy,  to  a  poison- 
ing of  the  ganglia  and  optic  nerves,  the  toxins  having  a  special  selective  action  for 
them.  Such  selective  action  of  poisons  is  well  kno-uii- — for  example,  tetanus, 
strychnin.  This  theory  appeals  strongly  to  the  author.  Pregnancy  seems  to  dis- 
pose to  the  occurrence  of  neuroretinitis,  with  a  tendency  to  hemorrhages  and  exu- 
dates. Posey  and  Hirst  believe  that  the  optic  neuritis  and  retinitis,  due  to  the 
toxemia  of  pregnancy,  may  indicate  the  basal  trouble  before  changes  show  in  the  urine. 


506  THE    PATHOLOGY   OF   PREGNANCY,    LABOR,    AND    THE    PUERPERIUM 

Acute  amblyopia  or  amaurosis  occurring  in  the  course  of  pregnancy  demands  im- 
mediate urinalysis,  and  if  albumin  or  other  signs  of  renal  or  hepatic  insufficiency  are 
present,  the  induction  of  labor.  Another  form  of  amblyopia  and  amaurosis  may 
develop  in  the  course  of  renal  or  hepatic  disease  during  gestation — retinitis  albu- 
minurica.  This  is  easily  diagnosed  with  the  ophthalmoscope  by  the  hemorrhages 
and  the  white  spots  and  lines  which  show  the  degeneration  of  the  retinal  vessels. 
These  changes  may  long  precede  the  complaint  of  loss  of  vision.  Exophthalmos 
is  sometimes  associated  (Barker).  First  the  women  complain  of  specks  before  the 
eyes,  cUmness  of  vision,  sometimes  hemeralopia,  colored  lights,  amblyopia,  and 
finally'  of  complete  blindness.  Retinitis  albuminurica  may  occur  in  all  forms  of 
kidney  disease  during  pregnancy,  but  the  prognosis  is  somewhat  better  than  those 
cases  which  occur  outside  of  gestation.  It  is  more  frequent  in  the  chronic  forms  of 
disease,  and  it  always  indicates  the  immediate  emptying  of  the  uterus.  This  is  to 
save  the  sight  and  to  prevent  eclampsia  and  uremia.  Abruptio  retinae  may  com- 
plicate the  retinitis.  After  delivery  the  sight  returns,  but  usually  incompletely, 
though  a  few  cases  of  cure  are  on  record.  In  a  subsequent  pregnancy  the  condition 
usually  recurs,  but  even  though  it  may  not,  one  should  always  counsel  the  dis- 
continuance of  child-bearing.  Edema  of  the  lids,  of  the  bulbar  conjunctivae,  and 
even  of  the  retina  are  found  in  nephritis. 

During  labor  hemorrhages  in  the  conjunctivae  and  behind  the  bulb  have  been 
noted,  also  hysteric  amaurosis  and  xanthopsia. 

During  the  puerperium  all  the  conditions  mentioned  may  occur  or  be  carried 
over  from  pregnancy.  I  have  seen  one  case  of  hysteric  amaurosis  and  several  of 
blepharitis  marginalis,  of  hordeolum,  and  one  of  phlyctenular  conjunctivitis,  which 
three  are  generally  ascribed  to  the  influence  of  lactation.  Treatment  consists  of  the 
administration  of  lime,  phosphates,  and  general  roborants.  Muscular  asthenopia 
has  been  noted,  and  I  have  seen  numerous  cases  of  headache  in  the  puerperium  from 
eye-strain.  The  women  look  down  at  the  baby  while  it  is  nursing,  and  the  eyes 
are  unaccustomed  to  such  prolonged  action.  Reading  in  bed  and  with  poor  light 
may  also  be  causative.  A  true  weakness  of  accommodation  occurs  also.  The  re- 
lation of  the  nasal  sinuses  to  the  eye  should  be  remembered. 

Optic  neuritis  may  be  associated  with  ulnar  or  polyneuritis,  with  the  same  etiol- 
ogy. In  septic  cases  blindness  may  result  from  double  retinitis  septica,  from  pan- 
ophthalmitis, or  from  embolism  of  the  central  artery  of  the  retina. 

Severe  hemorrhage,  especially  if  associated  with  other  diseases  which  weaken 
the  optic  nerve,  may  cause  temporary  or  permanent  blindness.  It  may  aggravate  a 
myopia  and  favors  optic  atrophy.  This  effect  may  come  on  at  once,  or  it  may  appear 
after  several  weeks.  It  is  due  to  anemia  of  the  retina  and  nerve  or  to  degenerative 
changes  in  them,  and  lasts  a  few  hours  in  the  first  instance,  and  may  be  more  or  less 
permanent  in  the  latter.  Choked  disc  with  blindness  has  been  observed  after  severe 
bleedings.  It  is  easily  seen  how  important  is  the  quick  restitution  of  the  blood  to  a 
normal  state,  and  Berger  and  Loe^vy  even  recommend  transfusion  with  defibrinated 
blood,  in  addition  to  the  other  usual  remedies   (Runge,  Silex,  Shute). 

The  Ear. — Aurists  find  that  pregnancy  sometimes  unfavorably  affects  diseases 
of  the  ear.  ■\Iiddle-ear  infections  grow  worse,  chronic  thickenings  increase,  and 
deafness  becomes  more  marked,  all  of  which  is  especially  noticeable  in  repeated 
gestations.  Ringing  in  the  ears  may  be  a  symptom  of  toxemia,  and  even  deafness 
may  be  caused  by  an  auditory  neuritis  analogous  to  the  same  disease  of  the  optic 
nerve.  In  cases  of  rapidly  increasing  deafness  due  to  pregnancy,  the  induction 
of  premature  labor  is  to  be  debated  with  the  family  and  attending  aurist.  It 
is  possible  that  some  of  the  "fainting  spells"  to  which  pregnant  women  are  liable 
may  be  due  to  circulatory  disturbances  in  the  labyrinths  (Brickner,  Milligan). 

The  Nose. — A  general  hyperemia  of  the  nose  and  throat  has  been  noted  by 
rhinologists,  some  even  claiming  that  a  diagnosis  of  pregnancy  may  be  made  from 


TRAUMATISM  507 

the  nasal  findings.  Hofhauor  proved  clinicall}'  and  niifTOSfopirally  that  decided 
changes  exist.  The  intumescent  eontUtions  of  tiie  turljinates  are  subject  to  aggrava- 
tion by  pregnancy.  Sinus  disease  is  not  more  common.  Its  treatment  is  the  same 
as  in  the  non-pregnant  con(htion — indeed,  all  suppurations  of  the  nose  and  throat 
must  be  cured  before  labor,  because  the  focus  of  suppuration  may  lead  to  infection 
of  the  genitalia  or  the  breasts. 

Fliess  claims  that  the  anterior  ends  of  the  lower  and  middle  turbinates,  if 
diseased,  may  cause  dysmenorrhea,  and  if  cocainized  during  the  attack,  the  pain 
ceases,  and  that  caut(M-izati(jn  of  these  areas  will  cure.  My  experience  with  this 
remedy  is  small  l)ut  entirely  negative,  there  having  been  not  even  an  improvement 
which  might  have  been  ascribed  to  suggestive  action.  He  also  claims  that  the  pains 
of  labor  and  hyperemesis  gravidarum  maj^  be  favorably  influenced  in  the  same  way. 
Epistaxis  has  been  noted  with  some  frequency  in  pregnanc3^  Usually  an  ulcerated 
spot  is  not  found,  the  Ijlood  coming  from  ruptures  of  one?  of  the  congested  capillaries. 
An  ulcer  may  l)e  cauterized,  even  though  Fliess  says  that  abortion  sometimes  results 
from  such  action.     Vicarious  menstruation  through  the  nose  has  been  referred  to. 

Lingual  varicosities  are  sometimes  aggravated  by  pregnancy,  and  the  hj'peremia 
may  lead  to  some  hoarseness,  but  in  general  the  effects  of  gestation  are  not  promi- 
nent. Tuberculosis  of  the  larynx  is  most  unfavorably  influenced,  the  ulcerations 
becoming  deeper  and  spreading  rapidly,  and  frequently  causing  edema  of  the  glottis. 
Pregnancy  seems  even  to  predispose  to  laryngeal  tuberculosis.  Some  singers  claim 
that  it  injures  the  voice  to  sing  during  pregnancy,  and  there  seems  to  be  a  scientific 
reason  for  it.     It  is  denied  by  others. 

As  the  result  of  violent  labor  efforts  hemorrhages  may  take  place  in  the  mucous 
membrane  of  the  nose  and  throat,  as  well  as  the  ocular  conjunctivae,  while  after 
severe  blood  loss  the  parts  are  very  anemic.  Women  who  shriek  continually  during 
prolonged  labor  may  show  on  examination  redness,  edema,  and  minute  blood  ex- 
travasations in  the  mucous  membrane  of  the  false  and  true  vocal  cords  and  the 
posterior  wall  of  the  larynx.     After  delivery  these  changes  rapidly  clear  up. 


TRAUMATISM 

Pregnant  women  bear  the  effects  of  violence  with  varying  resistance.  "Wounds 
heal  with  their  usual  promptness,  and  the  old  notion  that  bones  unite  poorlj'  is  in- 
correct. Suggillations  are  perhaps  a  little  more  extensive.  Violence  to  any  part 
of  the  body,  but  particularly  to  the  genitals,  may  bring  on  abortion,  but  sometimes 
terrible  shock  may  be  -without  effect  on  the  pregnane^',  as  in  Waldeyer's  case  of 
fracture  of  the  sacrum,  and  one  of  mine,  where  I  delivered  at  term  a  woman  on 
whom  an  inexperienced  surgeon  had  performed  curetage  at  three  months.  Opposed 
to  this  may  be  placed  the  well-authenticated  cases  of  a  slight  jar,  as  from  misstep, 
causing  abortion.  Operations  are  to  be  performed  on  any  part  of  the  bodj'  if  the 
indication  is  real  and  urgent,  but  operations  of  convenience,  for  example,  simple 
hernia,  hemorrhoids,  etc.,  are  better  postponed.  Ovariotomy  has  often  been  done 
successfully  in  pregnancy,  also  the  removal  of  fibroids  from  the  uterus  itself.  The 
necessity  for  the  ovaries  seems  gTeatest  in  the  early  months,  because  if  removed 
later,  both  gestation  and  labor  may  be  natural.  Shock  and  sepsis  are  the  usual 
causes  of  the  abortion  when  such  occurs.  Operations  on  the  labia  and  cer\'ix  have 
been  done  without  disturbing  the  pregnancy,  and  even  extirpation  of  the  breast. 
Then,  again,  a  slight  operation  on  some  distant  organ  or  extremity  will  bring  on  an 
abortion.  It  is,  therefore,  impossible  to  foretell  what  efTect  a  given  interference  will 
produce.  It  seems  that  operations  undertaken  at  the  time  the  woman  would  or- 
dinarily have  menstruated  are  more  likeh'  to  luring  on  pains.  Vesicovaginal  and 
rectovaginal  fistulas  have  been  cured  in  graviditate  and  the  local  changes  in  the 
tissues  seem  to  have  improved,  rather  than  impaired,  the  process  of  wound  heahng. 


508  THE   PATHOLOGY    OF    PREGNANCY,    LABOR,    AND    THE    PUERPERIUM 

Anesthetics  may  be  given  during  gestation,  but  there  is  danger  of  asphyxiating  the 
infant.  Probablj^  death  of  the  child  causes  some  of  the  premature  labors  recorded 
after  operations.  Ether  is  the  safest,  and  the  administration  should  be  as  short  and 
as  light  as  possible.  A  dentist  informed  me  that  he  had  given  gas  to  pregnant  women 
hundreds  of  times  without  injury,  but  in  one  of  my  cases  of  cesarean  section,  where 
gas-ether  narcosis  was  used,  the  child  was  mortally  asphyxiated.  Previously  it 
was  in  prime  condition,  and  the  actual  delivery  consumed  less  than  three  minutes. 
Operations  in  the  presence  of  pus,  especially  if  the  focus  of  infection  is  near  the  uterus, 
are  more  than  likely  to  be  followed  by  sepsis. 

Pregnant  and  puerperal  women  should  be  spared  mental  shocks,  if  at  all  pos- 
sible. Premature  labor  may  result,  even  fetal  death.  During  labor  a  shock  may 
suspend  uterine  action,  and  cases  are  recorded  where  collapse  and  death  resulted. 
A  shock  in  the  puerperiujn  has  been  ascribed  as  the  cause  of  diabetes,  acute  febrile 
reaction,  dementia,  convulsions,  hemorrhage,  and  death.  (See  "Sudden  Death.") 
A  shock,  too,  will  sometimes  alter  the  milk — either  dry  it  up  or  make  it  unfit,  even 
poisonous,  to  the  child.  How  these  changes  are  brought  about  is  still  a  subject  of 
conjecture. 

Literature 

Ahlberg:  "  Bacteriuria,"  Arch.  f.  Gyn.,  1910,  vol.  xc,  vol.  ii,  p.  298. — Barker  and  Hanes:  Amer.  Jour.  Med.  Sci.,  October, 
1909. — Berger  and  Loewy:  Augenkrankheiten  sexuellen  Ursprunges  bei  Frauen,  1906.  Translated  by  Beatrice 
Rossbach. — Bossi:  Society  d'Obstetrique  de  Paris,  June  16,  1904. — Brickner:  Amer.  Jour.  Obstet.,  June,  1911. 
Literature. — Burnett:  Jour.  Obst.  and  Gyn.  of  Great  Britain,  August,  1910. — Charrin  and  Roche:  Compt.  Rend, 
des  Sci.,  Paris,  May  25,  1903. — Cumston:  Amer.  Jour.  Med.  Sci.,  July,  1908. — Duncan:  London  Obstetric  Trans., 
1882,  vol.  xxiii,  p.  256. — Fehling:  Arch.  f.  Gyn.,  vol.  xxxix,  p.  180. — Frdnkl-Hochwart  u.  C.  von  Noorden: 
Erkrank.  der  weibl.  Gen.  in  Bez.  zur  inn.  Med.,  1912,  2  vols. — Kolischer:  Die  Erkrankungen  der  weibl.  Harn- 
rohre,  etc.,  Vienna,  1898. — Milligan:  Jour.  Laryngol.,  June,  1909. — Mirabeau:  "Ureteritis,"  Arch.  f.  Gyn.,  1908, 
vol.  Ixxxii,  vol.  ii. — Murray:  Jour.  Obst.  and  Gyn.,  British  Empire,  December,  1910,  p.  405. — Neu:  Centralbl.  f. 
Gyn.,  1911,  No.  35. — Offergeld:  Arch.  f.  Gyn.,  vol.  Ixxxvi,  H.  i,  p.  160,  September,  1908.  Literature. — Opitz: 
Zeitschr.  f.  Geb.  u.  Gyn.,  1905,  vol.lv,  p.  290,112  references. — Posey  and  Hirst:  Jour.  Amer.  Med.  Assoc, 
March  14,  1908,  p.  865. — Runge:  Geburtsh.  u.  Gyn.  u.  Auge,  Leipzig,  Barth,  1908. — Sani-Agnese:  Gineco- 
logia,  1908,  Fasc.  17. — Schade:  Inaug.  Diss.,  Marburg,  1906.  Literature. — Schnell:  Zeitschr.  f.  Geb.  u.  Gyn., 
1898,  vol.  xxxix,  p.  412. — Shuie:  Jour.  Amer.  Med.  Assoc,  June  24,  1911. — Silez:  Monatsschr.  f.  Geb.,  1897, 
vol.  V,  p.  373. — Venus:  Jour.  Amer.  Med.  Assoc,  September,  1911.  Analysis  of  224  articles. — Vinay,  Fellner, 
P.  Muller:  hoc.  cit. — Vineberg:  Amer.  Jour.  Obstet.,  June,  1908. — Walthard:  Handbuch  der  Geb.,  vol.  iii,  No. 
2,  p.  487.  Bacteriology. — Williamson  and  Barris:  Jour.  Obst.  and  Gyn.,  Brit.  Empire,  December,  1911. — 
Wildbolz:  Centralbl.  f.  Gyn.,  1912,  No.  1,  p.  64. — Williams:  Amer.  Jour.  Med.  Sci.,  January,  1909. — 
Zangemeister:    Arch.  f.  Gyn.,  1902,  vol.  Ixvi,  No.  2,  p.  413. 


CHAPTER  XLI 
LOCAL  DISEASES  ACCIDENTAL  TO  PREGNANCY 

DEFORMITIES  OF  THE  PARTURIENT  CANAL 

Embryologically,  tlu>  uterus  and  vagina  are  formed  by  the  fusion  of  the  two 
Mlillorian  ducts,  the  union  taking  ])lace  from  below  upward.  Lack  of  fusion  at 
any  i)oint  or  throughout  tlie  length  of  the  two  canals  explains  almost  all  of  the  anom- 
alies that  are  observed,  and  rudimentary  development  of  one  duct  will  account  for 
the  balance.  All  degrees  of  lack  of  fusion  are  to  ]je  noted,  there  being  one  case  on 
record  where  two  complete,  but  single  and  chstinct,  parturient  canals  with  two  vulvae 
were  found, — uterus  didclphys, — and  it  is  not  rare  to  find  the  fundus  uteri  indented 
in  the  middle, — the  "uterus  arcuatus," — which  is  just  the  indication  of  the  upper 
end  of  the  line  of  fusion  of  the  two  ducts.  In  some  animals  the  two  ducts  do  not 
fuse,  but  two  tubular  uteri  exist. 

Not  always  are  the  two  sides  of  the  uterus  and  vagina  equally  developed,  and 
we  observe  gradations  from  completeness  of  the  two  halves  to  almost  entire  absence 
of  one  Miillerian  duct.  The  rudimentary  side  lies  as  an  appendage  to  the  well- 
developed  uterus,  but  since  its  canal,  four  times  out  of  five,  does  not  communicate 
with  the  vagina,  trouble  frequently  ensues,  such  as  hematosalpinx,  hematometra, 
pregnancy  in  the  closed  horn,  etc.  (Ahlfeld,  Muncle,  Santos). 

General  Considerations. — In  all  these  deformities  the  two  halves  are  usually 
not  symmetric :  one  or  the  other  horn  is  larger,  or  the  vaginas  are  unequal — some- 
times one  of  them  ends  blind  at  its  lower  end.  Coitus  is  rarely  interfered  with,  the 
larger  vagina  being  used.  Menstruation  'comes  from  both  uteri  simultaneously, 
but  sometimes  only  from  one  at  a  time.  Pregnancy  may  occur  in  one  or  both  horns, 
twins  having  been  found  in  one  horn.  If  each  horn  contains  an  ovum,  the  two  chil- 
dren may  have  been  conceived  at  different  impregnations  and  be  delivered  at  in- 
tervals, thus  raising  the  suspicion  of  superfetation.  Pregnancy  is  ordinarily  un- 
disturbed, the  side  not  involved  gro^\^ng  and  forming  a  decidua  similarly  to  ectopic 
gestation.  The  decidua  of  the  empty  side  may  be  cast  out,  while  the  pregnancy 
continues  on  the  other  side.  The  course  of  the  case  resembles  an  abortion,  and 
unless  the  duplicity  of  the  uterus  is  known,  the  accoucheur  may  attempt  to  curet, 
thus  unwittinglj^  destroying  a  living  ovum.  Usually  the  decidua  comes  away  in 
the  puerperium  with  the  lochia.  Mliller  records  cases  of  menstruation  from  the 
empty  horn  during  pregnancy.  Abortion  may  occur,  and  it  may  be  diflacult  to  clean 
out  the  uterus,  especially  if  there  is  only  one  cervix.  It  is  doubly  important  to  in- 
sert the  finger  for  the  curetage.  In  septic  abortions  it  is  necessary  to  empty  both 
sides.  Labor  is  often  normal,  but  these  complications  have  been  observed — weak 
pains  and  atony  in  the  third  stage,  with  postpartum  hemorrhage;  the  non-preg- 
nant portion  of  the  uterus  may  prolapse  under  the  other,  and  act  like  a  tumor 
incarcerated  in  the  pelvis;  the  non-pregnant  cervix  may  be  forced  down  to  the 
vulva  with  the  head;  the  uterus  may  rupture,  because  of  poor  musculature;  the 
septiun  in  the  vagina  may  be  an  obstruction.  Septate  uteri  may  have  these 
complications:  breech  and  transverse  presentations;  weak  pains;  atonj'  post- 
partum; rigichty  of  the  cervix;  placenta  on  the  septum  and  adherent;  and,  if  the 
septum  is  in  the  cervix,  obstruction  to  deliver}'.  In  one  of  mj'  cases  the  child 
straddled  the  septum. 

Pregnancy  in  a  rudimentary  horn  resembles  ectopic  gestation  very  closely. 

509 


510 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


Mauriceau  and  Vassal,  in  1669,  put  the  first  case  on  record,  and  now  over  100  have 
been  described.     If  tlie  accessory  horn  is  very  rudimentary,  it  may  be  closed  at 


FiQ.  43S. — Utekus  Duplex,  Bicornis,  cum  Vagina 
Septa. 


Uterus  Duplex,  Bicornis,  cum  Vagina  Septa. 
— One  finds  two  openings  into  two  separate 
vaginal  canals,  a  cervix  pointing  into  each,  and, 
if  the  OS  of  each  of  the  two  separate  uterine 
cavities  is  open,  a  finger  passed  into  them  will 
feel  a  septum  separating  the  two  ova.  In  my 
case,  from  which  the  diagram  is  drawn,  the 
woman  was  eight  months  pregnant,  with  a  child 
in  each  horn,  O.L.P.  and  O.D.T.,  and  a  deep 
furrow  could  be  felt  between  the  two  sides  of 
the  uterus.  One  horn  could  be  rotated  almost 
completely  around  the  other.  Fig.  439  shows 
the  appearance  of  the  vulva.  Another  prac- 
titioner conducted  the  labor. 


Fig.  4.39. — Vulva  of  Uterus  and  Vagina  Duplex.    Pregnant  in  Both  Uteri  (author's  case). 


both  ends,  making  pregnancy  impossible,  but  an  accumulation  of  menses  probable. 
Should  the  fertilized  ovum  be  inserted  in  the  small  horn,  there  is  no  hope  of  its 
finding  a  way  into  the  uterine  cavity  of  the  other,  because  the  connecting  bridge  of 


LOCAL    DISEASES    ACCIDENTAL   TO    PREONANCY 


511 


tissue  is  usually  imix'rlorute,  or  even  if  the  two  halves  are  broadly  apposed,  the 
two  cavities  usually  do  nut  coininunicate,  or  the  opening  is  too  small.  Hyper- 
trophy of  the  muscle-wall  of  the  horn  may  occur  and  permit  the  ovum  to  grow  to 


Fig.  440. 


FiK.  44L 


Figs.    440  and  411. — Uterus    Septus  Duplex,  or  Uterus 

BiLOCULARIS. 


Fig.  442. — Uteru.9  Sub-        Fig.  443. — Uterus  Bicor- 
SEPTUS  Unicollis.  nis  Unicollis. 


Uterus  S('/)tu.s  Duplex,  or  Ulerim  Biloc- 
ularis. — One  vu^ina  exi.st.s,  and  it  i.s  ca- 
parioiis,  with  marked  anterior  and  po.s- 
U'l'ioi'  coluiniiU'  and  two  eci\ice.s,  witli  a 
ialcilonn  ridge  between  them.  In  the 
author'.s  case  the  woman  wa.s  pregnant 
in  the  left  uterine  cavity  and  aborted 
at  the  third  month.  If  the  fundus  also 
shows  signs  of  spHtting,  it  is  called  uterus 
duplex  t)ieornis  (Figs.  440  and  441). 


Uterus  Subseptus  Unicollis. — This  is 
a  simple  septum  in  an  otherwise  single 
uterus.  In  one  of  my  cases  the  septum 
came  down  (at  term)  within  an  inch  of 
the  internal  os,  which  was  single.  The 
woman  had  had  five  still-births,  breech 
deliveries,  all  difficult  because  of  a  flat 
pelvis.  In  the  sixth,  conducted  by  the 
author,  the  child  suffered  a  depressed 
fracture  of  the  skull,  but  survived.  In 
another  case  the  breech  presented  in  each 
of  two  labors,  and  the  placenta  both  times 
was  adherent  to  the  septum.  This  form 
of  uterus  occurs  in  dogs,  camels,  sheep, 
etc.  If  there  are  indications  that  the 
fundus  also  is  split,  it  is  called  uterus  sub- 
septus uniforis,  or  uterus  bicornis  unicollis 
(Fig.  443). 


Uterus  Subseptus  Unicorporeus. — Consists 
simply  of  a  septate  cervix,  the  rest  of  the  uterus 
being  normal  or  presenting  only  an  indication  of 
double  formation.  In  the  author's  case  the  child, 
presenting  liy  the  lireech,  straddled  the  septum, 
which  had  to  be  cut  to  allow  delivery.  Both 
recovered. 


Fio.  444.- 


-Uterus  Subseptus  Unicorporeus. 
Septate  Cervix. 


Fig.  445. — Uterus  Arcuatus. 


Uterus  Arcunt us. —Th\s  has  already  been 
spoken  of;  it  is  the  simplest  and  most  common 
anomaly,  often  causing  difficulty  in  dilTerential 
diagno.'^ls  from  ectopic  gestation,  pregnancy  in 
the  tubal  corner,  etc.  It  often  causes  trans- 
verse   and  breech  presentations. 


term,  but  more  commonly  rupture  of  the  gestation-sac  occurs  during  the  middle  of 
pregnancv,  and  furious  internal  hemorrhage  ensues.  Practically,  what  was  said 
about  ectopic  gestation  applies  to  this  subject.  Since  there  is  no  communication 
with  the  vagina,  the  spermatozoids  must  cross  over  from  the  open  tube  to  the  closed 


512 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


side,  to  fertilize  the  ovum  from  the  ovary  on  the  side  of  the  pregnancy,  or  the  ovum 
from  the  open  side  wanders  over  to  the  closed  horn  before  or  after  fertilization. 

The  diagnosis  of  pregnancy  in  a  rudimentary  horn  is  occasionally  made,  but 
usually  the  abdomen  is  opened  for  rupture  of  a  supposed  extra-uterine  pregnancy. 


Septate  Vagina. — Double  hymen  is  frequently  ob- 
served, but  gives  no  trouble,  either  in  diagnosis  or  treat- 
ment. A  septum  may  exist  at  any  point  of  the  vagina, 
or  even  throughout  its  whole  length.  In  these  cases 
the  lower  end  of  the  Miillerian  canal  failed  to  fuse,  but 
the  upper  portions  did,  forming  a  perfect  uterus. 
Occasionally  there  are  two  cervices.  The  septum  is 
usually  sagittal,  but  may  be  frontal  in  direction. 


Fig.  446. — Septa  ix  the  Vagina,  from  in 
Front  and  fhom  the  Side. 


Fig.  447. — Uterus  Bicornis  Unolatere  Ru- 
dimentarius. 


Fig.  448. — Uterus  with  Closed  Accessory 
Horn. 


Uterus  Bicornis  Unolatere  Rudimentarius. — Of 
great  clinical  importance,  because  pregnancy  may  occur 
in  the  rudimentary  horn,  and  such  an  accident  is  worse 
than  ectopic  gestation,  with  which  it  is  usually  con- 
founded. 


Shows  the  accessory  horn  closed  at  both  ends,  and 
one  can  see  how  menstrual  blood  will  accumulate  in  it, 
causing  hematometra,  or,  if  the  vagina  is  also  partly 
formed,  hemelytrometra. 


Uterus  Unicornis. — Here  the  one  Miillerian  canal 
failed  to  develop.  It  is  normal  in  birds.  Such  a 
uterus  may  bear  children  without  trouble. 


Fig.  449. — Uterus  Unicor.nis. 


On  the  specimen  it  is  easy  to  find  the  connecting  l)and  between  the  rudimentary 
and  the  spindle-shaped  larger  horn,  and  to  determine  that  the  round  ligament  and 
the  tube  come  off  from  the  outside  of  the  gestation-sac.  The  sac  has  much  muscle 
at  its  base.     Clinically,  on  bimanual  examination  the  diagnosis  of  ectopic  preg- 


LOCAL    DLSKASES    ACCIOEXTAL    TO    PREGNANCY 


513 


nancy  is  usiuilly  first  made;  then,  when  the  form  of  tho  uterus  (spindle  sliaped  in- 
stead of  pear-like)  and  the  course  of  the  round  ligamcmt — on  the  outside  of  the  sac — 
evoke  suspicion,  one  proceeds  to  palpate  out  the  structures  more  minutely,     Sep- 


LiKamontum 
vcsiooreetale 


Rectum 


Fio.  450. — Double  Uterus  and  Vagixa. 
From  the  Lehrkanzel  fiir  path.  Anat.,  Vienna,  Handbuch  der  Gob.,  v.  Winckel. 


Rudimentary  horn 


Left  tube 


Left  round  hgament 


Right  ovary 


Fig.  45L — Uterus  Unicornis  with  Ruptured  Rudimextart  Horn. 
The  ovum  wandered  over  from  the  left  ovary.     The  horn  ruptured  in  tho  tenth  week.     The  ligaments  have  been  dis- 
sected (Luschka,  Monatsschr.  f.  Geb.  u.  Frauenk..  vol.  xxii,  p.  32;. 

33 


514      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

tate  vagina  or  cervix  may  be  indicative  of  the  presence  of  some  anomaly,  and  pal- 
pation of  the  pedicle  (see  Fig.  451)  will  clinch  the  diagnosis.  If  the  fetus  dies, 
identical  changes  in  the  ovum  may  follow,  as  in  ectopic  ova,  and,  later,  owing  to 
adhesions,  shrinkage  of  the  sac,  etc.,  the  preoperative  diagnosis  is  usually  of  a 
fibroma  or  an  ovarian  cyst.  Contractions  occurring  in  the  sac  of  the  tumor  may 
give  the  clue  to  a  correct  diagnosis. 

Treatment  is  the  same  as  for  extra-uterine  pregnancy,  and  even  more  actively 
interfering  as  soon  as  the  diagnosis  is  made.  Rupture  of  the  sac  is  attended  with 
more  fatal  results — in  82  per  cent.,  according  to  Kehrer.  At  the  laparotomy  it  is 
best  to  remove  the  whole  sac,  if  possible;  if  not,  or  if  it  is  septic,  it  is  sewn  into  the 
abdominal  wall  and  drained  (Wells,  Engstrom). 

Diverticula  of  the  uterus  have  been  described,  and  in  one  case  the  placenta  was 
developed  in  an  accessory  uterine  cavity  connected  with  the  main  portion  by  a 
passage.  It  is  probable  that  these  are  cases  of  septate  uterus  with  incomplete  sep- 
tum. Incarceration  of  the  placenta  in  a  horn  of  the  uterus  is  not  rare,  and  some- 
times the  placenta  seems  to  occupy  a  compartment  of  its  own. 


THE  LOCAL  INFLAMMATIONS 

Vulvitis. — Owing  to  the  succulence  and  congestion  of  the  parts  and  to  the  pro- 
nounced pelvic  floor  projection  which  exposes  the  organ  more  to  injury,  vulvitis  is 
not  rare  in  gestation.  Lack  of  cleanliness,  obesity,  difficulty  in  keeping  the  parts 
clear  of  mucus  and  smegma,  which  accumulates,  purulent  discharges,  together  with 
the  openness  of  the  introitus,  invite  infection  and  eczema.  Mycotic  infection,  re- 
sembling thrush  of  the  mouth,  which  may  cover  the  whole  of  the  hyperemic  and 
moist  vulva,  and  pus  infections,  including  the  gonorrheal,  occur.  Vegetations  may 
be  seen  on  the  labia  minora  or  in  the  raphe,  and  they  may  occasionally  attain  enor- 
mous size.  They  are  sometimes  gonorrheal,  but  may  as  often  be  due  to  simple  un- 
cleanliness.  If  small,  the  usual  treatment  of  vaginitis  and  vulvitis  may  be  carried 
out.  If  large,  they  should  be  excised  and  the  base  touched  with  the  thermocautery 
to  stop  hemorrhage.  Even  if  the  signs  of  inflammation  fail,  the  pudendal  region 
becomes  the  habitat  of  the  Bacterium  ccli,  the  staphylococcus  and  the  streptococcus, 
with  hosts  of  others.  For  mycosis  vulvee  painting  with  10  per  cent,  silver  nitrate 
or  tincture  of  iodin  and  a  dusting-powder  of  boric  acid  will  be  curative;  the  other 
infections  are  treated  by  antiseptic  washes,  after  frequent  ablution  with  tincture  of 
green  soap. 

Bartholinitis  is  almost  always  due  to  the  gonococcus,  alone  or  in  association 
with  pus-germs.  Because  of  the  danger  of  puerperal  infection,  an  abscess  should 
be  cured  before  labor,  by  exsection,  if  possible.  Cysts  of  the  labia,  if  not  infected, 
are  best  left  until  after  the  puerperium  is  completed,  because  the  hemorrhage  from 
the  dilated  veins  is  troublesome. 

Vaginitis  is  not  so  common  as  vulvitis,  but  it  is  not  rare  to  find  a  reddened, 
granular,  thickened  mucosa  in  the  fornices — vaginitis  granulosa.  If  great  in  extent 
and  accompanied  by  profuse  purulent  discharge,  gonorrhea  is  to  be  searched  for. 
Winckel  described  a  rare  condition  known  as  colpohyperplasia  cystica  (Fig.  452), 
which  is  inflammatory,  perhaps  due  to  the  Bacillus  emphysematosus  vaginae  (Lin- 
denthal),  and  is  characterized  1)y  fine  vesicles  under  the  epithelium  of  the  mucosa, 
filled  with  fluid  or  gas — trimethylamin  (Zweifel).  Vaginitis,  if  marked,  should  be 
treated  with  antiseptic  irrigations  during  pregnancy,  but  it  usually  disappears  only 
after  delivery.  The  reason  that  more  women  do  not  get  puerperal  infection  from 
the  septic  vagina  is  probably  because  the  local  immunities  are  developed.  Birth 
injuries,  however,  are  poorly  borne  in  these  cases  and  often  heal  unsatisfactorily. 

Gonorrhea. — Venereal  diseases  are  of  great  importance  in  obstetric  practice. 
Acute  gonorrhea  is  commoner  in  primiparse,  being  conveyed  at  the  time  of  impregna- 


LOCAL    DISEASES    ACCIDENTAL   TO    PREGNANCY 


515 


tion.  Unlike  ordinary  cases,  where  the  infhinnnulion  is  Hinited  to  or  most  marked 
in  the  uretlira,  tlie  vulvar  ghmds,  and  the  cervix,  in  pregnancy,  favored  by  the 
succulence  of  the  tissues,  the  gonococcus  attacks  the  vaginal  and  vulvar  epithelium 
in  addition  to  those  mentioned.  Profuse  secretion  of  greenish-yelhnv  pus  results; 
th(>  vulva  is  red,  sometimes  covered  with  grayish  exudate,  sometimes  ulcerated,  or 
covered  with  gonorrheal,  pointed  condylomata;  the  vagina  is  thick  and  granular, 
like  a  nutmeg-grater,  and  bleetls  even  on  light  touch;  the  cervix  is  swollen,  vascular, 
eroded,  easily  vulnerable,  and  emits  a  foul  mucopus  in  which  the  gonococci  are  most 
readily  found.  Chronic  infection  is  the  form  usually  met,  and  it  has  left  the  sur- 
faces, covered  by  sciuamous  epithelium,  to  localize  in  the  urethra,  Skene's  tubules, 
the  crypts  around  the  hymen,  tiie  Bartholinian  ducts  and  glands,  and  the  cervix, 


//. 


':•  'fi  i'k  //'  i.  -'  >'•  I  '■■ .  "I  "^"iiff  <f.,i\y,V.  %^l'y7: 


f  ^  y^rf /iVHJ?;,< 


Fig.  452. — Colpitis  Emphysematosa. 


in  which  it  is  recognizable  by  the  usual  signs.  Acute  as  well  as  chronic  gonorrhea 
may  aflfect  the  uterine  decidua  and  produce  abortion,  but,  as  a  rule,  the  gonorrheal 
endometritis  remains  latent  until  after  delivery.  Indeed,  many  women  having  a 
slight  mucopurulent  leukorrhea  are  delivered  wdthout  the  accoucheur  being  aware 
of  the  existence  of  an  infection  until  the  baby's  eyes  show  gonorrheal  ophthalmia. 
Through  the  traumatism  of  labor  the  gonococci  are  pressed  out  of  the  deep  cervical 
glands,  and  by  virtue  of  the  open  cervix  and  the  puerperal  processes,  unlimited  op- 
portunities are  afforded  them  for  further  virulent  development.  As  a  result,  gonor- 
rheal endometritis,  salpingitis,  ovaritis,  and  pelvic  peritonitis  are  set  up,  reference 
to  which  will  be  made  when  treating  of  puerperal  infection.  Acute  infections  are 
likely  to  show  the  exacerbation  in  the  first  days  of  the  puerperium,  because  of  the 
associated  streptococci  and  staphylococci,  while  chronic  gonorrhea  causes  the  "late 


516  THE    PATHOLOGY   OF   PREGNANCY,    LABOR,    AND    THE    PUERPERIUM 

fevers, " — on  the  tenth  to  the  thirtieth  day, — an  ascending  inflammation  which  re- 
sults in  pus-tubes  or  adhesive  obliterating  peritonitis,  leaving  permanent  sterility 
and  gynecologic  invalidism.  Acute  gonorrhea  in  gestation  can  cause  rheumatism, 
with  disorganization  of  the  joints,  wrist,  knee,  hip,  etc.,  or  even  endocarditis  and 
general  septicemia  {q.  v.). 

Diagnosis. — In  maternities,  because  of  the  danger  of  carrying  infection  from 
one  patient  to  another,  it  is  highly  important  to  detect  the  first  case  of  gonorrhea, 
but,  unless  it  is  in  the  florid  stage,  this  is  almost  impossible.  Repeated  bacterio- 
logic  examination  of  the  secretions  is  often  required  for  the  detection  of  the 
gonococcus — one  negative  result  does  not  exclude  it.  The  history  is  valuable.  An 
obstinately  inflamed  single  joint  is  strongly  suggestive.  Ophthalmia  in  the  infant 
does  not  prove  the  existence  of  gonorrhea  in  the  mother  unless  the  gonococcus  be 
found  in  the  pus  and  other  sources  of  infection  of  the  child's  eyes  be  eliminated. 

Treatment  must  always  be  instituted  during  pregnancy,  but,  owing  to  the 
tendency  to  abortion,  gentle  means  are  adopted.  Vaginal  irrigation  morning  and 
evening  with  potassium  permanganate,  1 :  3000,  zinc  permanganate,  1 :  4000,  1  per 
cent,  ichthyol;  painting  the  vagina  with  5  per  cent,  silver  nitrate;  light  packing 
with  2  per  cent,  protargol  gauze,  removed  after  twenty-four  hours — will  usually 
quickly  reduce  the  disease  to  its  chronic  state.  Should  abortion  occur,,  curetage 
is  not  to  be  undertaken  if  it  is  at  all  avoidable. 

During  labor  in  cases  of  known  gonorrhea  the  vagina  should  be  douched  every 
four  hours  with  a  weak  antiseptic  solution,  for  example,  1  per  cent,  lysol,  vaginal 
explorations  and  operations  limited  to  an  irreducible  minimum,  the  bag  of  waters 
saved,  if  possible,  until  the  child's  head  is  fully  born,  and  every  precaution  taken  to 
prevent  the  entrance  of  vaginal  mucus  into  the  conjunctival  sacs.  During  the 
puerperium  no  douches  may  be  given,  and  the  woman  should  be  kept  in  bed  fully 
eighteen  days — Bumm  says  five  to  six  weeks, — that  is,  until  the  involution  of  the 
uterus  is  complete, — this  to  prevent  the  ascension  of  the  infection  through  the 
uterus  to  the  tubes. 

Erosions  and  hypertrophy  of  the  cervix  are  not  infrequent,  and  since  the  soft- 
ened vascular  structure  bleeds  readily,  the  flowing  may  give  rise  to  the  suspicion  of 
abortion.  The  author  has  twice  seen  a  nodular  hypertrophy  of  the  cervix  with  ec- 
tropion and  cystic  degeneration  of  the  glands,  which  to  the  touch  resembled  can- 
cer, but  which  subsided  almost  entirely  after  delivery.  Erosions  during  pregnancy 
are  treated  by  irrigation  with  1  :  3000  potassium  permanganate  and  application 
of  10  per  cent,  silver  nitrate  to  the  patches  thrice  weekly.  Rest  in  bed  aids  the 
treatment  and  prevents  hemorrhage. 

Endometritis  Deciduae. — Acute  endometritis  frequently  accompanies  the  in- 
fectious diseases,  scarlet  fever,  typhoid,  cholera,  etc.  It  may  occur  as  the  result  of 
attempts  at  criminal  or  even  therapeutic  abortion.  In  one  of  my  cases  it  was  evi- 
dently due  to  external  infection  through  a  very  patulous  cervix,  perhaps  by  coitus. 
Gonorrhea  may  cause  it,  there  sometimes  being  tiny  abscesses  containing  gonococci 
in  the  decidua.  Abortion  is  probably  often  the  result  of  gonorrhea,  acute  and 
chronic.  Pus  may  accumulate  in  the  decidua  and  be  expelled  during  labor.  In 
two  of  my  cases  a  discharge  of  pus  from  the  uterus  followed  the  child,  no  complica- 
tion resulting. 

Chronic  endometritis  is  not  so  common  as  was  formerly  thought.  Hitschmann 
and  Adler  have  conclusively  shown  that  many  of  the  cases  of  so-called  glandular 
hypertrophic  and  hyperplastic  endometritis  are  only  the  normal  menstrual  changes 
of  the  uterus.  Interstitial  (mdometritis  may  be  accompanied  l^y  a  hyperplasia  of 
the  glands,  but  unless  the  "exudate  cells,"  especially  the  ''plasma"  cells,  are  found, 
one  may  not  diagnose  endometritis.  Chronic  endometritis  is  most  often  the  result 
of  gonorrhea,  next  of  abortion,  then  of  displacements  and  lacerations  of  the  uterus. 
These  last  predispose  to  infection  of  the  uterine  mucosa,  and  Albert  proves  that 


LOCAL   DISEASES    ACCIDENTAL   TO    PREGNANCY 


517 


Polypoid  heinorrliagie  dccidua 


there  is  a  latent  microbic  endoniotriti.s.  liic};ular  livinji;,  c(nisestions  during  men- 
struation, sexual  excess,  abnornuil  sexual  practices,  traumatism  and  infection  at 
childbirth,  retention  of  pieces  of  iiunibrane,  but  especially  gonorrhea  and  abortion, 
cause  endometritis.  The  classifications  of  the  various  forms  arc  not  fully  satis- 
factory, even  to  the  gynecologists. 

During  pregnancy  the  ])athologic  study  of  the  uterine  mucosa  is  doubly  diffi- 
cult, and  without  doubt  needs  reinvestigation  with  modern  methods.  Most  authors 
distinguish  two  main  conditions — endonu^tritis  decidua?  interstitialis  and  glandularis. 
The  inflammation  is  usually  ])reseiit  l)efore  conception,  l)ut  may  arise  during  preg- 
nancy, for  exami)le,  from  a  syphilitic  ovum  or  from  gonorrhea.  Fig.  4."))^  shows  a 
piece  of  decidua  vera  expelled  in  an  abortion  at  ten  weeks.  It  is  thickened,  infil- 
trated with  round-cells,  degenerated  in  places,  strewn  with  minute  hemorrhages, 
and  shows  a  lunipj^,  uneven, 
polj'poid  surface.  \'ircliow 
first  describ(Hl  it  as  endo- 
metritis deciduae  tuberosa 
or  polyposa,  or  both.  The 
glands  may  hypertroi)liy 
also,  while  sometimes  atro- 
phic areas  are  found.  Syph- 
ilis may  occasionally  cause 
such  changes. 

If  the  glands  are  af- 
fected, either  l\y  hypertro- 
phy or  by  inflanmiatory  hy- 
peremia, a  profuse  secretion 
results,  which  is  yellowdsh, 
serous,  slightly  mucous  or 
bloody.  Schroder  called 
this  endometritis  deciduae 
catarrhalis,  which  may 
give  the  clinical  course 
of  hydrorrhcea  gravidarum. 
Should  the  mouths  of  the 
glands  be  occluded,  cysts 
containing  a  milky  fluid 
form  in  tliem— the  endo- 
metritis dcciduae  cystica  of 
Breus.  It  is  possible  that 
many  of  the  specimens 
called  by  the  older  writers 

decidua  with  "uterine  milk"  were  of  this  nature.  Endometritis  deciduse  is  of  great 
clinical  importance.  It  causes  relative  sterility,  frequent  al^ortion,  and,  since  abor- 
tion often  leaves  endometritis,  a  vicious  circle  is  established— abnormal  insertion  of 
the  ovum  (for  example,  placenta  prsevia),  abnormal  formation  as  to  shape,  size, 
and  thickness  of  the  placenta,  infarcts,  retarded  development  of  the  fetus,  abruptio 
placenta?,  and  thickening  and  retention  of  the  decidua.  During  pregnancy  one 
may  find  pain  in  the  uterus;  aggravation  of  the  sympathetic  cUsturbances,  espe- 
cially hyperemesis;  painful  uterine  contractions,  sometimes  called  "rheumatism 
of  the  uterus,"  particularly  at  or  near  term;  local  tenderness,  and,  in  the  more 
acute  cases,  slight  fever,  malaise,  and  bloody  discharge,  which  arouses  a  suspicion  of 
abortion.  Much  depends  on  the  location  of  the  chsease  and  the  extent  and  time  of 
its  occurrence.  If  the  decidua  serotina  is  involved,  early  death  of  the  fetus  and 
abortion  occur,  but  if  the  affection  is  mild,  pregnancy  may  go  to  term,  and  one  will 


Fia.  453. — Endometritis  Decidia  Tiberosa  Polyposa. 


518      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

note  only  anomalies  in  the  mechanism  of  placental  separation,  perhaps  placenta 
acereta.  The  earlier  the  disease  manifests  itself,  and  the  greater  its  extent,  the 
more  the  likelihood  of  abortion.  The  ovum  may  be  transformed  into  a  bloody  or 
fleshy  mole. 

Chronic  endometritis  affects  the  course  of  labor.  Since  usually  the  muscle  of 
the  uterus  is  involved,  weak  or  painful  pains  are  noted.  Premature  rupture  of  the 
membranes,  hemorrhages  into  the  decidua,  sometimes  at  the  placental  site,  with 
abruptio  placentae,  abnormalities  in  the  mechanism  of  the  third  stage,  atonia  uteri, 
from  myometritis,  retention  of  bits  of  placenta  or  membrane — all  these  may  require 
obstetric  interference.  Pieces  of  thick,  hard,  cheesy  decidua  may  remain  in  the 
uterus  after  the  placental  deUvery  and  keep  up  a  prolonged,  even  dangerous,  oozing, 
requiring  manual  removal,  the  same  being  true  of  the  firm  blood-clots  which 
usually  surround  them.  If  these  foreign  matters  are  allowed  to  come  away  in  the 
puerperium,  they  cause  profuse,  prolonged,  bloody,  sometimes  fetid,  lochia,  occa- 
sionallj'  slight  fever,  and  always  delayed  involution. 

Evidences  of  endometritis  on  the  placenta  are :  Thickened  serotina,  which  may 
be  quite  opaque  and  ragged  in  places;  vascularization  of  the  margin  of  the  closing 
plate  of  Winkler,  which  may  extend  some  distance  under  the  membranes.  One 
may  see  arteries  and  veins  running  in  the  thick  decidua  vera  for  two  to  four  inches. 

The  maternal  surface  may  be  rough,  sometimes  hard,  and  there  are  numerous 
white  infarcts.  The  contour  of  the  placenta  may  be  irregular,  as  if  it  grew  easier  in 
one  direction  than  another;  there  is  a  tendency  to  the  formation  of  placenta  suc- 
centuriata,  and  placentula  succenturiata,  also  velamentous  insertion  of  the  cord. 
When  the  serotina,  through  chronic  inflammation,  or  because  of  lost  tissue  through 
previous  operations  or  disease,  cannot  react  with  sufficient  decidua,  the  villi  bore 
into  the  uterine  wall  and  the  placenta  is  adherent  to  the  musculature — placenta 
acereta.     (See  Postpartum  Hemorrhage.) 

Diagnosis. — The  diagnosis  may  be  suspected  during  pregnancy,  but  even  when 
the  symptoms,  as  given,  are  present,  a  certain  diagnosis  may  be  made  only  post- 
partum. If  the  condition  is  suspected,  appropriate  treatment  must  be  instituted 
for  the  prevention  of  the  evil  effects,  for  example,  placenta  prsevia,  premature  de- 
tachment of  placenta,  postpartum  hemorrhage,  premature  labor. 

Treatment. — Prophylactically,  much  can  be  done  to  prevent  endometritis  in  the 
early  cure  of  gonorrhea,  the  proper  care  of  abortion,  the  prevention  of  sepsis,  etc. 
Repeated  abortions  due  to  endometritis  may  sometimes  be  prevented  by  curetage. 
Bier's  suction  treatment,  etc.,  not  omitting  general  hygienic  measures.  During 
pregnancy  no  treatment  will  reach  the  diseased  part  unless  the  latter  be  syphilitic, 
and  here  the  appropriate  drugs  are  to  be  exhibited.  It  is  my  custom  to  give  all 
such  patients,  whether  syphilitic  or  not,  tonic  doses  of  mercury — ^-^  grain  of  corro- 
sive suljlimate  in  ta?jlet  three  times  daily.  If  pallor  and  general  asthenia  are 
present,  minute  doses  of  arsenic  and  iron  are  added.     Lomer  uses  potassium  iodid. 

Hydrorrhoea  Gravidarum. — ^A  periodic,  or  at  least  intermittent,  discharge  of 
clear,  yellowish,  or  sometimes  bloody  fluid  from  the  uterus  has  been  given  this 
name,  and  the  cause  is  almost  always  endometritis  dcciduae  catarrhalis,  but  similar 
fluids  may  issue  from  the  uterus — first,  from  the  space  l^etween  the  chorion  and 
amnion,  and,  second,  from  the  amniotic  cavity  itself,  that  is,  liquor  amnii  may 
escape.  In  typical  hydrorrhea  the  catarrhal  secretion  accumulates  between  the 
vera  and  reflexa,  and  periodically  breaks  through  the  mucous  plug  which  fills  the 
cervix,  or  there  may  be  a  continuous  dribbling.  As  much  as  a  pint  may,  but  rarely, 
accumulate,  and  the  expulsion  of  such  an  amount  often  provokes  abortion  or  pre- 
mature lah)or.  The  disease  is  most  common  from  the  third  to  the  sixth  month,  but 
may  begin  or  continue  in  the  last  trimester.  The  pathology  is  not  fully  understood, 
except  that  an  endometritis  deciduse  is  usually  back  of  it.  It  occurs  in  anemic  and 
sickly  women,  especially  multiparjE,  and  may,  if  slight,  be  overlooked. 


LOCAL    DISEASES    ACCIDENTAL   TO    PREGNANCY  519 

In  the  differential  diagnosis  rupture  of  the  bag  of  waters,  rupture  of  the  chorion, 
and  the  escape  of  subchorionic  fluid  and  hydrorrhea  are  to  be  considered.  The 
latter  two  cannot  be  distinguished  from  each  other,  but  liquor  amnii  can  often  be 
recognized  by  the  fiocculi  of  vernix  caseosa,  if  late  in  pregnancy,  by  the  laiiug(j  hairs, 
and  soniftiuu's  \)y  niecijuiuni.  Usually  it  is  impossible  to  make  the  diagnosis,  and 
in  all  cases  the  patient  is  treated  as  if  she  were  threatened  with  abortion. 

Formerly  it  was  held  that  if  the  ovular  sac  opened  and  the  liquor  amnii  drained 
away,  the  uterus  would  inevitably  empty  itself  within  a  short  period.  For  the 
vast  majority  of  cases  this  is  true,  but  sometimes  the  membranes,  after  rupture, 
shrink  up,  leaving  the  fetus  in  the  uterus,  but  outside  of  the  chorion.  Development 
of  the  child  is  much  hindered;  it  is  puny,  shrunken,  with  many  of  its  joints  anky- 
lotic,  and  showing  decubitus  over  bony  prominences.  In  addition  to  this  form,  or 
graviditas  exochorialis,  another  variety  exists:  the  amnion  breaks,  but  the  chorion 
tloes  not,  and  the  shrunken  amnion  is  found  hanging  around  the  insertion  of  the  cord, 
but  the  chorion  is  intact — graviditas  examnialis. 

Endometritis  Syphilitica. — This  was  considered  under  Syphilis  (p.  483). 

Bacterial  Endometritis. — Gonorrheal  endometritis  has  already  been  mentioned, 
as  also  have  the  acute  processes  which  complicate  the  infectious  diseases.  Tuber- 
cular endometritis  may  occur  in  consumptives  and  in  miliary  tuberculosis.  In 
one  of  my  cases  a  tubercular  peritonitis  developed  acutely,  after  a  physician,  a 
sufferer  from  phthisis,  had  cureted  the  patient  without  sterilizing  his  instruments. 
Streptococci,  staphylococci,  and  Bacterium  coli  commune  (author)  have  been 
demonstrated  in  the  uterine  decidua,  and,  in  addition,  other  unidentified  kinds. 
It  is  generally  held  that  while  the  vagina  may  harbor  pathogenic  bacteria,  they  live 
a  saprophytic  existence  there  and  do  not  wander  up  into  the  uterus.  A  few  authors 
believe  that,  under  favorable  circumstances,  such  a  transference  of  infection  may 
occur,  and  to  me  this  appears  very  probable.  Clinical  experience  points  to  it — 
for  example: 

Mrs.  W.,  aged  thirty-six,  quartipara,  four  months  pregnant,  with  large,  patulous  os,  sickens 
with  fever,  chills,  and  general  evidences  of  serious  disease,  but  with  the  single  local  finding,  a  shght 
fetid  vaginal  discharge.  Attempts  at  criminal  abortion  absolutely  excluded:  patient  desired  this 
child,  having  arranged  the  time  of  coitus.  Curetage  showed  the  decidua  in  lower  portion  of  the 
uterus,  gra}^  discolored,  and  soft.     After  operation,  chill  and  sharp  fever,  which  subsided  gradually. 

INIrs.  C.,  multipara  at  term.  On  complete  dilatation  of  the  cervix  the  membranes  were 
ruptured  and  a  quart  of  unbearably  fetid,  thin,  meconium-stained,  gray-green  liquor  amnii  escaped. 
Delivery  normal;  puerperium  normal;  child  survived.  In  another  similar  case  the  child  suffered 
from  fever  and  severe  icterus  for  weeks. 

While  in  the  latter  instances  a  hematogenic  infection  of  the  liquor  amnii  may 
be  assumed,  in  the  first  one  the  bacteria  were  surely  introduced  from  the  cervix. 
It  is  certain  that  germs  can  permeate  the  membranes,  both  from  the  cervix  and  from 
the  uterine  wall,  as  in  adherent  appendiceal  abscesses. 

Under  this  caption  should  be  briefly  mentioned  the  fever  of  pregnancy.  No  one 
believes  that  the  processes  of  pregnancy  are  ever  normally  attended  by  fever,  Seitz 
collected  numerous  cases  which  tend  to  show  that  a  bacterial  endometritis  can  cause 
fever  during  pregnancy,  subsiding  when  the  uterus  is  emptied.  Uterine  pain, 
tenderness,  even  local  peritonitic  symptoms  were  present  in  a  few  of  the  cases; 
repeated  abortion  with  bacteria  in  the  decidua;  eclampsia,  hj^peremesis,  in  others. 
Coitus  carries  feces  and  other  contamination  into  the  vagina,  and  it  is  more  than 
probable  that  infection  of  the  ovum  frequently  thus  takes  place,  vnth  consecutive 
abortion,  which  may  or  may  not  be  followed  l\v  general  sepsis.  If  Albert  is  correct, 
that  a  microbic  endometritis  can  cause  eclampsia,  it  is  now  easy  to  ex^^lain  why 
eclamptics  are  so  prone  to  puerperal  infection  in  spite  of  most  rigorous  asepsis  and 
antisepsis.  Evidently,  here  is  a  fertile  and  unexplored  field,  but  this  much  is  to  be 
said — a  most  thorough  and  painstaking  general  examination  must  be  made,  and  a 


520      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

diagnosis  of  bacterial  endometritis  may  be  reached  only  by  exclusion.  The  rela- 
tion, of  such  infections  to  puerperal  fever  will  be  taken  up  later. 

Salpingitis  causes  sterility  because  it  is  almost  always  bilateral  and  occlusive. 
Chronic  tubal  inflammation  may  heal,  but  the  folds  of  the  mucosa  have  usually 
become  glued  together,  and  this  is  a  frequent  cause  of  ectopic  gestation.  Double 
pus-tubes,  of  course,  preclude  pregnancy,  but  sometimes  a  pus-tube  forms  after 
conception  has  occurred,  the  woman  having  been  infected  and  impregnated  at  the 
same  time.  In  rare  cases  a  tube  adherent  to  a  gangrenous  appendix  may  become 
infected.  Acute  salpingitis  is  a  very  serious  complication  of  gestation,  and  without 
doubt  is  the  hidden  cause  of  numerous  cases  of  sepsis  intrapartum  and  postpartum. 
During  gestation  the  diagnosis  is  almost  impossible ;  a  peritonitis  will  be  assumed, 
and  if  the  symptoms  are  urgent,  laparotomy  will  have  to  be  performed.  During 
pregnancy  a  departure  should  be  made  from  the  method  of  treatment  of  pyosalpinx. 
Labor  will  almost  certainly  rupture  the  abscesses,  and  it  is,  therefore,  best  to  re- 
move the  sacs.  It  is  a  question  whether  it  is  advisable  to  wait  for  the  contents  to 
become  sterile.  If  at  operation  there  is  reason  to  believe  that  the  streptococcus  is 
associated  with  the  gonococcus,  it  may  be  wisest  to  extirpate  the  uterus  at  the  same 
time  that  the  tubes  are  removed,  but  the  prognosis  is  bad  in  such  cases. 

Peritonitis  in  pregnancy  arises  from  appendicitis  or  salpingitis,  rupture  of  the 
infected  bladder  in  uterine  incarceration,  from  necrosing  fibroids,  infected  ectopic 
gestation-sacs,  twisted  ovarian  tumors,  and  after  attempts  at  criminal  abortion. 
In  many  autopsies  performed  by  the  coroners  catheters,  knitting-needles,  hat-pins, 
etc.,  have  been  found  in  the  belly,  usually  embedded  in  pus. 

Tuberculosis  of  the  peritoneum  practically  always  causes  sterility.  It  is  of 
special  interest  from  the  standpoint  of  differential  diagnosis  from  pregnancy,  many 
grievous  mistakes  having  been  made.  Montgomery  relates  the  sad  case  of  a  refined 
English  woman  who  fled  to  America  to  escape  the  gossip  of  her  former  friends  about 
her  growing  abdomen,  and  at  the  autopsy,  held  in  New  York,  the  finding  of  a 
tubercular  peritonitis  justified  her  oft-repeated  assertion  of  innocence. 

Rupture  of  an  extra-uterine  pregnancy  may  simulate  an  acute  peritonitis,  and 
there  may  be  even  fever  of  102°  to  103°  F.  to  render  the  diagnosis  difficult.  In  all 
cases  of  acute  peritonitis  in  early  pregnancy  criminal  practices  are  first  to  be  thought 
of,  and  the  abdomen  is  to  be  opened  at  once. 

Chronic  peritonitic  adhesions  have  already  been  considered  in  connection  with 
distortions  and  displacements  of  the  uterus.  Pregnancy,  by  the  softening  and 
vascularization  of  such  bands,  may  be  actually  curative,  the  rising  uterus  stretching 
and  breaking  them.  This  process  may  be  attended  by  more  or  less  pain,  and  in  one 
such  case  the  author  had  to  prescribe  rest  in  bed  and  opiates.  Labor  in  such  pa- 
tients may  be  slow  and  tedious.  It  is  believed  that  "missed  labor"  occurs  more 
often  under  these  conditions. 

Literature 

Ahlfeld:  Die  Missbildungen  des  Menschen. — Albert:  Arch.  f.  G.vn.,  1901,  vol.  Ixiii,  H.  3,  p.  4S7. — Cushing:  Annals  of 
Gyn.  and  Pcd.,  1898,  vol.  xi.  No.  7,  p.  518. — Enfjstrom:  Mittheilungen  aus  der  Gyn.  Klinik,  Berlin,  vol.  iii.  Heft 
2. — Hilschmann  and  Adler:  Zeitschr.  f .  Geb.  u.  Gyn.,  1907,  vol.  Ix,  p.  6.3. — Kehrer,  E.:  Inaug.  Diss.,  Heidelberg, 
1899. — Lindenlhal:  Zeitschr.  f.  Geb.  u.  Gyn.,  No.  40. — Lomer:  Zeitschr.  f.  Geb.  u.  Gyn.,  1901,  vol.  xlvi.  Heft  2, 
p.  300. — Mundk:  Amer.  Jour.  Obstct.,  1893,  vol.  xxviii. — Santos:  Zeitschr.  f.  Geb.  u.  Gyn.,  vol.  xiv.  Literature. 
— Seitz:  Handbuch  der  Geb.,  v.  Winckcl,  vol.  ii,  1904,  2,  p.  1111. — Wells,  Brooks:  Amer.  Jour.  Obstet.,  1900, 
vol.  xli,  p.  321.     Literature. 


CTTAPTEE   XLTT 

PREGNANCY  COMPLICATED  BY  NEOPLASMS 

Tumors  in  and  near  the  uterus  may  cause  serious  trouhlo  before,  during,  and 
after  delivery,  though  of  late  years  tlic  cases  are  not  so  frecjuent  nor  so  forniicUible 
as  formerly,  l)ecaus(>  most  of  the  tumors  are  removed  when  found,  and,  further, 
owing  to  modern  asepsis,  infections  are  almost  always  avoided,  and  operations  dur- 
ing lal)or  more  successful. 

FIBROIDS 

The  effects  of  pregnancy  on  myomata  are  well  known  and  appreciated.  It  is 
not  believed  that  the  changes  incident  to  gestation  directly  cause  myomatous  forma- 
tions, though  perhaps  the  infections  postpartum  may  lay  the  foundation  for  their 


Long-drawn-out  uterine  cavity 
Line  of  amputation 


Fig.  454. — Fibroids  axd  Early  Pregn.\.nct,  Mrs.  G. 
Tertipara.     Excessive  pain  and  irregular  hemorrhages  during  the  first  months  of  pregnancy.     Supravaginal  ampu- 
tation of  the  uterus.     One  ovary  left.     Cyst  developed  in  it  two  years  later. 


future  development.  During  pregnancy  fibroids  which  were  not  noticeable  l:)efore 
take  part  in  the  general  succulence  and  hypertrophy  of  the  uterine  muscle,  enlarge, 
and  are  discovered.  Larger  fibromata,  especially  if  located  in  the  pelvis,  may  grow 
so  much  that  incarceration  and  dangerous  compression  of  the  pelvic  organs  result. 
Aside  from  hypertrophy,  hyperplasia,  and  the  increased  vascularity  of  the  tumor, 
cystic  and  other  degenerations,  and  in  rare  instances  suppuration  and  gangrene, 
may  occur.  The  so-called  red  degeneration  is  one  of  the  most  serious.  Peritoneal 
irritation,  even  adhesions,  in  the  absence  of  gangrene,  are  sometimes  caused. 
Another  result  of  pregnancy  is  the  dislocation  and  change  of  shape  of  the  tumors. 
Myomata  attached  to  the  cervix  respond  to  the  upward  traction  of  the  fundus  uteri 

521 


522 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


and  rise  into  the  abdomen,  which  is  fortunate,  because  otherwise  they  would  block 
delivery.  This  retraction  of  the  tumor  above  the  brim  may  occur  even  during 
labor,  and  the  accoucheur  may  be  most  agreeably  surprised  to  find  what  promised 
to  be  a  formidable  case  become  a  simple  matter.  The  fibroid  may  be  flattened  by 
the  growing  ovum,  or,  if  there  are  several  tumors,  they  may  be  separated  from  each 
other.  Subserous  myomata  may  become  twisted  and  necrose,  or  they  may  pro- 
lapse into  the  pelvis;  interstitial  tumors  usually  become  more  superficial;  sub- 
mucous fibroids  are  likely  to  become  polypoid  and  may  then  be  extruded  through 
the  cervix  during  the  puerperium.  During  labor  the  fibroids  may  be  crushed  by 
the  advancing  head,  by  attempts  at  delivery,  or  by  too  strong  "Crede"  expression. 
In  the  puerperium  myomata  usually  undergo  involution  with  the  rest  of  the  uterus. 


Fig.  455. — Mrs.  K.     Mural  Cervical  Fibroids  at  Beginning  of  Labor. 


Many  authors  report  the  total  disappearance  of  the  tumors  as  the  result  of  involution, 
but  I  have  not  observed  it  in  the  few  cases  I  have  been  able  to  follow  up,  the  tumors 
all  having  been  found  as  large  as,  or  even  larger  than,  they  were  before  pregnancy, 
though  smaller  than  they  were  during  gestation.  Landau  says  the  same.  Necrosis 
and  infection  of  the  tumors  occur,  but  this  accident  is  unusual,  is  favored  by  immense 
size  of  the  growth,  by  bruising  during  delivery,  but  particularly  by  infection,  which 
is  invited  by  the  wounding  of  the  endometrium  over  the  tumor.  The  fibroid  may 
be  converted  into  a  necrotic,  purulent  mass  which  breaks  into  the  bladder  or  dis- 
charges per  vaginam,  a  cure  thus  l)oing  effected.  Sometimes  the  uterine  contractions 
deliver  the  tumor  outside  the  cervix  or  vulva,  the  capsule  breaks,  and  the  myoma 
escapes  through  the  rent,  but  more  often  gangrene  sets  in,  requiring  operation. 
The  influence  of  pregnancy  on  the  symptoms  caused  by  myomata  is  also  one  of 


PREGNANCY    COMPLICATED    HY    NEOPLASMS 


323 


ap;gravation.  Pain  was  marked  in  ail  my  cases,  iicmonliasc,  sinmlatinj;  tlircatoned 
abortion,  in  one.  If  tiie  tumor  is  large,  the  symptoms  of  abdominal  overdistontion 
result,  t()}>;etlier  with  wasting;  and  even  eachexia. 

The  efteets  of  tlie  fibromata  on  the  i)reKnaney  are  very  variable.  Women  \^^th 
such  tumors  arc  frequently  sterile,  and  though  Martin  says  this  is  not  true,  larger 
statistics  seem  to  prove  it.  Abortion  is  more  apt  to  occur,  especially  with  the  sub- 
mucous varieties.  The  interstitial  have  less  influence,  and  the  subserous,  unless  large 
or  near  the  cervix,  hardly  any.  Placenta  prjjevia  seems  to  be  favored  by  the  pres- 
ence of  uterine  tumors,  probably  through  the  concomitant  endometritis  or  edema. 
Retroflexio  uteri  gravidi,  with  incarceration,  has  been  noted.  In  labor  the  fibroids 
usually  do  not  give  trouble  unless  impacted  or  adherent  in  the  pelvis,  or  unless  the 


Fig.  450. — Mrs.  K.     Same  Fibroids  after  Complete  Dilatation  of  the  Cervix. 


placenta  has  attached  itself  to  the  tumor.  A  subserous  impacted  myoma  causes 
the  worst  trouble,  because  it  is  less  likely  to  be  elevated  by  the  contracting  and  re- 
tracting uterus  (Figs.  456  and  457).  Interstitial  tumors  may  be  flattened  against 
the  wall  of  the  pelvis,  so  that  they  allow  the  child  to  pass;  they  may  be  retracted 
upward,  or,  if  low  in  the  cervix,  they  may  be  pushed  out  of  the  vulva,  even  delivered 
free,  thus  permitting  the  birth  of  the  child.  The  last  occurrence  is  more  likely  Anth 
fibroid  pol\']:)i.  Fibromyomata  exert  an  influence  on  the  mechanism  of  labor.  The 
pains  are  usually  strong;  indeed,  when  delivery  is  blocked  by  the  tumor,  rupture  of 
the  uterus  may  ensue;  on  the  other  hand,  weak  pains,  even  atony,  may  be  present; 
abnormalities  of  position  and  presentation,  face,  forehead,  breech,  shoulder,  are 
prone  to  occur;  prolapse  of  the  cord,  interlocking  of  the  fetus  and  the  tumor,  and 
inversion  of  the  uterus  have  also  been  noted. 


524      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

In  the  third  stage  hemorrhage  is  very  common  because  the  distorted  uterus 
has  difficulty  in  closing  the  vessels  of  the  placental  site.  Anomalies  in  the  separa- 
tion of  the  placenta  are  especially  apt  to  occur  when  it  is  located  on  the  tumor, 
since  pathogenic  adherence  is  the  rule  in  such  cases.  If  the  uterine  canal  is  kinked, 
the  placenta  may  be  incarcerated,  and  even  the  best  operator  may  not  be  able  to 
remove  it. 

During  the  puerperium  fibroids  may  obstruct  the  lochial  flow  and  cause  lochio- 
metra;  they  always  delay  involution;  they  predispose  to  phlebothrombosis ,  and 
when  they  are  infected,  the  worst  forms  of  sepsis  may  result. 

Diagnosis. — Most  complicated  diagnostic  problems  are  here  presented  to  the 


Fig.  457. — Subserous  Myoma  in  Pelvis.     Removed  through  Posterior  Colpotomy. 

obstetrician,  and  mistakes  witliout  number  have  been  made.  If  a  woman  who  is 
known  to  have  myomata  becomes  pregnant,  the  diagnosis  is  not  difficult  and  will  rest 
on  some  of  these  points:  Cessation  or  irregularity  of  the  menses;  the  sympathetic 
symptoms  and  breast  signs;  the  rapid  enlargement  of  the  uterine  tumor;  the  develop- 
ment on  it  of  a  soft  area;  the  contractions  of  the  uterine  tumor;  and,  in  the  second 
trimester,  the  fetal  heart-tones.  All  these  may  be  equivocal  except  the  last,  and  even 
the  fetal  heart  may  be  inaudible  because  covered  by  an  immense  tumor.  If  the  diag- 
nosis of  the  existing  pregnancy  is  made,  it  is  usually  easy  to  determine  that  there 
are  fibroids  in  addition,  but  here,  too,  mistakes  have  occurred,  a  twin,  an  ovarian 
tumor,  pyosalpinx,  abdominal  wall  fibromata,  fat,  etc.,  having  been  taken  for 
uterine  tumors.     During  delivery  the  myomatous  nodules  are  made  prominent  when 


PREGNANCY    COMPLICATED    BY    NEOPLASMS  525 

the  uterus  hardens,  and  unless  liidden  Ix^hind  the  uterus,  are  almost  always  dis- 
coverable. They  may  be  mistaken  for  other  tumors  or  a  second  child.  Forceps 
have  been  a[)plied  to  a  myoma  which  imposed  as  a  fetal  head.  If  located  in  a  posi- 
tion which  causes  interference  with  the  mechanism  of  labor,  new  i)roblems  are  pre- 
sented for  diagnosis.  When  the  uterus  is  emptied,  its  large  size  and  the  presence 
of  nodules  will  easily  indicate  the  trouble,  though  on  one  such  occasion  six  talented 
gynecologists,  from  external  examination,  diagnosed  a  second  twin.  In  the  puer- 
perium  the  fundus  remains  high,  involution  proceeding  very  slowly.  Infection 
of  the  tumor  is  announced  by  the  usual  signs  of  sepsis. 

The  differential  diagnosis  between  a  large  symmetric  interstitial  fibroid  and 
{)regnancy  is  sometimes  one  of  the  most  difficult  to  make.  Times  innumerable  the 
belly  has  been  opened  and  only  the  normal  pregnant  uterus  found,  and,  indeed,  it 
may  be  almost  impossible  to  distinguish  the  two,  even  after  the  tumor  is  out  of  the 
belly,  in  the  liantls  of  the  operator. 

In  such  a  case  much  weight  is  to  be  placed  on  careful  and  repeated  examinations 
made  before  operation: 

Myoma  Pregnancy 

1.  Symptoms,  as  nausea,  etc.,  usually  absent.         1.  Present. 

2.  Alenses  present;  breast  signs  almost  always      2.  Menses  absent;  breast  signs  present. 

absent. 

3.  Uterine  tumor  usually  asymmetric  or  nod-      3.  Usually  symmetric  or  characteristically  de- 

ular.  formed. 

4.  Tumor  usually  hard.  4.  Soft. 

5.  Contractions  of  the  tumor  excessively  rare.  5.  Usual  and  involve  the  whole  organ. 

6.  Round  ligaments,  tubes,  and  ovaries  anomal-  6.  Normally  placed. 

ously  located. 

7.  Cervix  retracted,  high  in  pehns,  hard,  and  a      7.  Cer\ax  low  in  the  pehns,  large,  soft,  and  part 

sort  of  appendix  to  the  tumor.  of  the  uterine  wall. 

8.  Auscultatory  signs  of  pregnancy  absent.  S.  Almost  always  present. 

9.  X-T&y  negative  unless  tumor  is  calcareous.        9.  May  outline  skeleton  of  fetus. 

After  the  belly  is  opened,  the  differential  diagnosis  is  made  by  the  darker  color 
of  the  pregnant  uterus,  the  congested,  thickened  tubes  and  ligaments,  the  presence 
of  a  large  corpus  luteum  in  one  ovary,  ballottement,  the  contractions  of  the  tumor, 
which  molds  itself  on  the  promontory,  while  a  fibroid  is  usually  lighter  in  color, 
rocks  heavily  on  the  promontory,  is  as3anmetric,  and  the  experienced  operator 
usually  can  determine  from  the  feel  whether  or  not  a  pregnancy  exists.  If  the  doubt 
cannot  be  dispelled,  it  is  justifiable  very  slowly  to  cut  into  the  tumor,  layer  by  layer, 
and,  should  an  ovum  be  discovered,  unless  other  indications  exist,  the  wound  is  to 
be  immediately  sutured  and  the  belly  closed.  Pregnancy  is  usually  not  interrupted 
by  the  exploratory  operation. 

Prognosis. — Without  doubt  the  dangers  of  myomata  complicating  pregnancy 
are  misrepresented  by  the  reports,  which  is  due  to  the  fact  that  only  the  bad  cases 
are  considered  worthy  of  publication.  Wertheim,  in  quoting,  gives  a  mortality  of 
50  per  cent,  for  the  mothers  and  57  to  66  per  cent,  for  the  children,  and,  in  addition, 
30  per  cent,  of  abortions.  These  figures  are  decidedly  too  high.  Unless  the  tumor 
obstructs  delivery,  recover}^  is  the  rule,  but  the  fetus  is  more  endangered. 

Treatment  in  Early  Pregnancy. — Since  the  majority  of  pregnant  women  with 
fibroids  go  to  and  througli  labor  without  difficulty,  it  is  almost  never  necessary 
to  induce  abortion  on  their  account.  Indeed,  the  interruption  of  pregnancy  is 
difficult  because  of  the  distortion  of  the  uterine  canal,  and  dangerous  because 
of  the  hemorrhage  and  liability  of  infecting  the  tumors.  Excessive  pain  and  re- 
peated and  profuse  hemorrhages  may  require  treatment,  and  if  ordinarj'  means 
do  not  suffice,  an  operation  may  be  necessary.  It  is  best,  wherever  at  all  possi- 
ble, to  wait  until  term  or  near  it  before  operating.  It  may  even  be  wise  to  try 
the  test  of  labor,  because  nature  sometimes  accomplishes  wonders  in  getting  the 
tumors  out  of  the  way  of  the  child's  delivery.     In  the  absence,  therefore,  of  un- 


526      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

bearable  pain,  of  severe  hemorrhage,  of  very  rapid  growth  (the  "galloping  type" 
of  Pozzi),  of  great  distress  from  overdistention  of  the  belly,  and  of  signs  of  necro- 
sis of  the  tumor,  it  is  justifiable  to  wait  and  watch.  To  assist  nature  in  elevating 
the  tumors  out  of  the  pelvis  the  patient  assumes  the  knee-chest  position  frequently 
every  day.  Myomectomy  has  been  frequently  done  during  pregnancy,  but  it  is  a 
very  bloody  operation,  and  is  followed  by  abortion  in  17  per  cent,  of  cases  (Win- 
ter). Hysterectomy  has  also  been  performed,  sometimes  when  only  enucleation 
of  the  tmnors  was  intended,  but  made  necessary  because  of  technical  difficulties, 
hemorrhages,  etc. 

Near  Term  or  in  Labor. — (a)  Clean  Cases. — Should  the  woman  approach  the 
end  of  her  pregnancy,  a  careful  examination  is  made  to  determine  whether  the  tu- 
mors will  obstruct  labor,  and  it  must  be  borne  in  mind  that  a  degree  of  contraction  of 
the  parturient  passage  caused  by  a  fibroid  is  worse  than  the  same  caused  by  a  con- 
tracted pelvis,  because  of  the  possible  sloughing  of  the  tumor  resulting  from  crushing 
during  spontaneous,  but  especially  operative,  delivery.  Even  during  pregnancy 
gentle  attempts  at  reposition  are  allowable.  Should  a  subserous  or  mural  cervical 
myoma  be  so  large  or  so  firmly  fixed  in  the  pelvis  that  it  apparently  will  completely 
block  delivery,  cesarean  section  is  to  be  performed  as  soon  as  labor  has  declared  itself. 
When  the  patient  is  anesthetized,  it  is  justifiable  to  make  an  attempt  at  manual  re- 
position of  the  tumor.  If  it  succeeds,  labor  is  allowed  to  continue;  if  not,  abdominal 
delivery  is  performed.  After  the  child  and  placenta  are  removed,  an  attempt  is  to  be 
made  to  raise  the  tumor  out  of  the  pelvis  and  to  extirpate  it.  If  this  is  impossible  be- 
cause the  fibroid  is  too  densely  adherent,  or  because  it  has  grown  out  into  the  broad 
ligaments,  the  question  of  total  extirpation  comes  up.  Only  a  skilful  obstetric  sur- 
geon may  attempt  such  an  operation.  Hemorrhage  is  often  profuse.  It  may  be 
wiser  to  leave  the  tumor  for  future  removal.  Drainage  of  the  uterine  cavity  into 
the  vagina  with  gauze  is  to  be  provided. 

(6)  Suspect  Cases. — When  labor  has  been  in  progress  for  a  long  time;  when  the 
woman  is  presumably  infected;  or  where  unsuccessful  attempts  at  delivery  or  re- 
position of  the  tumor  have  been  made — the  condition  becomes  very  formidable. 
Here,  unless  manual  reposition  under  anesthesia  succeeds,  the  abdomen  must  be 
opened.  Now,  if  at  all  possible,  the  tumor  is  to  be  raised  out  of  the  pelvis,  and  de- 
livery from  below  executed  by  an  associate ;  then  supravaginal  amputation  or  total 
extirpation  performed.  If  the  child  is  dead,  it  is  best  to  remove  the  uterus  en  hloc, 
without  opening  it  to  extract  the  child,  the  object  being  to  prevent  the  contact 
of  the  infectious  uterine  contents  with  the  peritoneum.  In  deciding  whether  or 
not  to  remove  the  uterus  it  may  be  necessary  to  consult  the  wishes  of  the  patient 
and  her  husband,  because  if  the  child  is  dead,  they  may  wish  progeny  later.  In 
presumably  infected  cases  the  danger  of  peritonitis  should  be  pointed  out,  and  the 
removal  of  the  uterus  advised  as  a  means  of  reducing  it.  In  clean  cases  the  enuclea- 
tion of  the  tumor  may  be  attempted,  or  even  the  whole  mass  left  for  removal  at  a 
future  labor  or  intermediate  operation. 

(c)  Smaller  tumors  may  be  loft  for  the  test  of  labor,  and,  as  a  rule,  they  will  be 
retracted  or  softened  and  flattened  so  as  to  allow  the  passage  of  the  fetus.  If  they 
are  very  low  in  the  cervix  or  pedunculated,  they  may  be  enucleated  or  amputated 
through  the  vagina.  LaV^or  may  then  b(!  allowed  to  proceed  naturally,  or  if  the 
conditions  are  fulfillod,  delivery  is  efTected.  Enucleation  is  not  to  be  attempted 
unless  the  tumor  is  quite  superficial  and  its  shelling-out  promises  to  be  very  simple, 
because  sometimes  hemorrhage  is  so  profuse  that  the  belly  has  to  be  hurriedly 
opened  to  control  it. 

In  conducting  a  lal)or  with  fibroids  abutting  on  the  parturient  canal  it  is  im- 
portant to  avoid  all  bruising  of  tlie  tumors,  because  necrosis  and  infection  are  so 
liable  to  set  in  afterward.     In  making  a  reposition  of  the  tumor  the  utmost  gentle- 


PREGNANCY    COMPLICATED    BY    NEOPLASMS  527 

noRS  is  to  1)0  pnif'tiscd,  because  its  cujjsule  may  be  ruptured  or  its  pedicle  injured, 
resulting  in  intra-ai)doniinal  hemorrhage  or  shnighing,  witii  subscfjuent  peritonitis. 
In  trying  to  pull  a  fibroid  out  of  the  pelvis  with  the  belly  opened  much  aid  is  afforded 
by  an  associate  pushing  the  tumor  upward  gently  from  below.  If,  now,  the 
delivery  can  be  accomplished  through  tlu^  vagina  and  the  operation  comjjleted 
without  establishing  connection  between  the  peritoneal  cavity  and  the  parturient 
canal,  a  distinct  advantage  is  gained. 

Operations  in  the  uterine  cavity,  as  version  and  manual  removal  of  the  pla- 
centa, may  be  rendered  laborious  by  obstructing  fibroid  tumors,  and  it  may  be 
necessary  to  jiush  uj)  or  even  extirpate  the  masses  l)efore  the  hand  can  be  introduced. 
Removal  of  a  placenta  adherent  to  a  submucous  fibroid  may  refjuire  the  digging- 
out  of  the  two  at  once,  whereby  care  is  observed  not  to  puncture  the  uterus.  In 
such  an  event,  or  if  the  extraction  of  the  placenta  fails,  abdominal  section  would  be 
indicated.  If  not  in  ])osition  to  perform  major  operations,  and  finding  it  impossible 
to  remove  the  placenta,  the  accoucheur  should  pack  the  uterovaginal  canal  firmly 
with  gauze.  After  forty-eight  to  sixty  hours  of  tamponade  the  placenta  will  usually 
be  found  loose  enough  for  easy  delivery. 

During  the  puerjierium,  unless  symptoms  are  present,  the  myomata  are  not 
disturbed.  Ergot  is  Ijest  omitted  unless  the  tumor  is  pedunculating  itself  ready  for 
extrusion  and  the  same  is  to  be  hastened.  Signs  of  gangrene,  fever,  fetid  lochia,  etc., 
repeated  hemorrhages,  and  evidences  of  spontaneous  extrusion  of  the  tumor  may 
require  interference.  In  three  cases  I  was  able  to  enucleate  the  sloughing  tumor 
per  vaginam,  but  in  another  abdominal  extirpation  was  necessary  in  the  sixth  week 
postpartum.  During  a  laparotomy  for  sloughing  fibroids  the  peritoneum  is  to  be 
walled  off  as  carefully  as  at  all  possible,  and  the  cutting  across  of  the  pedicle,  after 
ligation  of  the  broad  ligaments,  done  with  the  Paquelin  cautery.  Drainage  through 
the  vagina  follows.     The  peritoneum  must  not  be  contaminated. 


CARCINOMA  CERVICIS 

Of  10,000  consecutive  obstetric  cases  at  the  Chicago  Lying-in  Hospital  and 
Dispensary,  only  one  was  complicated  by  cancer  of  the  cervix,  and  since  the  service 
here  most  closely  resembles  private  practice,  as  opposed  to  an  exclusive  hospital 
service,  this  may  be  taken  as  a  fair  index  of  the  frequency  of  the  condition,  though 
Sarwey,  combining  many  statistics,  gives  the  ratio  as  1  to  2000  labors,  which  agrees 
with  Kerr's  figures.  To  the  fact  that  cancer  occurs  mostly  in  the  non-reproductive 
period,  we  can  ascribe  its  rarity  as  a  complication  of  pregnancy.  It  occurs 
almost  exclusively  in  multiparse.  It  is  a  most  unfortunate  complication,  since  of 
reported  cases  43  per  cent,  of  the  mothers  and  60  per  cent,  of  the  children  died 
during  labor  (Wertheim). 

The  efTect  of  pregnancy  upon  the  cancer  is  unfavorable.  Rarely  the  growth 
begins  after  conception;  usually  the  pregnancy  supervenes  after  the  cancer  has 
started.  Owing  to  the  vascularization  and  lymphatic  imbibition  of  the  cer\'ix 
caused  by  pregnancy  the  tumor  grows  fast  and  invades  the  lymphatics  and  glands 
very  quickly.  Hemorrhage  and  necrosis,  with  putrid,  sanious  leukorrhea,  are  very 
marked  in  all  cases  except  the  slow-growing  epithelioid  varieties.  Labor  may 
break  up  the  tumor,  the  more  or  less  deep  lacerations  causing  hemorrhage,  sepsis, 
and  rapid  extension  of  the  neoplasm.  In  the  puerperium  the  last-mentioned  changes 
become  evident,  but  the  prostration  and  quick  cachexia  are  most  striking. 

Upon  pregnancy,  labor,  and  the  puerperium  cancer  of  the  cer^'ix  exerts  a  bad 
influence.  In  the  first  place,  sterility  is  the  rule  in  cancer,  especially  in  advanced 
cases,  for  obvious  reasons;  second,  abortion  is  frequent,  because  of  the  endometritis 
usually  present,  the  infection  and  death  of  the  ovum,  the  hemorrhages,  and  the 


528      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

restriction  of  the  g^o^^i;h  of  the  uterus  by  the  neoplasm.  Labor  is  obstructed,  not 
so  much  because  of  the  size  of  tlie  mass,  as  because  of  the  rigicUty  of  the  cervix  pro- 
duced by  the  carcinomatous  infiltration.  If  the  tumor  is  soft  and  takes  up  part  of 
the  cer-vix,  the  rest  may  dilate  and  allow  the  child  to  pass.  If  the  whole  cervix  is 
involved  and  in  a  hard  mass,  ol^struction  is  produced,  and  the  case  is  formidable. 
Placenta  pr8e\da  is  a  not  very  uncommon  complication,  and  because  of  the  fria- 
bility of  the  uterine  wall  near  the  tumor,  rupture  of  the  uterus  may  occur  if  the 
pains  do  not  quickly  succeed  in  overcoming  the  resistant  cervix.  Should  the  cervix 
give  way,  the  tear  maj^  extend  up  into  the  parametrium,  giving  rise  to  terrific  hemor- 
rhages, which,  owdng  to  the  friable  nature  of  the  parts,  cannot  be  stopped  by  suture. 
Missed  labor  has  been  observed,  also  premature  rupture  of  the  membranes,  and 
primary  and  secondarj^  uterine  inertia.  Sepsis  is  common  in  the  puerperium,  and 
a  cancerous  puerpera  is  a  menace  to  other  puerperse  in  the  same  ward. 

Diagnosis. — Every  woman  who  has  irregular  hemorrhages  or  purulent  or 
putrid  leukorrhea  should  be  examined  for  cancer  of  the  uterus,  and  even  if  the  meno- 
pause has  taken  place,  pregnancy  should  be  suspected  when  the  uterus  is  found  en- 
larged. The  usual  criteria  of  cancer  are  available,  and  the  tumor,  hard  and  nodular, 
is  more  easily  differentiated,  since  the  cervix  is  softened.  I  have,  on  two  occasions, 
found  a  hard,  nodular,  but  not  ulcerative  condition  of  the  cervix  during  the  middle 
of  pregnane}',  attended  by  slight  bleedings  and  fetid  discharge,  but  which  were  not 
carcinomatous  and  which  disappeared  after  delivery.  It  is  wise,  therefore,  in 
doubtful  cases  to  examine  a  piece  of  the  tumor  microscopically.  Pregnancy  will 
not  be  interrupted  by  exsecting  a  bit  of  the  cervix. 

Treatment. — If  an  operable  cancer  of  the  cervix  is  discovered  in  the  early 
months  of  pregnancy,  this  question  arises:  In  view  of  the  fact  that  recurrence  in 
such  cases  is  so  quick  after  delivery  and  the  woman,  therefore,  doomed  to  early 
death,  would  it  not  be  best,  in  the  interests  of  the  child,  to  wait  until  the  termination 
of  pregnancy?  Pinard,  Pozzi,  and  most  French  authors  say  yes,  but  the  German 
and  American  authorities  believe  in  the  immediate  radical  operation.  The  family 
must  decide,  it  being  explained  to  them  that,  by  waiting,  the  time  for  radical  cure, 
which  obtains  in  25  per  cent,  of  cases,  is  lost,  and  the  cancer  may  become  inoperable, 
the  death  of  the  woman  being  thus  hastened  by  at  least  two  years.  If  operation 
is  chosen,  the  abdominal  extirpation  offers  the  best  hope  of  cure,  but  the  vaginal 
route  still  has  many  adherents.  Spencer,  Glockner,  and  Beckman  found  50  and  82 
per  cent,  of  cases  of  cancer  in  pregnancy  operable. 

Should  the  carcinoma  be  discovered  when  the  child  is  near  viability,  it  may  be 
justifiable,  in  its  interest,  to  wait  a  few  weeks.  After  viability  there  is  no  question 
as  to  the  necessity  of  interference  in  operable  cases,  and  most  authors  agree  that 
the  vaginal  cesarean  section,  followed  at  once  by  extirpation  of  the  uterus,  is  the 
operation  of  choice.  Technically,  the  operation  is  rendered  difficult  by  the  rigidity 
of  the  parts,  and,  if  the  cancer  is  on  the  anterior  wall,  it  may  require  careful  dis- 
section to  free  the  bladder,  but  this  is  absolutely  necessary.  In  the  extirpation  of 
the  uterus  which  follows  the  delivery  of  the  placenta  it  may  be  helpful  to  split  the 
uterus  in  two.  Zweifel  recommended  cesarean  section  and  amputation  of  the 
uterus,  followed  by  extirpation  of  the  cervix  and  tumor  from  below.  English 
operators  prefer  the  abdominal  panhysterectomy  after  delivery  of  the  child,  and 
proceed  in  the  same  fashion  as  in  non-pregnant  cases. 

When  pregnancy  supervenes  on  an  inoperal^le  carcinoma,  the  woman  is  allowed 
to  go  to  term,  and  local  treatment,  as  curetage,  cauterization,  and  tamponade, 
performed  only  if  hemorrhage  or  sepsis  demands  it.  Abortion  is  not  invariably 
produced  Vjy  such  interference.  At  term,  pains  are  not  awaited,  ])ut  cesarean  sec- 
tion is  performed,  the  uterus  amputated  as  low  as  possible,  the  peritoneum  closed 
over  the  stump,  and  a  drain  through  the  cervix  into  the  vagina  left. 


PREGNANCY    COMPLICATED    BY    NEOPLASMS  529 


OVARIAN  TUMORS 

Much  rurcr  than  (ibfoids  arc  ovarian  tumors  (|iii'iii<i;  prcpjnancy.  Since  cysts 
of  the  ovary  are  (iiiile  foininon,  the  concUisioii  is  juslihcd  tliat  1  hey  ))redispose 
to  steriUty.  In  8G2  cases  collcctecl  by  McKcrron,  simple  and  nniUiloeuhir  cysts 
occurred  in  08  per  cent.;  dermoids,  in  23  per  cent.;  fibromata  and  soHd  adeno- 
mata, in  2  per  cent.,  and  mahgnant  neopUisms,  in  5  per  cent. 

The  influence  of  ])re^nancy  on  tlie  tumor  is  usually  not  bad,  most  women  going 
to  term  without  the  knowled<>;e  of  its  existence,  and  the  growth  of  the  neoplasm  is 
not  accelerated,  as  in  the  case  of  fibroids.  While  dyspnea,  palpitation,  etc.,  due  to 
excessive  size  of  the  tumor,  are  exceedingly  rare,  torsion  of  the  pedicle,  hemorrhage 
into  the  cyst,  suppuration,  and  necrosis  have  occasionally  been  noted.  Labor 
exerts  no  influence  unless  the  tumor  lies  in  the  pelvis,  exposed  to  the  traumatism 
of  delivery.  In  this  case  it  may  be  crushed  or  burst,  or  its  pedicle  torn,  while  in 
some  instances  the  advancing  head  has  forced  the  tumor  through  the  rectum  or  the 
vagina  outside  the  body — a  spontaneous  ovariotomy.  The  puerperium  shows  no 
special  influence,  but  complications  are  likely  to  arise  as  the  result  of  the  bruising 
of  the  tumor.     Torsion  has  been  observed  much  more  frequently  than  usual. 

Pregnancy  is  but  little  affected  by  ovarian  cysts.  Abortion  is  commoner  only 
with  those  tumors  which  are  very  large  or  are  incarcerated  in  the  pelvis,  interfere 
with  the  growth  of  the  uterus,  or  become  twisted  or  infected.  Hydatid  mole  has 
been  frequently  observed,  sometimes  with  lutein  cysts.  Upon  labor,  ovarian  cysts 
exert  a  bad  action  only  when  they  are  incarcerated  in  the  pelvis  and  block  the  path 
of  the  child.  To  a  certain  extent,  but  not  so  much  as  with  fil^roids,  nature  helps 
herself  by  drawing  the  tumor  out  of  the  way  by  means  of  the  pedicle,  and  a  small  or 
soft  tumor  may  still  allow  the  passage  of  the  child.  A  soft  tumor,  however,  when 
it  diminishes  the  available  pelvic  cavity,  is  far  worse  than  an  equal  amount  of 
contraction  caused  bj^  deformed  pelvis.  The  puerperium  is  often  stormy,  since, 
because  of  the  bruising  of  the  tumor,  necrosis,  hemorrhages,  infection,  suppuration, 
sometimes  with  breaking  of  the  pus  into  the  neighboring  organs,  occur.  Tumors 
which  become  adherent  to  the  rectum  are  likely  to  be  infected  with  colon  bacilli. 
Dermoids,  in  the  writer's  experience,  are  the  worst  cases  in  all  respects. 

Diagnosis. — In  the  early  months  it  is  usually  very  easy  to  differentiate  the 
pregnant  uterus  from  the  rounded,  movable,  pedunculated  tumor  lying  at  its  side, 
but  sometimes  great  difficulties  are  encountered.  When  the  tumor  is  intraliga- 
mentous or  prolapsed  in  the  pelvis  behind  the  uterus,  a  careful  differentiation  from 
ectopic  gestation  and  retroflexed  gravid  uterus  must  be  made.  Both  of  these  have 
already  been  considered  under  their  respective  headings  {q.  v.).  A  large  tumor  may 
conceal  the  uterus  and  pose  as  a  pregnancy,  and  since  the  signs  and  symptoms  of 
the  latter  are  present,  the  mistake  is  very  likely  to  be  made. 

In  the  later  months,  and  during  lal^or,  the  location  of  the  tumor  causes  a  variety 
of  difficulties.  If  high  in  the  abdomen,  it  may  slip  under  the  liver  and  spleen.  If 
adherent  to  the  uterus,  the  suspicion  of  twins,  of  fibroid,  or  double-horned  uterus, 
arises.  If  attached  to  the  pelvis  low  down,  a  shoulder  presentation  may  be  thought 
of.  In  one  of  my  cases  a  dermoid  was  adherent  to  the  promontory  of  the  sacrum 
and  could  just  be  reached  by  the  examining  finger.  If  the  head  had  not  lieen  pushed 
far  forward  over  the  pubis  by  something  behind  the  uterus,  it  is  more  than  probal^le 
that  the  tumor  would  have  been  overlooked.  Tumors  incarcerated  in  the  pelvis 
during  labor  are  very  easily  discovered,  l^ut  their  nature  and  origin  are  not  so  quickly 
determined.  A  cyst  under  the  compression  of  labor  becomes  as  hard  as  a  fibroid, 
and  if  it  is  adherent,  may  simulate  a  tumor  of  the  pelvic  periosteum,  as  occurred  in 
one  of  my  cases.  Rectal  examination  will  exclude  this  class  of  neoplasms.  An 
ovarian  cyst  has  been  held  to  be  the  head  of  a  second  twin,  and  forceps  applied;  a 
fibroid — and  enucleation  attempted;  a  prolapsed  kidney;  a  full  rectum;  a  hematoma. 
34 


530 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


An  important  part  of  the  diagnosis  is  the  decision  as  to  whether  the  tumor  will 
block  the  delivery,  and  in  estimating  this  one  must  never  forget  to  measure  the  bony 
pelvis  also. 

Prognosis. — Nowadays  few  women  die  from  this  complication  because  the 
tumors  are  usually  removed  as  soon  as  found,  and  because  operation  is  substituted 
for  the  brutal  obstetric  deliveries  of  the  olden  time.  Marshall,  in  the  latest  collec- 
tion, finds  a  maternal  mortality  of  only  3.3  per  cent,  in  cases  operated  on  during 
pregnancy,  and  5  per  cent,  after  laparotomy  at  term.  I  believe  this  is  too  favorable 
a  report,  since  many  bad  results  are  not  published.     Wertheim  quotes  two  statis- 


Hemorrhage  in  a  dermoid 


Dermoid 


Fig.  458. — Mrs.  K.     Three  Dermoid  Tumors,  One  Blocking  the  Pelvis. 
Replacement.     High  forceps.     Ovariotomy.     Recovery. 


tics — 39.2  per  cent,  and  31.3  per  cent,  maternal  deaths — for  cases  treated  expec- 
tantly. 

Treatment. — During  Pregnancy. — Most  authors  are  strongly  in  favor  of  im- 
mediate removal  of  the  tumor  when  discovered,  but  the  writer  agrees  with  Fehling 
and  Martin  that  here,  as  always,  one  must  individualize.  Operation  is  the  rule, 
preferably  laparotomy,  though  Diihrsscn  urges  the  vaginal  route.  Abortion  follows 
the  operation  in  22.5  per  cent,  of  cases  (Orgler),  and  even  though  it  follows  in  17 
per  cent,  of  cases  treated  expectantly,  it  may  be  wiser  to  postpone  the  removal  of 
the  tumor  until  the  last  month  of  pregnancy  or  during  labor  or  the  puerperium. 


PREGNANCY    COMPLICATED    BY    NEOPLASMS  531 

Such  exceptions  to  Ihc  rule  wmild  he:  (1)  Small,  freely  in()val)le  tumors  high  in  the 
abdomen;  (2)  an  aged  priiiiipara  in  whom  the  probability  of  further  pregnancies  is 
slight;  (3)  double  ovarian  tumois  where  the  woman  has  no  children  and  desires 
offspring.  In  these  cases,  if  oix-ration  nuist  be  done,  a  i)art  of  the  ovary  should, 
where  possil)le,  be  left.  Should  the  i)atient,  after  the  situation  in  all  its  bearings 
has  been  explained  to  her,  decide  to  wait,  she  must  be  instructed  to  report  at  once 
any  untoward  s>'mptom,  and  as  the  time  of  her  confinement  approaches,  seek  a  good 
maternity  hospital.  If  the  ])(>lvis  is  not  obstructed,  labor  may  be  allowed  to  take 
place  as  usual,  and  the  tumor  extir]iated  with  deliberation  a  few  days  afterward. 

Indications  for  innnediate  operation  in  pregnancy  are:  Torsion  of  the  pedicle; 
signs  of  infection  of  the  tumor;  incarceration  in  the  pelvis;  broad-ligament  develop- 
ment; overdistention  of  the  belly.  If  general  anesthesia  is  employed,  ether  should 
be  used;  the  i)regnant  uterus  must  be  handled  as  little  and  as  gently  as  possible, 
and  morphin  is  to  be  given  for  several  days  afterward  in  an  attempt  to  restrain 
uterine  action. 

During  Labor. — A  sharp  chstinction  is  to  be  made  between  eases  in  the  hospital 
under  the  hands  of  the  obstetric  surgeon  and  those  at  home  in  the  care  of  the  family 
practitioner.  The  location  of  the  neoplasm;  the  state  of  the  parturient  canal  as 
regards  infection,  and  the  tumor  as  regards  prolonged  pressure,  bruising  from  at- 
tempts at  reposition,  delivery,  etc.,  are  also  to  be  thoughtfully  considered.  The 
following  lines  of  procedure  have  been  followed :  (a)  Forceful  delivery  alongside  the 
tumor,  mentioned  first  to  be  unqualifiedly  condemned  and  thus  disposed  of;  (b) 
reposition  of  the  tumor,  followed  by  spontaneous  or  operative  delivery;  (c)  punc- 
ture or  incision  and  evacuation  of  the  cyst,  succeeded  by  delivery  from  below, 
then  removal  of  the  sac;  (d)  vaginal  ovariotomy;  (e)  abdominal  ovariotomy,  fol- 
lowed by  delivery  from  below;  (/)  cesarean  section,  followed  by  extirpation  of  the 
tumor,  with  or  without  the  uterus. 

In  all  cases  the  first  procedure  is  an  attempt  to  dislodge  and  replace  the  tumor 
above  the  brim,  out  of  the  way  of  the  advancing  head.  This  is  to  be  made  in  deep 
anesthesia,  the  patient  lying  in  the  Trendelenburg  or  the  exaggerated  Sims  position 
(Fig.  557) ;  the  fetal  head  is  to  be  pushed  upward,  and  then,  with  the  uttermost 
gentleness,  using  the  whole  hand,  the  tumor  is  disengaged  from  the  pelvis.  If  the 
manoeuver  is  successful,  the  child  is  delivered  by  version  and  extraction  or  forceps, 
or  the  case  left  to  nature,  depending  on  the  conditions  present.  After  the  delivery 
of  the  child  immediate  laparotomy  is  performed  and  the  tumor  extirpated.  It  is 
best  not  to  wait  to  remove  the  cyst,  because  the  latter  may  have  been  ruptured  or 
injured  by  the  manipulations  or  delivery,  and  delay  might  mean  fatal  peritonitis. 

If  the  case  is  a  "clean"  one,  that  is,  not  infected,  and  without  previous  inter- 
ference or  prolonged  labor,  and  a  single  attempt  at  reposition  fails,  laparotomy'  is 
to  be  performed,  the  tumor  removed,  and  then  delivery  accomplished  from  below. 
A  long  abdominal  incision  is  necessary;  the  uterus  may  have  to  be  turned  out  of 
the  belly,  and  an  assistant  may  have  to  dislodge  the  tumor  from  below  before  the 
mass  becomes  accessible.  After  the  tumor  is  removed,  if  the  uterus  cannot  be 
replaced  in  the  belly  (rare),  it  may  be  covered  with  hot  towels,  delivery  effected 
from  below,  and  then  it  will  be  easy  to  replace.  Extensive  adhesions,  impaction 
of  the  tumor  under  the  promontory,  and  solid  and  malignant  neoplasms  may 
render  such  a  course  impossible,  as  in  one  of  my  cases,  and  the  uterus  may  have 
to  be  emptied  in  order  to  reach  the  pelvis.  In  all  cases  a  consistent  attempt  is  to 
be  made  to  remove  the  tumor  whole,  because  the  contents,  especially  if  dermoid,  are 
likely  to  be  infectious.  Should  such  an  infected  mass  burst  into  the  free  peritoneal 
cavity,  the  uterus  is  to  be  also  extirpated  and  vaginal  drainage  established.  In 
determining  whether  a  cyst  is  infected  or  not,  in  addition  to  the  appearance,  pus, 
ichor,  and  the  odor,  the  history  of  inflammatory  attacks  is  important.     A  tumor 


532      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

firmly  attached  to  the  rectum  or  colon  is  frequently  infected,  and  unusual  care 
is  to  be  observed  in  removing  it. 

Suspicious  or  infected  cases  are  best  attacked  through  the  vagina — indeed, 
Dlihrssen,  Wertheim,  and  most  German  authorities  recommend  this  way  as  the 
rule  for  all  cases.  Spencer,  Kerr,  Hofmeier,  Williams,  and  most  English  and  Amer- 
ican authors  advise  the  abdominal  route. 

Vaginal  Ovariotomy. — A  long,  preferably  longitudinal  incision  is  made  over  the  most  promi- 
nent part  of  the  tumor,  the  cyst  grasped  with  vulsellum  forceps,  its  contents  evacuated  through  a 
broad  incision,  accessory  cavities  explored  and  emptied  with  the  finger,  and  the  sac  then  drawn  down 
and  its  pedicle  ligated.  Should  the  pedicle  be  inaccessible,  or  should  the  head  enter  the  pelvis 
upon  the  cyst  being  emptied,  the  sac  is  fixed  to  the  vaginal  opening  by  a  strong  suture,  or  the 
opening  lightly  packed  with  gauze  and  delivery  effected,  after  which  the  tumor  becomes  easily 
managable  through  the  A^aginal  incision  and  should  be  extirpated.  It  has  happened  that  laparot- 
omy became  necessary  during  the  vaginal  operation,  because  the  pedicle  could  not  be  ligated,  or 
the  tumor  was  so  brittle  that  it  could  not  be  pulled  down,  or  the  ligature  slipped,  or  the  tumor  was 
sohd  or  too  densely  adherent. 

What  should  the  general  practitioner  do  in  the  home,  far  from  help?  In  the  presence  of  an 
urgent  indication  for  delivery,  the  cyst  is  to  be  punctured,  after  opening  Douglas'  pouch,  the  sac 
emptied,  anchored  to  the  vaginal  wall  by  a  suture  or  light  gauze  packing,  and  labor  completed. 
The  sac  is  to  be  extirpated  -within  twenty-four  hours. 

In  the  puerperiiun  ovariotomy  is  to  be  performed  in  all  cases,  and  preferably  within  twenty- 
four  hours.  If  operation  is  postponed,  a  minute  watch  is  kept  for  the  first  symptoms  of  infection 
of  the  tumor  or  torsion  of  its  pedicle. 

Other  Tumors  Complicating  Pregnancy. — Reference,  only,  may  be  made  to  those  rare  con- 
ditions which  the  obstetrician  may  meet.  They  are  all  treated  on  general  principles.  Enlarged 
and  prolapsed  kidneys,  usually  the  left  (Bland-Sutton)  (Cragin,  vaginal  nephrectomy);  extra- 
uterine pregnancy  combined  with  intra-uterine  (Zinke) ;  echinococcus  cysts  (Franta) ;  parametritic 
abscesses  and  infiltrates;  cancer  of  the  rectum  (Myhoff,  26  cases) ;  rectal  stricture;  tumors  of  the 
bladder;  vesical  calculi,  requiring  lithotomy;  bony  tumors  and  enchondromata,  to  be  considered 
later. 

Literature 

Beckman:   Zeitschr.  f.  Gyn.  u.  Geb.,  1910,  vol.  Ixvii,  p.  445.     Much  literature. — Bland- Sutton:    The  London  Lancet, 

1901,  vol.  i,  p.  .529. — Cragin:  Amer.  Jour.  Obst.,  1898,  vol.  xxxviii,  p.  36. — DiXhrssen:  Deutsch.  med.  Woch., 
1904,  No.  42,  p.  1529. — Franta:    "Echinococcus  Cysts  of  Pelvis  and  Abdomen,"  Annales  de  Gyn.  et  d'Obst., 

1902,  p.  165.  Full  literature  to  date.— GZocfcner.-  Centralbl.  f.  Gyn.,  1902,  pp.  508  and  1446.— Grae/e;  Zeitschr. 
f.  Geb.  u.  Gyn.,  1906,  vol.  Ivi,  H.  3. — Kelly  and  Cullen:  Uterine  Myomata,  1909. — Kerr:  Operative  Mid- 
wifery, 1908,  p.  223. — Landau:  Treatise.  Fibroids  and  Pregnancy,  1911. — Marshall:  Jour.  Obstet.  and 
Gyn.  British  Empire,  February,  1910.  Gives  literature  since  1903. — McKerron:  Pregnancy,  Labor,  and 
Childbed  -svith  Ovarian  Tumors,  1903. — Milller,  P.:  Die  Krankh.  des  weibl.  Korpers,  pp.  304-334. — Noble: 
Amer.  Jour.  Obst.,  1896,  vol.  xxxiii,  p.  874. — Orgler:  Arch.  f.  Gyn.,  1902,  vol.  Ixv,  i,  p.  126.  Literature. — 
Pinard:  Annales  de  Gyn.,  September,  1901,'  ibid.,  April,  1901,  p.  309. — Piquand:  "Fibroids,"  L'Obstetrique, 
Paris,  July,  1909. — Sarwey:  Veit's  Handbuch  der  Gyn.,  1899,  vol.  iii,  ii,  p.  491. — Spencer:  Jour.  Amer.  Med. 
Assoc,  1909,  vol.  i,  p.  1612;  ibid.,  Trans.  Lond.  Obst.  Soc,  1905,  vol.  xlvi,  p.  355. — "Myomata,"  Trans.  Amer. 
Gyn.  A.SSOC.,  Washington,  1903. — Wertheim:  Handbuch  d.  Geb.,  1903,  vol.  ii,  No.  1,  p.  514. — Zinke:  Amer. 
Jour.  Obst.,   1902,  vol.  xlv,  p.  023.     Full  literature  to  date. 


CHAPTER  XLIII 
MINOR  DISTURBANCES  OF  PREGNANCY 

The  accouclunir  is  often  consulted  about  annoying,  if  not  dangerous,  symptoms 
during  pregnancy,  and  it  is  wise  to  instruct  the  gravida  to  report  such  phenomena 
to  him,  since  lie  may  detect  in  them  the  beginning  of  serious  illness.  Alost  of  the 
troubles  have  been  considered  in  chapters  appropriate  to  them;  here  will  be  men- 
tioned only  those  not  previously  treated. 

Insomnia  is  rare,  and  is  usually  due  to  digestive  disturbances  and  neurotic 
tendencies.  The  same  may  be  said  of  constant  dreaming.  If  regulation  of  the 
diet  and  bowels  does  not  suffice,  simple  remedies  often  will ;  for  example,  one  or  two 
glasses  of  hot  malted  milk  just  before  bedtime;  a  hot-water  bag  at  the  feet;  sleep- 
ing alone,  with  a  su]i(>rabundance  of  fresh  air;  suggestion,  by  means  of  electricity, 
drugs,  warm  or  medicated  l)aths,  an  electric  vibrator  to  the  back  of  the  neck,  etc. 
Only  rarely  is  a  dose  of  sodium  bromid  necessary,  and  a  few  drams  of  elixir  of  chloral- 
amid  or  5  grains  of  veronal  may  be  used  as  succedanea — never  morphin. 

Sleepiness  is  a  frequent  symptom  of  early  pregnancy  and  requires  no  treat- 
ment. Late  in  gestation  it  is  always  to  be  regarded  Avith  suspicion,  as  it  may  pres- 
age the  advent  of  eclam]:)sia.     Mental  dulness  may  mean  the  same. 

Numbness  and  tingling  of  the  hands  and  feet,  usually  combined  wdth  slight 
puffincss,  not  real  edema,  are  the  evidences  of  a  mild  neuritis,  perhaps  toxic  in 
origin.  Occasionally  local  anesthesia  and  tenderness  of  the  corresponding  nerves 
are  discovered.  While  the  symptom  rarely  has  any  disturbing  sequels,  it  should 
be  watched.  Treatment  is  on  the  theory  that  it  is  due  to  toxemia.  Neuralgias 
have  already  been  considered.  Symptoms  of  real  tetany  seldom  appear,  though 
the  women  oftencr  com]ilain  of  cramps  and  spasms  in  the  arms  and  legs. 

Pain  in  the  abdomen  is  frequently  complained  of.  In  the  earlj^  months  a 
careful  bimanual  examination  is  demanded  to  exclude  ectopic  gestation.  Pain  is  a 
symptom  of  many  conditions  which  have  already  been  considered — appendicitis, 
ureteritis,  cholelithiasis,  adhesions,  etc.  Intercostal  neuralgia  is  rare,  the  pain  in  the 
lower  ribs  from  which  so  many  women  suffer  being  most  often  due  to  dragging  on 
the  thoracic  cage  by  the  recti  muscles,  which  carry  the  weight  of  the  large  uterus. 
An  abdominal  supporter  is  indicated.  Rheumatic  pains  also  occur,  and  relief 
may  be  obtained  from  the  use  of  a  liniment,  for  example: 

I^.     01.  gaulthcruc, 

01.  camphoratai aa  30  c.c. 

Lin.  saponis q.  s.  ad  120  c.c. 

Most  often  the  pain  is  due  to  constipation,  with  intestinal  colic  and  flatulence. 
Pain  associated  with  immense  vulvar  varicosities  may  be  due  to  a  similar  condition 
of  the  broad  ligaments.  An  abdominal  binder  and  the  occasional  assumption  of 
the  knee-chest  position  \xi\\  bring  relief.  Pain  over  the  puliis  and  in  the  lower  back, 
attended  with  difhculty  of  locomotion,  is  often  due  to  softening  and  relaxation  of 
the  pelvic  joints.  Stretching  of  the  sldn  and  the  formation  of  stria?  gravidarum 
are  sometimes  painful.  Relief  may  be  obtained  from  lubricants,  such  as  solid 
alliolene,  cocoa-V)uttcr,  or  rose-water  ointment. 

Fainting  spells,  dizzinc^ss,  and  attacks  of  weakness — if  a  thorough  examination 
excludes  organic  disease  of  the  heart,  lungs,  etc. — are  treated  s^^llptomaticalIy. 
Sometimes  a  too  highly  nitrogenous  diet  is  the  cause,  and  relief  is  obtained  through 

533 


534      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

dietary  measures.  An  iron  and  phosphorus  tonic  is  often  useful,  but  occasionally  a 
small  dose  of  digitalis  does  the  most  good.  Fresh  air  is  essential.  Palpitation  of 
the  heart  is  relieved  by  a  cold  drink,  but  if  frequently  repeated  and  not  due  to  or- 
ganic disease,  sodium  bromid,  10  grains  three  times  a  day,  may  be  given.  Dyspnea 
is  often  due  to  unhygienic  dress,  indigestion,  and  the  dragging  of  the  uterine  tumor 
on  the  chest.     It  may  be  toxemic,  hemic,  cardiac,  or  simply  neurotic  in  origin. 

Frequent  urination  is  usually  due,  in  the  early  months,  to  distraction  of  the 
base  of  the  bladder;  in  the  later  months,  to  the  restraint  of  the  distention  of  the, 
viscus  b}^  the  large  uterus,  but  a  slight  catarrh  of  the  trigonum  is  not  rare.  The 
knee-chest  position,  a  binder,  and  a  week's  treatment  with  urotropin  and  methy- 
lene-blue  will  often  cure.  Cloudy  urine  should  not  be  present  during  normal  preg- 
nancy. When  it  does  occur,  it  is  sometimes  due  to  bacteriuria,  and  I  have  occasion- 
ally seen  it  precede  albuminuria.  Regulation  of  the  diet,  free  drinking  of  butter- 
milk, and  urinary  antiseptics  are  indicated.  Lack  of  control  of  the  urine  on  making 
a  sudden  movement,  as  cough  or  a  jar,  is  usually  due  to  previous  injury  of  the  neck 
of  the  bladder,  with  cystocele  or  urethrocele.  The  knee-chest  posture  may  help  a 
little,  but  a  cure  cannot  be  effected  during  pregnancy.  When  a  pregnant  woman 
complains  of  urinary  troubles,  a  careful  bimanual  examination  and  urinalysis  are 
to  be  made  at  once. 

Skin  Eruptions. — Acne,  mostly  facial,  may  prove  rebellious  under  treatment. 
The  rc-ray  should  not  be  used  because  the  eruption  disappears  after  labor.  Wash- 
ing the  parts  ^^dth  tincture  of  green  soap,  and  opening  the  pustules  with  a  fine  lancet 
comprise  the  treatment.  Urticaria  is  treated  in  the  usual  way.  The  author  has 
found  the  following  recipe  very  useful  for  urticarial,  papular,  and  all  dry,  itchy 
eruptions : 

I^.       Zinci  carbonatis  prsecip., 

Zinci  oxidi aa    30  gm, 

Mentholis, 

Ac.  carbolici aa      1  gm. 

Aquse  calcis ad  250  c.c. 

M.  et  Sig. — External  use. 

For  the  eczema  intertrigo  in  the  genital  creases  and  under  the  breasts  of  fat 
women  frequent  ablution  with  tar-soap  and  water,  followed  by  verj^  careful  drying 
and  a  dusting-powder  of  zinc  stearate,  will  usually  suffice.  If  these  fail,  starch  and 
a  small  amount  of  salicylic  acid  may  be  added  to  the  powder.  Rarely,  a  salve  con- 
taining boric  acid,  2  per  cent.,  carbolic  acid,  ^A  per  cent.,  zinc  oxid  and  rose-water 
ointments,  of  each  a  sufficient  quantity,  will  be  necessary.  If  leukorrhea  or  myco- 
sis is  present,  proper  treatment  is  needed.     (See  Vulvitis.) 

Pityriasis  versicolor,  occurring  principally  on  the  chest,  shoulders,  and  back, 
and  due  to  the  Microsporon  furfur,  is  easily  removed  by  frequent  scrubbing  with 
tar-soap  and  hot  water,  followed  by  washing  with  vinegar  or  1  :  1500  bichlorid. 

Edema  of  the  extremities  always  commands  attention,  because,  while  many 
instances  are  due  to  stasis,  the  swelling  disappearing  when  the  woman  lies  down, 
most  of  them  are  toxemic  or  nephritic  in  origin. 


CHAPTER  XLIV 


DISEASES  OF  THE  OVUM 


Under  this  iicatliiijj;  will  Me  considered,  l)i-ie(iy,  the  diseases  of  the  fetus,  tera- 
tology, the  pathology  of  the  fetal  adnexae,  the  chorion,  the  amnion,  and  the  umbilical 
cord. 

The  Fetus. — To  J.  W.  Ballantyne  is  due  the  credit  of  having  assembled  our 
knowledge  of  the  affections  of  the  uul)orn  child,  and  having  really  created  a  depart- 
ment of  medicine — antenatal  pathology. 

Most  of  the  acute  infectious  diseases  of  the  mother  have  been  demonstrated  in 
the  child,  as  has  already  been  shown.  Chronic  infectious  diseases,  tuberculosis, 
and  s}^3hilis,  the  form(>r  rarely,  the  latter  usually,  pass  over  also.  The  fetus  may 
l)ccome  diabetic  or  toxemic  from  its  mother,  though 
leukemia  has  not  yet  been  proved  to  affect  it.  Icterus 
of  the  mother  sometimes  does  and  sometimes  does  not 
discolor  the  child.  Icterus  from  toxemic  causes  is  very 
fatal  to  the  fetus.  Opium,  alcohol,  chloroform,  ether, 
the  iodids,  methylene-blue,  etc.,  pass  over  and  affect  the 
child.  ]\Iethylene-blue  given  to  the  mother  in  the  last 
\ve(>k  of  pregnancy  may  be  demonstrated  in  the  urine 
and  feces  of  the  new-born  for  three  days  after  birth. 
j\Iost  antitoxins  go  to  the  child  through  the  placenta. 
Outside  of  these  transmitted  affections,  the  fetus  has  a 
pathology  of  its  own.  It  will  be  impossible  to  do  more 
than  mention  the  best  known  maladies. 

1.  General  fetal  dropsy;  general  cystic  elephanti- 
asis; congenital  elephantiasis. 

2.  Congenital  microcephalus,  usually  with  idiocy; 
spastic  spinal  paralysis  (Little's  disease);  chorea,  Fried- 
reich's ataxia,  and  other  diseases  of  the  nerves. 

3.  Ichthyosis,  mild  and  severe;  hypertrichosis; 
congenital  absence  of  patches  of  skin,  due  probably  to 
amniotic  adhesions. 

4.  Diseases  of  the  iDones,  which  may  be  grouped 
under  the  general  term  "  chondrodystrophia  foetalis," 

but  are  otherwise  hardly  to  be  classified.     Some  cases  resemble  rachitis;    some 
show  bone  aplasia,  hypoplasia,  or  irregular  hyperplasia. 

5.  Abdominal  affections:  peritonitis,  ascites  (which  may  be  a  cause  of  serious 
dystocia),  congenital  stenosis  of  the  l^ile-ducts,  hypertrophic  stenosis  of  the  pylorus, 
and  neoplasms  of  the  liver. 

6.  Nephritis;  congenital  cj^stic  kidneys  (which  show  a  familial  tendency  and 
may  be  so  large  as  to  cause  obstruction  to  delivery) ;  dilatation  of  the  bladder,  A%-ith 
hypertrophy. 

7.  Circulatory  diseases:    endocarditis,  atheroma,  goiter. 

8.  Congenital  cataract,  iritis,  etc. 

9.  Congenital  uterine  prolapse  and  injuries  to  the  child  from  without. 

A  minute  study  of  these  conditions  would  be  well  repaid,  and  probably  would 
lead  to  the  discover^'  of  valuable  remedies  for  the  antenatal  treatment  of  the  diseases, 

535 


Fig.  4.39. — Achondroplasic  Fetc* 
Cauthor's  specimen). 


536 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


or  at  least  a  recognition  of  some  of  the  causes  and  the  means  of  obviating  their 
action. 

The  Death  of  the  Mother. — Since  the  dying  mother  takes  oxygen  from  the 
fetus,  the  death  of  the  latter  usually  occurs  first.  If  the  mother  dies  suddenly,  the 
child  may  live  for  a  variable  period.  Brotherton  reports  a  case  where  a  living  child 
was  extracted  twenty-three  minutes  after  the  death  of  the  mother,  and  Tarnier  one 
where  the  child  lived  twenty  minutes  after  the  death  of  its  mother,  who,  while  in 
the  Maternite,  was  killed  by  a  stray  bullet  during  the  Commune  (Polk). 

Rigor  mortis  may  occur  in  utero  (Fig.  460),  and  probably  is  common,  though 
rarely  observed  and  still  more  rarely  published.     It  affects  fetuses  of  all  ages,  be- 


i 


Fig.  460. — Rigor  Mortis  in  Utero. 

Child  died  as  the  result  of  pressure  and  prolonged  delay  during  molding  through  a  masculine  pelvis.     Delivery  of  the 

dead  infant  very  laborious  because  of  its  rigidity. 

gins  from  a  few  minutes  to  as  late  as  five  hours  after  fetal  death,  may  be  total  or 
partial,  and  may  cause  difficulty  in  delivery.  Its  pathology  is  identical  with  that 
of  rigor  mortis  of  the  adult  and  is  due  to  the  presence  of  lactic  acid  and  colloid  im- 
bibition of  the  muscular  fibers  (Meigs) .  Curiously,  the  heart  may  beat  a  few  times 
even  after  rigidity  of  the  body  has  developed.  Rigor  mortis  is  found  more  fre- 
quently in  cases  of  prolonged  labor,  eclampsia,  hemorrhage,  and  slow  asphyxia.  It 
is  not  a  sign  that  the  child  was  delivered  alive — a  point  of  extreme  importance  in 
medicolegal  cases.     (See  Paddock,  Wolff.) 


Literature 

Ballantyne:  Antenatal  Pathology  and  Hygiene,  1902,  2  vols. — Brotherton:  Edinburgh  Med.  ,Tour.,  1868. — Meigs: 
Amer.  Jour.  Physiology,  1910,  p.  191. — Paddock:  Amer.  Jour.  Obst.,  August,  1903.  Literature. — Polk:  Amer. 
Jour,  Obst.,  1885,  vol.  xviu,  p.  n'J2.— Wolff:  Arch.  f.  Gyn.,  1903,  vol.  Ixviii,  H.  3,  pp.  549-575. 


CHAPTER  XLV 
TERATOLOGY 

For  details  of  this  sul)jo('t  tlic  reader  is  referred  to  works  on  pathology.  Only 
the  barest  outlines  of  classification  and  a  few  principles  of  treatment  can  here  be 
given.     (See  Eirnbaum,  Schwalbe.) 

Classification. — Congenital  deformities  are  not  rare.  A  child  born  with  a  de- 
formity so  mark(>d  that  it  interferes  with  the  general  or  local  development  of  the 
body  is  called  a  monster.  Monsters  often  die  in  the  early  formative  stage,  which 
may  be  proved  by  an  inspection  of  aborted  ova,  and,  if  delivered  alive,  they  usually 
suceuml)  within  a  few  hours  or  days,  being  incapaljle  of  extra-uterine  existence.  The 
frecjueney  of  monsters  in  aborted  ova  is  noteworthy. 

Of  monsters  there  are  two  classes — single  and  double.  We  distinguish  three 
general  varieties  of  single  monsters  (Gurlt) : 

1.  Monstra  per  defectum — where  all  or  part  of  an  organ  is  missing. 

2.  Monstra  per  fabricam  alienam — where  an  organ  is  wrongly  formed  or  dis- 
placed. 

3.  IMonstra  per  excessum — where  an  organ  is  enlarged  or  duplicated. 

Causation. — Recent  experimental  work  has  clone  much  to  clear  up  the  causa- 
tion of  monstrosities,  and  it  is  quite  certain  that  external  agencies  have  much  to  do 
with  their  formation.  Heredity  has  indubitable  influence,  since  we  see  the  same 
peculiarity  in  several  generations  or  members  of  the  family.  Sometimes  a  genera- 
tion is  skipped,  and  the  deformity  reappears  in  the  third — atavism.  We  do  not  yet 
understand  these  internal  causes,  and  for  want  of  a  better  term  they  are  called 
germinal,  since  they  are  inherent  in  the  ovum.  That  the  sperma  has  some  in- 
fluence in  the  production  of  monstrosities  is  rendered  plausible  by  the  experiments 
of  Bardeen,  who  saw  deformed  ova  result  from  fertilization  by  the  sperma  of  toads 
which  had  been  exposed  to  the  x-ray. 

Of  external  causes  may  be  mentioned  injury  to  the  abdomen  or  uterus,  short 
of  the  actual  destruction  of  the  fetus  or  ovulum;  diseases  of  the  chorion  (]\Iall)  and 
of  the  amnion;  abnormal  implantation  of  the  ovum,  for  example,  in  the  tube  (Mall)  ; 
arrest  of  development,  and  changes  in  the  ovum  during  the  blastula  or  morula 
stages,  the  result  of  thermic,  chemical,  or  other  physical  action.  It  has  been  proved 
that  lithium,  sodium,  potassium,  and  magnesium  have  a  special  selective  action  on 
the  various  cells  of  the  morula,  and  produce  characteristic  monsters,  some  of  the 
poisons  affecting  the  nervous  system  and  others  the  heart.  Stockard  and  Lewis 
produced  50  per  cent,  of  cyclopean  monsters  from  the  eggs  of  the  common  mimiow 
by  treating  them  with  solutions  of  magnesium  chlorid.  Hertwig  suggests  that 
perhaps  chemical  poisons  circulating  in  the  maternal  blood  may  affect  the  young 
embryo  and  cause  monsters,  a  theory  which  the  author  has  held  for  many  years. 
Nowadays  few  practitioners  and  none  of  the  scientists  believe  the  old  notion  that 
the  mental  state  of  the  mother  has  a  direct  influence  on  the  development  of  the 
child,  but  many  careful  observers  are  convinced  that  shock,  worry,  deprivation, 
etc.,  may  produce  vascular  and  nutritional  disturbances,  general  and  local,  in  the 
endometrium,  which  may  seriousl}'  aft'ect  the  gro^^ih  of  the  ovum,  a  position  which 
the  author  has  long  held,  and  Ballantyne,  one  of  our  most  authoritative  teratologists, 
also  holds. 

Amniotic  adhesions,  formerly  held  responsible  for  many  of  the  single  mon- 

537 


538      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


Fig.  463. — Exexcephalus.  Fig.  464. — Cyclops. 

These    illustrations  were  all  drawn  from  .specimens  of  the  Northwestern  University,  Medical  Department. 


TERATOLOGY  539 

stcrs,  Mall  holiovos  to  1)0  usually  secondary,  rather  than  primary.     The  role  of 
syphilis  in  the  pnjduetion  of  monsters  nmst  again  be  emphasized. 

Single  Monsters. — 1.  Monalrd  Per  Defectum. — The  most  corninoriofsingirr  monsters  are  clue 
to  absoiu'c  of  closure  of  the  medullary  canal,  which  may  be  due  to  primary  agenesi.s  or  aplasia 
of  the  medullary  canal  to  early  hydrocephalu.s  or  hydrorachis,  or  to  adhesion  of  the  delicate, 
newly  formed  medullary  canal  to  the  amnion.  The  deformities  result in}^  from  this  are  ^;roupeci 
under  the  name  "craniorachischisis."  The  .splittinp;  maybe  partial,  either  involving  only  the 
cerebral  vertebra",  when  we  have  cranioschisis,  or  oidy  the  spine — rachischisis.  If  all  the;  struc- 
tures covering  the  meilullary  canal  are  missing,  the  back  presents  a  smooth,  sliining  groove, 
with  or  without  traces  of  brain  or  si)inal  cord  (Figs.  4G1  and  4C2j.  If  onlj'  the  bony  arch  is 
missing,  we  have  a  meningiK-cIe,  or  hernia  cerebri,  liernia  spinalis,  or  spina  bifida. 

A\'hen  there  is  a  ma.ss  of  brain,  more  or  less  large,  we  call  the  condition  acrarda;  when  all  the 
brain  is  missing,  anencephalus.  If  the  cranium  is  closed  but  smaller  than  normal,  it  is  called 
7nicrocej)lialu!i. 

Irregularities  in  the  closing  of  the  branchial  clefts  produce  deformities  about  the  face  and 
neck,  the  simplest  of  which  are  harelip,  and  the  severest  may  show  absence  of  large  parts  of  the 
face. 

The  anomalies  resulting  from  deficiency  of  closure  of  the  lateral  plates  of  the  body  walls 
are  hernia  umbilicalis,  hernia  abdominalis,  ectopia  vesica;,  ectopia  cordis,  etc.  These  are  grouped 
under  the  name  "thoracogastroschisis." 

The  splitting  may  go  so  far  as  to  involve  the  intestine,  showing  that  the  two  layers  of  the 
celom  failed  to  fuse.  Absence  of  fusion  of  the  lateral  halves  of  the  genital  and  urinarj'  organs 
produces  deformities  here  of  utmost  variety.  Hypospadias  is  the  mildest  and  most  common, 
ectopia  vesica?  with  split  pelvis  more  marked,  deformity. 

Agenesis  of  the  extremities,  fusion  of  the  extremities  or  of  fingers  and  toes,  and  deformities 
due  to  amniotic  bands  occur,  but  are  rare.  If  the  anterior  cerebral  vesicle  does  not  divide,  we 
have  a  cvclops  developed,  or  a  cyclocephalus.  Cyclops  monsters  are  among  the  easiest  to  produce 
artificially  (Fig.  4G-4). 

2.  Monstra  per  fahricam  alienam  are  mainly  cases  of  situs  inversus  viscerum,  abnormal 
position  of  the  kidneys,  testicle,  colon,  and  sometimes  of  the  joints,  and  congenital  luxations  and 
deformities.     These  latter  are  not  seldom  in  the  first  class. 

3.  Monstra  Per  Ezcessum. — Increase  in  the  number  of  a  part  or  organ  and  increase  in  the 
size  of  same. 

Double  Monsters. — Monstra  duplica  come  from  one  ovum,  and  are  developed 
from  one  germinal  vesicle.  Two  germinal  spots,  two  primitive  streaks,  or  two 
medullary  grooves  may  be  formed,  or,  later  in  growth,  a  duplication  of  one  or  the 
other  end  of  the  germinating  zone  takes  place.  Experiments  have  sho^^'n  that 
double  monsters  can  be  produced  in  the  blastula  stage  by  separating  the  blastomeres, 
which  is  accomplished  mechanically  or  chemically.  If  two  embryonal  areas  appear, 
it  is  possiljle  that  two  complete  individuals  (homologous  twins),  or,  if  the  two  areas 
are  not  entirely  separated,  united  twins,  will  result.  If  the  two  areas  are  unequal 
in  size,  one  of  the  incHviduals  is  stunted  and  attached  as  a  parasite  to  the  other,  or 
may  be  included  in  the  other.  The  etiology  of  such  monstrous  formations  is  un- 
known. Entrance  of  more  than  one  spermatozoid  into  the  ovum  is  not  the  cause, 
because  eggs  so  impregnated  usually  die.  Kohlbriigge  has  shown  that  in  some 
animals  the  accessory  spermatozoids  supply  food  for  the  germinating  ovum. 
Whether  there  is  a  splitting  of  one  primitive  streak  or  the  fusion  of  two  primarily 
developed  is  unkno\^^i — probably  fission  occurs.  Double  monsters  are  thus  classified 
(Foerster). 

Terata  Katadidyma. — In  these  beings  the  fission  or  doubling  is  from  the  head 
downward,  in  the  most  fully  developed  specimens  there  being  one  pelvis  and  two 
legs,  the  trunks  being  separate  (Figs.  -io5-469). 

Terata  Anadidyma.—Heve  the  splitting  is  from  below  upward,  all  grades  being 
observed  to  the  last,  where  the  two  complete  bodies  are  attached  at  the  head  (Figs. 
470-473). 

Terata  kata-atiadidyma,  the  fission  being  from  both  alcove  and  below.  The 
bond  of  union  may  be  very  broad,  extending  up  and  down  the  whole  venter  or 
dorsum  of  the  two  children,  or  very  small,  the  point  of  attachment  being  at  the 
sternmn,  the  abdomen,  or.  the  sacrum.  Rotation  may  bring  the  two  bocUes  into 
a  line,  as  in  the  Johnson  t\\dns  from  Wisconsin  (Figs.  474— i76). 

Homologous  twins  are  the  best  examples  of  the  last  class,  since  in  these  the 


Fig.   4Go. 


Fig.  46(5. 


Fig.  4G7. 


Fig.  408. 


Fig.  470. 


Fig.  471. 


Fig.  474. — Pygopagus — Blazelc  twins. 


Fig.   475. — Siamese   twins. 


Fig.  409.  Fig.  473.  Fig.  470. — Johnson  twins. 

Figs.     40.5-469.  —  Succes-  Fios.     470-473.  —  Successive  Figs.  474-470. — Tehata  Kata-anadidyma. 


8IVK  Dkorees  of  Fis- 
sion IN  Terata  Kata- 

DIDY.MA. 


Dkorees   of    Fission    in 
Terata  Anadidyma. 

All  these  sketches  are  copied  exactly  from  Ahlfold's  "Atlas." 

540 


TERATOLOGY 


541 


fission  of  tho  two  streaks  was  coniplctc.  If  tlie  dovolopmont  of  i]io  two  individuals 
is  o(iual,  l\v(j  wcll-fornicd  cliildfcii  result;  if  one  is  stronger  than  tiie  other,  its  heart 
overcomes  that  of  the  other,  whieh  later  shrinks  up  into  an  acardiacus.  Depending 
on  the  original  distribution  of  embryonal  cells,  one  or  the  other  portion  of  a  fetus 
will  be  represented  in  the  acardiacus,  the  head,  the  trunk,  or  the  lower  extremities 
(Figs.  177  and  17S).  Sometimes  all  or  a  part  of  a  primitive  streak  develops  inside 
the  other  embryonal  area,  antl  thus  inclusio  fa'tulis  and  teratomata  result. 

Homologous  portions  of  the  two  individuals  are  almost  always  united,  and  we 
name  the  monster  after  the  location  of  the  union;  for  example,  when  it  is  at  the 
sternum,  .sternopagiis;  the  ensiform  appendix,  xiphopagus  (Siamese  twins);  at  the 
sacrum,  pi/iio/xKiiis  (the  l^.ohctiiian  sisters);    at  the  head,  craniopagus,  etc. 

The  Clinical  Aspects  of  Monsters. — Since  single  monsters  are  more  common 


Fig.  477. — Acardiacus  Acephalus. 


Fig.  47S. — Acardiacus  Acormus  (Ahlfcld). 


than  d()ul)le,  they  present  greater  interest  to  the  accoucheur,  antl,  further,  they 
l^roduce  dystocia  more  frequently  because  they  more  often  develop  to  maturity  and 
because  enlargement  of  the  parts  is  so  often  met.  Hydrocephalus,  anencephalus 
with  })road  shoulders,  hernias,  and  accmnulation  of  fluid  in  the  body  cavities  are 
the  usual  conditions  found,  but  they  present  simple  prol^lems  of  treatment.  Dou1)le 
monsters,  curiously  enough,  are  frequently  expelled  spontaneously,  l:)ut  when  they 
do  give  rise  to  dystocia,  dangerous  and  most  compUcated  operations  are  often 
needed  to  effect  delivery. 

Diagnosis. — Even  before  labor  one  may  suspect  the  existence  of  an  abnormally 
formed  child.  Hydrocephalus  could  be  diagnosed,  and  an  acephalous  monster  too, 
if  the  examiner  were  on  the  alert.  A  woman  who  had  delivered  one  of  the  latter 
was  much  relieved  when,  at  the  seventh  month  of  a  subsequent  pregnancy,  it  was 
possible  to  assure  her  that  the  fetus  had  a  large,  well-formed  head.  Under  the  same 
circumstances  the  absence  of  a  cranium  would  as  easily  have  been  determinable. 


542      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

The  .T-ray  is  now  available.  Since  recurrence  of  monstrous  children  is  not  rare,  the 
history  is  of  service  in  the  diagnosis. 

During  labor  the  possibility  of  a  monstrous  formation  is  to  be  considered,  with 
other  things,  when  the  internal  examination  reveals  atypical  findings.  Before 
attempting  cesarean  section  it  is  wise  to  consider  the  shape  of  the  child,  as  well  as 
its  size  and  viability,  for  it  might  be  humiliating  to  deliver  a  monster  by  this  serious 
operation.     It  has  happened  to  clever  accoucheurs. 

An  anencephalic  monster,  as  shown  in  Fig.  462,  presenting  by  the  head,  might 
easily  cause  confusion  with  placenta  prsevia,  prolapse  of  the  cord,  simple  face  pre- 
sentation, or  breech  presentation.  The  frequent  association  of  deformities  will 
help  in  diagnosis;  for  example,  when  in  a  breech  delivery  a  spina  bifida  is  found, 
hydrocephalus  may  be  expected,  or  if  the  delivered  head  shows  harehp  and  delay  in 
delivery  of  the  trunk  ensues,  one  should  think  of  a  monster,  single  or  double.  Poly- 
hydramnion  is  so  frequently  present  with  fetal  anomalies  that  one  should  always 
look  for  the  latter  when  it  exists. 

Double  monsters  have  never  been  diagnosed  before  labor;  at  most,  twins  have 
been  suspected.  Two  bags  of  waters  exclude  a  double  monster.  The  rule  has  been 
that  only  after  labor  stopped  was  the  obstruction  recognized  to  be  due  to  joined 
fetuses,  but  inspection  of  the  part  delivered  may  give  a  hint  as  to  the  cause  of  the 
delay,  for  example,  harelip  or  atresia  ani  (Lyell).  If  delay  in  delivery,  not  overcome 
by  the  usual  manipulations,  should  occur,  an  examination  with  the  half  hand  or,  if 
necessary,  with  the  whole  hand,  is  to  be  made.  For  the  sake  of  deliberation  and 
thoroughness  an  anesthetic  had  best  be  given,  and  in  primiparse  a  deep  episiotomy 
is  advisable.  Such  an  exploration  must  decide  the  presence  of  enlargement  of  a 
part  of  the  fetus,  a  tumor  of  the  uterus  or  the  fetus,  a  double  monster,  and,  if  the 
last,  the  location  and  extent  of  the  area  of  fusion,  the  number  of  arms  and  legs,  and 
the  movability  of  one  child  on  the  other. 

Treatment. — Nature  helps  in  the  dehvery  of  monsters  by  interrupting  the  pregnancy  while 
the  fetuses  are  still  small,  but  cases  are  on  record  of  united  twins  weighing  15  and  173^  pounds, 
causing  formidable  dystocia.  In  general,  breech  presentation  is  most  favorable  for  all  mon- 
strosities, and  if  duplicate,  it  is  best  if  all  three  or  four  legs  are  accessible.  Single  monsters  with 
enlargement  of  parts  are  to  be  reduced  in  size;  a  hydrocephalus  is  punctured  (never  forceps);  a 
full  abdomen  is  emptied,  etc.,  and  if  delivery  is  indicated,  version  and  extraction  are  preferable. 
No  consideration  is  to  be  shown  either  a  single  or  a  double  monster  when  the  mother's  life  is  in 
danger.  Since  the  necessary  mortality  in  labor  and  afterward  is  enormous,  all  our  efforts  should 
be  directed  to  saving  the  mother.  Experience  has  shown  that  it  is  best  to  deliver  the  children 
whole,  and  not  to  amputate  a  head  or  trunk  which  has  been  expelled.  It  may  be  necessary  to 
amputate  the  delivered  portion  in  order  to  gain  access  to  the  rest  or  to  render  the  balance  of  the 
mass  movable,  but  such  occasions  are  rare.  Extremities  should  not  be  removed,  because  they  do 
not  interfere  with  our  manipulations;  further,  they  provide  a  grasp  on  the  locked-in  fetuses,  and, 
thirdly,  their  removal  destroys  the  relations  of  one  twin  to  the  other  and  adds  complications  in  the 
diagnosis  and  treatment.  Cesarean  section  may  be  necessary  if  attempts  at  delivery  from 
below  fail,  but  it  has  very  rarely  been  done — indeed,  the  patients,  when  they  come  to  this  point, 
are  the  poorest  possible  subjects  for  abdominal  delivery.  Contracted  pelvis,  as  a  complication, 
would,  of  course,  indicate  it,  and,  too,  if  a  double  monster  were  recognized  at  a  time  when  an 
abdominal  operation  could  be  performed  under  ideal  conditions — an  occurrence  not  yet  on  record. 

For  clinical  purposes  the  various  double  monsters  may  be  divided  into  three  forms,  as 
follows  (Veit): 

1.  Those  which  offer  obstacle  to  delivery  by  the  increase  of  the  size  of  the  body  at  one  or 
the  other  end;  for  example,  diprosopus,  cephalothoracopagus,  dipygus  parasiticus — such  as  an 
epignathus.  Most  of  these  monsters  belong  to  the  classes  terata  anadidyma  and  terata  katadi- 
dyma  (Figs.  465  to  473). 

2.  Those  monsters  where  fusion  is  at  one  or  the  other  end,  the  two  having  a  tendency  to 
form  a  straight  trunk — ischiopagus,  pygopagus,  craniopagus. 

3.  Where  the  mon.sters  are  well  formed  and  have  freedom  of  motion  at  the  point  of  fusion, 
for  example,  thoracopagus,  xiphopagus,  or  where  there  are  two  or  three  heads,  well  developed, 
on  one  trunk. 

In  the  first  class,  if  the  two  heads  present  and  engage,  one  after  the  other  is  delivered  by 
forceps;  if  not  engag(Kl,  version  is  performed,  then  exenteration  and  craniotomy  in  succession,  if 
necessary.  If  one  head  is  delivered  and  the  shoulders  do  not  come,  the  delivered  head  may  have 
to  be  amputated,  by  which  access  is  gainerl  to  the  double;  trunk.     The  second  head  is  led  into  the 

Sehis,  delivered,  and  then  the  double  trunk  reduced  in  size  by  cleidotomy  and  exenteration. 
t  the  duplicity  is  caudal,  all  four  extremities  are  to  be  delivered  at  one  time,  and  evisceration  of 


TERATOLOGY  543 

the  trunkH  pcrformofl,  after  which  the  extraflion  of  tho  common  shoulders  and  head  ia 
simple. 

The  second  clas.s  of  inonstens,  united  by  the  he;i(l  or  breeeh,  seldom  eauses  trouble,  the 
lonp;,  sausLifiie-.sluiix'd  trunk  sli])pint!;  through  with  no  didieuity.  Root  and  Bartlelt,  of  Chicago, 
found  an  isehiopagus,  bent  like  tiie  letter  U,  with  tlu;  two  fused  breeches  presenting.  The  junc- 
ti<jn  was  severed  and  delivery  ([uiekly  elTected,  one  fetus  at  a  time. 

Of  the  thirtl  class  of  eases,  the  Siamese  twins  are  a  good  example.  One  of  the.se  was  deliv- 
ered ])}'  the  head,  the  other  by  the  breech.  The  connecting  band  may  be  so  ela.stic  as  to  allow 
version  of  the  .second  twin  after  the  delivery  of  t  lie  first.  It  is  fortunate  if  the  two  children  pre- 
sent l)v  the  breecii,  and  tiie  jjosterior  one  should  be  delivered  first,  then  the  anterior  child.  If  the 
liond  of  union  is  liriner,  by  uneciual  t  ract  ion  t  he  head  of  the  jxisterior  fetus  is  to  be  drawn  into  the 
neck  of  the  anterior  and  both  delivered  togetlier.  E.xenteration  will  be;  done  or  the  bond  of  union 
.severed  whenever  necessary.  If  one  child  presenting  by  the  head  is  delivered  to  the  trunk  and 
labor  stojis,  the  other  may  be  turned  by  the  breech  and  the  two  then  delivered  side  by  side.  If 
two  heads  present  and  neither  engages,  version  on  both  twins  is  performed. 

As  a  rul(>,  the  operator  is  not  r(>quired  to  hurry,  but  may  proceed  with  calmness  and  deliber- 
ation. He  should  study  carefully  the  kind  of  nion.ster  he  has  to  deal  with,  its  size,  the  .shape  and 
size  of  the  pelvis,  etc.,  and  have  the  projxised  procedvu-es  completely  worked  out  before  operating. 

Overgrowth  of  the  child  will  be  considered  under  the  Pathology  of  Labor. 

Literature 

Ballantijtii':  Antciuital  Pathology,  1904,  vol.  ii. — Birnhaum:  Klinik  der  Missbildungen,  Berlin,  1909,  Springer. — ' 
Herlwiy:  Gcgcnbaur's  Festschrift,  189G,  vol.  ii. — Mall,  Franklin  P.:  Jour.  Morph.,  February,  1908,  vol.  xix, 
pp.  3,  3G8.  Full  literature. — Schwalbe:  Die  Morphologie  d.  Missbildungen  des  Menschen,  Jena,  p.  ii,  1907.^ 
Stockard  and  Lewis:  Jour.  Amer.  Med.  Assoc,  March  6,  1909.     Gives  literature  of  monsters. 


CHAPTER  XL VI 
DISEASES  OF  THE  FETAL  ENVELOPS 

THE  CHORION 

Clinically,  myxoma  diffusmn  and  fibrosum,  which  pathologists  describe,  are 
of  little  importance,  but  vesicular  degeneration  of  the  chorion  is  not  uncommon, 
and  requires  the  earnest  attention  of  the  accoucheur.  Hydatidiform  or  vesicular 
degeneration  of  the  chorion,  vesicular  mole,  or  grape-mole,  is  due  to  a  prohferation 
and  degeneration,  with  edema,  of  the  stroma  of  the  chorionic  villi  and  increase  of 
the  sjTicytium.     (See  Caturani,  Turazza.) 

Kossman  showed  that  Hippocrates  knew  of  this  condition,  and  ascribed  it  to  a  mucoid 
degeneration  of  the  vilU,  a  theory  which  Virchow  propounded  and  which  was  generally  accepted 

until  the  minute  and  convincing 

work  of   Marchand  and  Frankel 

was  published.  Aetius  of  Amida, 
in  the  sixth  century,  described  it, 
and  Vega,  in  1564,  and  Valleriola, 
in  Turin,  in  1573,  reported  typical 
cases.  The  latter  believed  the  dis- 
ease to  be  due  to  abnormal  devel- 
opment of  the,  at  that  time,  de- 
scribed "female  semen."  The 
vesicles  were  considered  "bladder 
worms,"  "pseudohelminths,"  or 
Acephalocystis  racemosa  (Clo- 
quet,  1822).  Velpeau  (1827)  called 
the  cysts  degenerated  villi,  as  we 
now  know  them  to  be;  Meckel 
(1847)  showed  the  hyperplasia  of 
the  connective  tissue  with  edema, 
and  Virchow  (1853)  called  it  a  mu- 
coid or  myxomatous  degeneration. 

A     hydatidiform     mole 

cannot  be  mistaken  (Fig. 
479).  It  resembles  a  bunch 
of  Catawba  grapes  of  most 
irregular  size,  varying  from 

Fig.  479. — Hydatidiform  Mole  (Author's  Specimen).  that  01    a  pm-neao.  tO  tnat  01 

a  hen's  egg  (rare),  but  usu- 
ally the  size  of  a  pea  or  bean.  A  loose  mass  of  thick  decidua,  and  cheesy  cellular 
material  with  blood-clots  interspersed  with  these  bladder-like  bodies,  is  usually  de- 
livered, but  the  specimen  may  be  a  compact,  egg-shaped  cast  of  the  uterus,  fibrous, 
and  filled  with  vesicles.  In  these  cases  the  growth  had  ceased  some  time  prior  to 
expulsion.  The  vesicles  hang  to  parent  stems  and  to  each  other  (Fig.  480).  Ordin- 
arily, all  traces  of  fetus  and  amnion  have  disappeared,  l)ut  cases  are  on  record  where 
both  have  been  preserved,  and  then  the  mass  may  be  expelled  entire  and  be  covered 
by  decidua.  All  the  chorion  may  be  changed,  which  is  the  usual  finding,  and  means 
that  the  degeneration  began  early  in  gestation,  but  either  the  chorion  frondosum  or 
the  chorion  lave  may  be  alone  affected.  Even  parts  of  the  placenta  may  be  intact, 
and  a  living  child  may  be  born,  or  only  one  ovum  of  a  twin  pregnancy  may  be  thus 
degenerated,  as  in  the  case  of  the  famous  anatomist,  Beclard,  whose  mother,  at  the 
fifth  month  of  gestation,  expelled  hydatids  (Parvin).  The  case  of  Depaul  was 
similar.     Ectopic  gestation  may  undergo  this  form  of  degeneration.     It  is  not 

544 


DISEASES    OF   THE    FETAL    ENVELOPS 


545 


certain  whctluT  tlic  (Ic^ciuTatiou  pi-ccedcs  the  dcutli  of  IIk;  cliilcl  or  follows  it — 
probaljly  both  occur.  The  author  has  frequently  lound,  in  aborted  ova,  one  or 
more  villi  (l('<>;<'n('rat('(l  au<l  fonninfi:;  N'csiclcs. 

Microscopically,  the  stroma  of"  the  villi  is  hyperplastic,  and  has  become  edema- 
tous and  necrotic,  so  that  only  at  the  pcri])h('ry  of  the  vesicles  can  the  fibrillary 
structures  and  cells  be  distin<j;uished  (Fig.  481).  Very  few  vessels  can  be  found, 
and  these  arc  empty.  Particularly  marked  is  the  proliferation  of  Langhans'  layer, 
which  may  invade  tlie  syncytium  and  grow  into  the  intervillous  spaces.  Its  cells 
are  enlarged  antl  degenerated,  staining  badly.  The  syncytium  also  liypertrophies 
and  undergoes  necrosis,  it,  as  well  as  Langhans'  layer,  showing  numerous  vacuoles. 
This  process  may  be  so  marked  that  the  syncytium  may  grow  through  the  decitlua 
into  the  uterine  musculature.  Even  the  vesicles  may  burrow  into  the  veins  and 
between  the  niuscle-filjers,  sometimes  as  far  as  into  the  peritoneal  cavity,  causing 
peritonitis  and  peritoneal  hemorrhage.  If 
the  uterine  wall  is  honey-combed  by  the  ad- 
vancing groA\i:h  of  the  prohferating  villi,  it 
may  rupture  during  the  process  of  abortion, 
or  l)e  jiimetured  by  the  finger  or  instruments, 
or  the  woman  may  die  of  external  hemor- 
rhage because  the  diseased  uterus  cannot 
contract  properly.  These  forms  are  called 
destructive  moles,  and  clinically  are  much 
feared. 

Special  mention  is  to  be  made  of  those 
destructive  hydatidiform  moles  which  even- 
tuate inchorio-epithelioma  or  malignant  syn- 
cytioma.  Meckel,  before  1795,  recorded  an 
instance  of  grape-mole  which  resulted  in  the 
woman's  death  by  metastases  of  a  tumor 
formed  in  the  uterus,  and  recently  it  has 
been  found  that  a  history  of  cystic  mole  is 
obtained  in  over  half  of  the  cases  of  syncy- 
tioma  malignum  which  come  to  treatment. 

The  syncytioma  may  develop  in  the 
uterus,  in  the  cervix,  or  in  the  vagina  (local 
metastases),  or,  if  the  vesicles  and  masses  of 
syncytium  are  carried  ])y  the  blood-stream 
to  distant  organs,  a  general  syncytiomatosis 
may  ensue,  but  usually  the  lungs  are  first  and 
most  involved.  Local  and  general  metastases 

may  occur  while  the  grape-mole  is  still  in  the  uterus.  Since  so  many  cases  of 
chorio-epithelioma  malignum  give  a  history  of  mole,  one  might  think  that 
the  hydatidiform  degeneration  of  the  chorion  was  very  frequently  the  cause, 
but  it  must  l)e  remembered  that  grape-mole  is  not  very  infrequent,  and  that 
a  case  of  syncytioma  will  almost  always  be  published,  while  the  mole,  being 
so  much  more  common,  is  not.  For  example,  the  author  had  nine  cases  of 
vesicular  mole,  not  published,  and  none,  as  far  as  known,  has  developed  metas- 
tases. Konig's  12,  Giglio's  13,  and  Kehrer's  50,  followed  up,  did  not  develop 
chorio-epithelioma.  Unfortunately,  it  is  impossible  to  determine  when  a  given 
mole  will  become  malignant. 

A  polycystic  degeneration  of  the  ovaries  has,  in  a  large  proportion  of  cases,  been 

found  coincident  with  this  condition,  an  observation  made  by  de  Grcgorini  in  1795. 

Both  ovaries  may  be  changed  into  tumors  as  large  as  a  fist,  composed  of  immensely 

proliferated  and  sometimes  edematous  ovarian  stroma,  full  of  cysts  which  vary  in 

35 


Fig.  -ISO. — Detail  of  Hydatidiform  Mole. 


546 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


size  from  a  few  millimeters  to  6  cm.,  and  which  are  lined  or  partly  filled  by  a  varie- 
gated layer  of  lutein  cells,  that  is,  the  ovaries  are  changed  into  lutein  cysts. 

While  the  two  conditions  are  often  associated,  we  cannot  draw  a  causal  con- 
nection between  them  nor  can  we  explain  their  frequent  coincidence. 

Etiology. — ]\Iultipar8e  are  oftener  affected  than  primiparse.  Such  moles  have 
been  found  in  women  fifty-two  and  fifty-three  years  of  age,  indeed,  the  frequency 
of  their  occurrence  after  thirty-five  is  remarkable  when  we  consider  the  smaller 


Fig.   481. — Hydatid  Mole. 
Compare  with  normal  placenta,  p.  39. 

number  of  births  at  this  period.  Molitor  records  the  birtli  of  a  vesicular  mole  in  a 
girl  nine  years  old.  Syphilis,  heart  disease,  and  general  affections  have  no  direct 
bearing,  but  the  association  with  nephritis  has  often  been  noted.  The  actual  ex- 
citing cause  of  the  degeneration  is  unknown,  and  probably  several  exist.  It  is 
possible  that  the  ovum  is  primarily  diseased,  because  cases  are  on  record  of  one 
twin  being  healthy,  the  other  changed  into  a  vesicular  mole,  and  secondly  aborted 
ova  often  show  a  mild  hydropic  disease  not  enough  to  cause  the  death  of  the  fetus, 


DISEASES    OF    THE    FETAL    ENVELOPS  547 

and  probably  secondary  to  tlic  latter.  The  ovarian  lutein  cysts  have  been  used  as 
an  arfrunient  for  the  theory  of  the  ovular  orif!;in  (jf  the  mole.  Abnormal  secretion 
from  a  diseased  corpus  luteum  jjroduciuf^  a  diseused  ovum  is  suf^f^ested  by  Friinkel. 
That  the  change  is  the  result  of  maternal  influences,  and  especially  an  endometritis, 
was  believed  by  Virchow  and  supported  by  Waldeyer,  Veit,  and  Aichel.  The  latter 
exposed  the  uteri  of  i)resnant  dogs,  injured  the  placental  site  by  pressure,  and  ob- 
served the  formation  of  hydatidiform  mole  in  7  of  13  experiments. 

Diseased  decidua  is  usually  found  with  moles,  and  the  recurrence  of  the  affec- 
tion also  points  to  the  endometrium  as  the  cause.  One  woman  had  vesicular  moles 
in  11  pregnancies  and  another  in  4,  while  the  latter's  hasband  had  a  healthy  child 
by  another  woman.  Probably  endometritis  will  explain  mcjst  cases,  and  we  know 
that  the  nutritional  conditions  of  the  placental  site  are  vitally  important  to  the 
ht^alth  of  the  ovum.     (See  Marchand,  Hoerman.) 

Clinical  Course. — Enlargement  of  the  uterus  faster  than  is  consistent  with 
normal  pregnancy,  and  atypical,  irregular,  uterine  hemorrhages,  are  the  two  most 
prominent  symptoms.  Serous  or  sanguineous  discharges  may  persist  in  the  interval, 
and  exceptionally  hemorrhage  may  not  occur  until  abortion  begins.  All  my  pa- 
tients were  ill,  complaining  of  pain  in  the  lower  abdomen,  general  weakness,  and, 
when  the  floodings  were  profuse,  showing  the  effects  of  anemia.  Two  women  were  al- 
buminuric and  edematous  up  to  the  hips,  and  one  had  hyperemesis  gravidarum.  In 
the  latter  case,  during  the  therapeutic  abortion,  undertaken  for  the  cure  of  the  per- 
nicious vomiting,  the  vesicular  mole  was  discovered,  no  bleedings  having  preceded. 
All  my  other  cases  except  one  terminated  in  abortion  before  the  sixth  month,  and 
in  the  one  the  mole  ceased  growing  and  was  expelled  at  term.  Depaul  and  jMadden 
had  cases  which  went  over  term. 

Expulsion  of  the  vesicular  masses  is  usually  complete  when  once  started; 
rarely  does  only  one  vesicle  or  cluster  escape.  Hemorrhage  is  always  marked  during 
the  abortion  unless  growth  has  ceased  and  the  mass  has  become  shrunken  and  dry. 
Death  from  acute  anemia  is  not  rare.  In  my  experience  the  blood  has  been  of  a 
lighter  red  than  normally  and  showed  less  tendency  to  clot.  Uterine  action  is 
sluggish,  the  abortion  sometimes  dragging  on  for  days,  and  contraction  and  retract- 
tion  of  the  organ  unsatisfactory  after  it  is  once  emptied.  Destructive  moles,  where 
the  proliferating  syncytium  and  vesicles  burrow^  into  the  uterine  w^all,  or  even 
through  it  into  the  peritoneal  cavity,  causing  intraperitoneal  hemorrhage,  are  very 
rare,  but  the  pos.sil)ility  of  a  weakened,  honey-combed  musculature  giving  way  under 
the  finger  or  curet  is  always  to  be  borne  in  mind.  Sepsis  seems  to  be  favored  by 
hydatidiform  mole.  Occasionally  purplish  tumors  are  found  on  the  cervix,  in  the 
vagina,  or  about  the  vulva,  which  on  section  show  sync^i^ium,  blood,  and  degenerated 
villi.  These  usually  occur  after  the  uterus  is  emptied,  but  may  be  found  coinci- 
dent with  the  mole,  and  are  probal)ly  local  syncjiioma  metastases.  Thej'  are 
generally  benign  {vide  infra.). 

Diagjwsis. — Rapid  growth  of  the  uterus,  atypical  uterine  hemorrhages,  ab- 
sence of  fetal  movements  and  of  a  fetal  body  on  palpation,  a  soft,  elastic,  not  doughy, 
feel  of  the  uterus,  and  tlie  general  evidences  of  illness  allow  the  accoucheur  to  make 
a  strong  assumption  of  the  presence  of  a  vesicular  mole.  Rarely  does  a  piece  of  it 
escape,  but  here  the  diagnosis  would  be  positive,  and  the  same  may  be  said  if  the 
mole  is  felt  through  the  cervix.  A  vaginal  metastasis  will  indicate  a  mole  in  the 
uterus.  In  the  differential  diagTiosis  polyhydramnion  might  lie  considered  when 
the  distention  of  the  uterus  is  acute  and  great,  and  grape-like  sarcoma  of  the  cervix 
if  part  of  the  tumor  should  hang  out  of  the  uterus.  In  two  of  my  cases  the  uterus 
got  smaller,  not  larger,  before  the  mole  was  expelled. 

Proguo.'^is. — In  very  rare  instances  is  the  child  viable,  which  means  that  only 
part  of  the  chorion  is  involved.  The  rule  is  that  the  fetus  dies  early  and  is  ab- 
sorbed.    Combining  the  statistics  of  Dorland  and  Gerson,  Hirtzman,  and  "William- 


'^ 


548      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

son,  we  find  a  maternal  mortalitj^  of  19  per  cent.  One  of  my  9  cases  died  from  acute 
sepsis.  The  dangers  are  uncontrollable  hemorrhage,  perforation  of  the  uterus 
(spontaneous  and  instrumental),  infection,  which  is  quite  common,  and  the  develop- 
ment of  syncytioma  malignum. 

Treatment. — As  soon  as  the  diagnosis  is  made  the  uterus  must  be  emptied. 
Dilatation  of  the  cervix  sufficient  to  admit  two  fingers  is  necessary,  and  should  be 
obtained  by  cervical  tamponade  with  gauze  or  a  small  colpeurynter.  (See  Chapter 
LXIX.)  A  firm  vaginal  pack  of  sterile  cotton  should  be  inserted  as  a  safeguard 
against  hemorrhage  while  the  os  is  being  dilated.  At  the  time  of  operation  all  prepara- 
tions should  have  been  made  for  hemorrhage  and  the  treatment  of  anemia.  Curets 
and  placenta  forceps  should  never  be  used  because  of  the  danger  of  perforating  the 
uterus  whose  walls  may  have  been  weakened  by  a  destructive  growth.  Even  the 
fingers  may  perforate  the  thinned  uterus,  all  of  which  should  warn  to  caution,  yet 
every  safe  effort  is  to  be  made  to  remove  all  the  masses,  thus  to  eliminate  the  danger 
of  the  development  of  a  neoplasm  and  of  sepsis.     As  in  placenta  prsevia,  blood  must 

be  spared  at  every  move 
_  _  _  ,      and  the  uterus  firmly  tam- 

iSA^a'f^/^iCv^l     '^■V'::^^.^     Poned  if  it  shows  a  ten- 

dency  to  relax  and  bleed. 
Findley  advises  curetment 
after  several  weeks  to  as- 
sure the  cure,  but  this  is 
seldom  feasible.  Certainly 
the  woman  is  to  be  kept 
under  close  observation 
for  two  years,  and  the 
uterus  removed  if  signs  of 
a  malignant  tumor  de- 
velop in  it. 

Chorio-epithelioma. 
— Sanger,  in  1889,  de- 
scribed the  case  of  a 
woman  who  died  from 
metastatic  tumors  seven 
months  after  an  abortion. 
^  „   ,  The  large  cells  foiind,  he 

Wall  of  vem  ^  ' 

17     A^o    r.  ^^  c  .r  thought,    were     decidual, 

Fig.  482. — Chobio-epithelioma — Mass  of  Syncytium  m  a  Vein.  i     i  ,i  n  n      i 

and  he,  therefore,  called 
the  tumor  sarcoma  de- 
ciduocellulare.  Since  then  over  300  cases  have  been  reported,  and  a  mass  of  liter- 
ature on  the  subject  has  accumulated.  Only  recently  have  our  ideas  regarding  the 
nature  of  the  affection  crystallized,  and  the  confusion  which  existed  may  be  ap- 
preciated after  a  glance  at  the  names  which  have  been  suggested  for  it — sarcoma 
deciduocellulare,  carcinoma  syncytiale,  deciduoma  maligimm,  blastomo-deciduo- 
chorion-cellulare,  syncytioma  malignum,  invasive  placental  polyp,  chorion  epithe- 
lioma. Marchand's  views  of  the  nature  of  the  tumor  are  now  generally  accepted, 
and  the  name  Frankel  and  Pick  proposed,  chorio-epithelioma,  is  the  one  most 
employed.  Frankel  first  called  attention  to  the  chorio-epithelial  nature  of  the 
growth.     (See  Veit,  Frank,  Ewing.) 

Chorio-epithelioma  is  a  tumor  developed  from  the  fetal  ectoderm,  which  may 
begin  during  pregnancy  (normal  or  almormal)  or  after  the  uterus  is  emptied,  and 
which  is  characterized  by  exuberant  growth,  early  and  extensive  local  and  general 
metastases,  and  rapid  cachexia,  often  coml^ned  with  sepsis. 

Its  causation  is  unknown.     We  know  that  syncytium  has  invasive  power,  that 


DISEASES    OF   THE    P'ETAL    ENVELOPS 


549 


the  villi  erode  their  way  into  the  uterine  wall,  int(j  the  blood-vessels,  but  what  keeps 
this  power  in  normal  limits  and  what  permits  the  growth  of  the  cells  to  pass  all 
bounds  cannot  even  be  conjectured.  Hydatidiform  mole  preceded  the  develop- 
ment of  this  disease  in  over  half  of  the  cases,  which  shows  that  some  connection 
exists  between  the  two. 

Pathology. — The  growth  begins  at  the  placental  site  and  protrudes  into  the 
uterus  as  a  very  vascular,  soft,  purplish  mass,  usually  sharply  differentiated  from 
the  mucosa.  It  may  grow  through  the  uterine  wall  and  make  tumors  which  pro- 
ject into  the  peritoneal  cavity  or  the  })road  ligaments.  More  often  the  veins  are 
invaded,  and  thus  general  metastases  brought  about.     Vaginal  metastases — the 


/-  £*^     %    ^V-MVt /■....J7..i.#.—.V...  Proliferating  syi 


5 


•O^*"  '««*.■ 


w<fi 


r'  f^*"^'  ^lu   *^'S>  ^ 


-r^^.^^ 


;'^ 


'•>-  • 


Mass  of  Langhans'  cells 


Fig.  483. — Chorio-epithelioma. 
Shows  extension  of  process  in  vein. 

most  frequent — are  probably  local,  from  surface  implantation.     In  appearance 
such  a  nodule  resembles  a  hematoma. 

Microscopically,  the  tumor  is  made  up  of  masses  of  syncji:ium  and  proliferated 
Langhans'  cells,  which  often  form  blood-spaces,  and  even  structures  which  resemble 
villi.  Round-cells  and  polynuclear  leukocytes  abound;  the  whole  tumor  is  very 
bloody.  ^Masses  of  syncytium  may  be  seen  advancing  in  the  veins,  and  if  hydatidi- 
form mole  was  present,  hydropsically  degenerated  villi  may  be  fomid.  ]\Iarchand 
distinguished  an  atypical  and  a  typical  variety,  both  equall}'  pathogenic,  but  in  the 
latter  the  tumor  cells  resembled  exactly  the  chorionic  cells  of  early  pregnancy.  The 
syncytium,  with  its  large,  irregularly  shaped  masses  of  protoplasm,  with  sharply 
staining  nuclei,  is  especially  well  represented,  but  Langhans'  cells  are  also  present. 
In  the  atj^ical  varieties,  w^hich  more  resemble  sarcomata,  there  is  a  more  diffuse 
infiltration  of  the  tissue  by  closely  packed,  deeply  staining,  irregularly  shaped  cells, 
\\ath  large  nuclei,  which  may  form  clmups  resembling  s>Ticji;ium,  and  are  probably 


550  THE    PATHOLOGY    OF    PREGNANCY,    LABOR,    AND    THE    PUERPERIUM 

altered  Langhans'  cells  (Fig.  483).  Sometimes  one  kind  of  cells  predominate  and 
again  the  other.  Combined  forms  exist.  Lutein  cysts  of  the  ovaries  develop  in  a 
large  proportion  of  the  cases  of  syncytioma,  as  in  vesicular  mole. 

Curiously  enough,  malignant  chorio-epithelioma  with  all  its  characteristics, 
even  with  structures  resembling  villi,  has  been  found  to  arise  from  teratomata  of 
the  testicle.  It  probably  originates  from  fetal  ectoderm,  included  in  the  congenital 
teratoma. 

Clinical  Course. — ^After  an  abortion,  especially  of  a  vesicular  mole,  or  after 
labor,  the  patient  complains  of  irregular  uterine  hemorrhages.  Usually  a  curetage 
is  performed,  but,  since  the  masses  thus  obtained  resemble  placental  tissue,  a  mi- 
croscopic examination  is  often  omitted.  In  half  of  the  cases  a  vulvar  or  vaginal 
nodule  first  drew  attention  to  the  condition,  and  in  my  case  the  uterus  enlarged 
enough  to  be  felt  by  the  patient.  The  growth  may  be  found  during  pregnancy, 
before  expulsion  of  the  mole,  as  early  as  a  week  after  delivery  (Williams'  case) ,  but 
usually  several  months  later,  and  in  three  cases,  two,  three  and  one-half,  and  four 
and  one-half  years  after  delivery  (Krosing) ,  at  a  time  when  the  causal  gestation  had 
been  almost  forgotten.  Repeated  hemorrhages  rapidly  exhaust  the  woman,  weak- 
ness and  the  symptoms  of  anemia  become  pronounced,  pallor,  subicterus,  albumin- 
uria, edema  of  the  feet,  and  puffiness  of  the  eyes,  that  is,  the  signs  of  cachexia, 


'^W^   »      *  ^  ^.     ^         ^m'^      4 


■  -4  ^         -«.        .jA  ■i* 

lu-   <\iJ»     — -    •  >        «  J,    '» 

•na       ''  '  '—  J~^_         ,  ' • 

Fig.  484. — Chorio-epithelioma. 
Mass  of  Langhans'  cells  resembling  decidua. 

supervene,  and  very  often,  since  the  tumor  masses  in  the  uterus  possess  such  a  ten- 
dency to  necrosis,  a  vaginal  discharge  with  gangrenous  odor  and  general  septicemia 
with  fever  occur.  Metastases  in  the  lungs  may  be  diagnosed  when  cough,  bloody 
expectoration,  and  pulmonary  findings  are  present.  Examination  of  the  sputum 
has  thus  far  been  negative.  Metastases  occur  in  the  lungs,  vagina,  liver,  spleen, 
and  brain.     Vaginal  tumors  may  eat  into  the  bladder,  like  cancer. 

Prognosis. — Later  writers  distinguish  a  less  malignant  type  of  chorio-epithe- 
lioma, one  that  disappears  spontaneously  or  after  the  removal  of  the  vaginal  metas- 
tases and  uterine  curetage.  As  a  rule,  however,  unless  early  operation  is  performed, 
these  patients  die  within  a  year  after  the  first  appearance  of  the  neoplasm.  This 
is  the  most  rapidly  destructive  growth  with  which  we  have  to  deal. 

Death  occurs  from  intractable  hemorrhage,  cachexia,  infection,  septicemia, 
and  occasionally  from  hemorrhage  into  the  peritoneal  cavity  or  peritonitis,  both 
the  result  of  perforation  of  the  uterus  by  the  invading  tumor. 

Diagnosis. — Repeated  hemorrhages  after  abortion  are  usually  due  to  a  pla- 
cental polyp.  Curetage  is  indicated,  and  the  scrapings  should  be  studied  by  a 
competent  pathologist.  Recurrence  of  a  uterine  growth  after  successful  curetage 
for  removal  of  the  products  of  gestation  is  often  due  to  chorio-epithelioma.  A 
vaginal  metastasis  will  usually,  but  not  always,  indicate  the  cause  of  the  symptoms. 
Removal  of  part  of  the  tumor  and  its  microscopic  study  are  essential  for  positive 


DISEASES    OF   THE    FETAL    ENVELOPS 


551 


diagnosis,  which  an  expert  pathologist  can  reachiy  make.  At  some  point  in  the 
section  the  characteristic  syncytial  formations  will  be  found.  In  the  differential 
diagnosis  fibroids,  other  neoplasms,  and  pelvic  exudates  nmst  be  considered. 

Treatment. — In  view  of  the  troaclierous  nature  of  the  disease  and  its  enormous 
mortality,  radical  extirpation  of  the  uterus,  adnexa,  and  accessible  metastases  is 
indicated.  Since  it  is  propagated  along  the  veins,  it  is  well  to  ligate  the  vessels  as 
far  outward  as  possible. 

DISEASES  OF  THE  PLACENTA 

Variations  in  Shape. — V:iri;iti()iiH  Iroiii  the  typic-al  round  shape  of  tho  placenta  are 
common,  and  K<'iienilly  have  no  practical  Hif^nificance.  (Sec  p.  .50.)  These  variations  are  due 
to  irn't^ularit ics  in  the  "nutritional  conditions  of  the  uterus.  A  placenta  nested  in  the  horn  of  the 
uterus  is  likely  to  he  round  and  show  a  niarfriiial  rinK-  One  near  the  os  may  encircle  the  orifice 
in  a  horseshoe  form.  One  attached  at  the  side  of  the  uterus  may  spread  on  both  anterior  and 
posterior  walls  an(l  he  hilohate,  etc.  Without  douht  the  placenta  may  he  bisected  or  trisected  by 
white  infarct  formations,  and  1  believe  this  is  the  commonest  cause  of  irregular  shapes. 

Placentae  and  placentulae  succenturiatse,  already  mentioned,  have  great  importance 
for  they  may  1)C  left  in  the  uterus  and  Ki\e  rise  to  hemorrhage  and  sepsis.  They  are  sup- 
posed to  he  (hie  to—  fl)  The  development  of  some  of  the  ^•illi  of  the  chorion  lajve;  (2)  to  cutting 
off  of  a  portion  of  the  placenta  by  white  infarcts;  (3)  to  development  of  villi  in  the  decidua  vera 
with  missing  reflexa.  Placenta  "membranacea,  which  is  normal  in  the  pachydermata,  has,  in 
excessively  rare  instances,  been  observed  in  the  human — nearly  the  whole  of  the  envelop  of  the 
egg  was  converted  into  thin,  membranous  placental  tissue.  Moderate  degrees,  that  is,  extensive 
thin  plac(Mita\  are  occasionally  observed,  hut  are  usually  due  to  infarct  formation.  The  thickness 
of  the  placenta  is  in  inverse  proportion  to  its  size. 

Heart  disease,  nephritis,  anemia,  diseases  of  the  uterus,  favor  abnormal  development  of 
the  placenta,  and  also  make  pathologic  changes  in  the  uterine  musculature,  such  as  hyaline 
degeneration,  which  in  turn  causes  atonia  uteri,  even  rupture,  etc. 

Infarcts. — Nearly  every  placenta  will  show,  on  careful  inspection,  whitish, 
nodular,  hard  areas,  occupying  the  fetal  or  maternal  surface,  or  both,  and  varying 


Membranes 


Ring 


Fia.  485. — Pl.\cent.v  Circumvallat.a.   (Northwestern    University  Medical  School  Museum). 


in  size  from  a  pin-head  to  several  centimeters.  Other  names  for  these  formations 
are  hepatization,  scirrhus,  placentitis,  apoplexy,  cirrhosis,  and  phthisis.  These 
structures  are  called  infarcts,  and  several  varieties  are  found,  having  different  causa- 
tion, though  little  is  positively  known  on  this  point.  The  different  kinds  will  be 
considered  in  the  order  of  their  frequency. 


552 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


1.  At  the  edge  of  the  placenta,  at  the  site  of  the  subchorial  decidua,  a  more  or 
less  complete  white  ring  is  found,  which  varies  in  width  from  2  to  16  mm.,  and  in 
thickness  from  1  to  4  mm.  Sometimes  the  ring  is  raised  from  the  surface  and  the 
attached  membranes  are  doubled  back  over  the  edge  of  the  placenta,  as  in  Fig.  485. 
This  is  called  placenta  circumvallata  or  nappiformis.  There  are  four  views  as  to 
the  manner  of  production  of  this  anomaly — (a)  The  placenta  is  located  in  a  tubal 
corner  of  the  uterus,  or  over  the  internal  os,  and  the  area  of  the  placental  site  grows 
more  rapidly  than  the  rest  of  the  uterus,  the  latter  constricting  the  former  at  their 
junction  (Fig.  485).  (6)  Owing  to  inflammatory  changes  in  the  decidua,  the  closing 
ring  of  Waldeyer  and  the  decidua  subchorialis,  whose  nutrition  is  precarious,  be- 
come necrotic,  and  temporarily  hinder  the  splitting  of  the  decidua  and  the  growth  of 


Fig.  4S6.  Fig.  4S7. 

Figs.  486  and  487. — Placenta  Circumvallata  in  Formation. 
Shows  development  of  the  fold  in  membranes  (from  Bumm). 


the  placenta  in  this  direction,  (c)  Endometritis  causes  early  adhesion  of  the  reflexa 
to  the  vera,  and  changes  at  the  site  of  the  closing  ring  of  Waldeyer  prevent  the 
growth  of  the  placenta  in  the  marginal  reflexa,  the  placenta,  therefore,  splitting  the 
vera.  We  sometimes  find  that  the  cotyledons  extend  1^4  inches  beyond  the  insertion 
of  the  membranes  (v.  Herff).  (d)  Hitschraan  believes  that,  as  the  result  of  a  sudden 
diminution  of  the  liquor  amnii,  the  coverings  of  the  ovum  must  shrink,  and  natur- 
ally there  would  be  an  infolding  at  the  edge  of  the  placenta  (Figs.  486  and  487) 
(Funck,  Sfameni). 

Placentae  marginataj  and  circumvallatse  have  much  clinical  importance,  be- 
sides the  interest  which  attaches  to  the  endometritis  so  often  causative.  Early  in 
pregnancy  smaller  or  larger  hemorrhages  sometimes  occur,  and  abortion  is  not  in- 
frequent.    Tubal  corner  placentas  might  be  called  a  distinct  clinical  entity,  causing 


DISEASES    OF   THE    FETAL   ENVELOPS 


553 


pain,  ])l(>(Mlinfi-,  aboriion,  ])r('niaturo  hibor,  i)uny  cliildrcii,  postpartum  hoinorrhap;o, 
and  (lidicultics  in  dia^ncjsis.  (See  Anjijular  Pregnancy,  p.  liOO.)  In  ])la('('nta  mar- 
ginal a  adhesion  of  the  membranes  is  very  common,  and  the  placenta  may  be  de- 
hvered  naked  or  decrowned  of  its  meml)ranes.  As  the  result  of  this  retention  hemor- 
riiage  and  sai)remic  fever  sometimes  ensue.  Al)normal  mechanism  in  the  third 
staf>;e,  with  retention  or  adhesion  of  the  after-birth,  requires  the  introduction  of  the 
hand  in  the  uterus  oftener  than  with  normal  i)lacentas. 

2.  On  the  fetal  surface  of  the  placenta  we  find  nodular  infarcts,  which  vary  in 
size  from  those  scarcely  visible  to  the  eye,  to  3  to  5  cm.  across  and  up  to  1  cm.  thick. 
The  smaller  ones  preponderate  and  may  be  bunched,  or  there  may  be  a  thin,  nodu- 
lar layer  of  fibrin  whicli  covers  a  good  part  of  the  fetal  surface. 

3.  Some  infarcts  take  in  the  whole  thickness  of  a  cotyledon  and  may  involve 
one  or  more  of  them.  In  Fig.  488,  which  came  from  a  nephritic,  nearly  one-half  of 
the  placenta  was  involved  in  infarct  formations  in  various  stages  of  development. 


Fig.  488. — Placenta  from  Case  of  Severe  Nephritis. 
On  the  left,  masses  of  infarcts,  oq  the  right,  an  immense  hemorrhage. 


Such  a  condition  may  compromise  the  nutrition  of  the  child,  which  is  liorn  weak  and 
puny,  or  if,  as  often  happens  in  Bright's  disease,  more  than  half  of  the  area  is  involved, 
the  child  will  die.  Such  placentas  are  likely  to  be  prematurely  detached  (abruptio), 
and  Fig.  402  show'S  a  hemorrhage  causing  a  separation.  This  last  form  of  infarct 
bears  the  most  resemblance  to  the  Cohnheim  infarct;  the  other  two  can  hardly  be 
called  thus,  though  Ackerman  gave  them  the  title  "white  infarcts." 

In  general  there  are  three  views  as  to  their  causation.  Ackerman  believed  a 
peri-arteritis  or  endarteritis  existed  in  the  villi  and  produced  ol)literation  of  the  vessel 
lumen,  with  consecutive  necrosis  of  the  villus  stroma,  then  of  the  villus  wall,  and  con- 
sequent clotting  of  the  blood  in  the  adjoining  intervillous  spaces.  Steffeck,  von 
Franque,  and  many  investigators  l^elieve  that  endometritis  and  decidual  overgro-uih 
and  consequent  necrosis  of  the  villi  with  fibrin  deposition  are  the  cause.  Primary 
alteration  or  desquamation  of  the  chorionic  epithelium,  which  is  not  abnormal  in  the 
last  wrecks,  causes  deposition  of  fibrin  and  infarct  formation,  according  to  Hitschman. 
It  is  probable  that  there  is  truth  in  all  these  theories,  and  that  the  first  explains  the 


554 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


multiple  infarcts  on  the  fetal  surface ;  the  second,  the  infarcts  on  the  maternal  side, 
and  placenta  marginata;  the  third,  the  microscopic  infarcts  made  up  of  necrotic 
ectodermal  cells  which  are  constantly  found  in  ripe  placentas.  Perhaps  the  general 
vascular  changes  of  nephritis  are  also  present  in  the  newly  formed  placental  blood- 
vessels, and,  through  endarteritis,  obliterate  their  lumen,  causing  infarcts  and 
hemorrhages,  and  finally,  the  typical  albuminuric  placenta.  May  not  these  infarcts 
be  one  expression  of  a  toxemia? 

Microscopically,  we  find  circumscribed  areas  of  placental  tissue  which  have 
undergone  coagulation  necrosis  (Figs.  489  and  490).  In  the  advanced  stages  the 
whole  mass  is  changed  into  fibrin  with  only  traces  of  the  previously  existing  villi. 
Sometimes  there  are  evidences  of  obliterating  endarteritis  and  peri-arteritis,  and. 


Fresh 

\    fibrin 


/  Normal 

•'  villus 


Fig.  489. — Placental  Infarct.    Young. 

when  endometritis  existed,  large  numbers  of  decidual  cells  undergoing  necrosis  and 
even  small-cell  infiltration,  which  may  affect  the  villi,  will  be  found. 

Clinically,  infarcts  cannot  be  diagnosed,  but  their  existence  can  be  expected 
in  cases  of  nephritis,  heart  disease,  syphilis,  endometritis,  and  when  they  were  pres- 
ent in  previous  pregnancies.  Mention  has  been  made  of  the  fact  that  those  infarcts 
which  take  in  one  or  several  cotyledons,  may  reduce  the  oxygenating  area  of  the 
fetus,  and  also  the  nutritional  functions  of  the  placenta,  so  that  the  child  is  puny  or 
even  starved  to  death.  Cognizance  is  taken  of  this  fact  in  deciding  on  the  induc- 
tion of  premature  labor  in  nephritis.  Extensive  infarct  formation  is  often  asso- 
ciated with  adherent  membranes  and  the  retention  in  the  uterus  of  masses  of  thick 
decidua,  which  often  give  rise  to  annoying  oozing  after  the  third  stage  of  labor,  and 
even  severe  postpartum  hemorrhage. 

Hemorrhages. — Xo  structure  in  the  body  possesses  blood-vessels  as  friable  as 
those  of  the  decidua,  and  as  a  result  hemorrhages  are  not  rarely  found  in  it.     These 


DISEASES    OF   THE    FETAL    ENVELOPS 


555 


are  almost  always  in  the  sorotina,  and  produce  a  varying  degree  of  separation  of  the 
placenta.  .Sometimes  they  lie  in  the  decidual  septa  between  the  cotyled(jns.  (It  is 
not  probable  that  these  septa  are  of  fetal  origin.)  In  the  latter  instance  they  im- 
pose as  intraplacental  hemorrhages.  It  is  not  clear  to  the  author  how  bleeding  can 
take  place  into  the  intervillous  spaces.  They  are  blood  sinuses  and  communicate 
freely  with  each  other,  so  that  a  sudden  increase  of  arterial  pressure  wcnild  be  dis- 
tributed evenly  through  the  whole  placenta,  and  would  not,  as  Seitz  believes,  cause 
the  blood  to  burst  into  the  surrounding  tissues.  Another  form  of  placental  hemor- 
rhage comes  from  rupture  of  the  marginal  sinus,  already  referred  to. 

It  must  not  be  forgotten  that  a  hemorrhage  can  occur  in  a  red  or  white  infarct. 
Hemorrhages  have  also  been  observcnl  on  both  surfaces  of  the  placenta.  Organiza- 
tion of  the  clot  occurs,  and  it  is  possible  to  trace  the  changes  through  the  stages  of — 


"Normal  villus 


»^ 

Fig.  490. —  I'lacf.ntm.  Infarct.     Adv.\nced. 

(1)  Soft,  red-black  clot;  (2)  brick-red,  firmer  mass;  (3)  fibrin  formation  in  the 
periphery,  with  some  liquid  content,  to  (4)  through-and-through  hard  fit)rous 
nodule.     These  nodules  resemble  white  infarcts. 

The  causes  of  these  hemorrhages  are  acute  and  chronic  congestion,  increased 
blood-pressure,  stagnation  of  the  venous  blood-current,  disease  of  the  villi,  of  the 
decidual  blood-vessels  (endometritis),  and  the  blood  changes  incident  to  Bright 's 
disease,  toxemia,  hemorrhagic  diathesis,  and  sj'philis.  Physical  or  mental  shock 
and  local  injury  also  may  cause  them.  I  believe  there  is  some  relation  between  the 
toxemia  of  pregnancy,  hemorrhages  in  the  decidua,  even  abruptio  placentae,  and  the 
hemophilic  conditions  which  arise  during  gestation. 

Clinically,  placental  hemorrhages  are  of  great  importance.  If  they  occur  early 
in  pregnancy,  abortion  may  result,  and,  perhaps,  fetal  monsters.  Later,  abruptio 
placentse  may  ensue.     Smaller  clots  may  not  be  found  until  after  delivery,  but  the 


556 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 


history  of  attacks  of  pain,  slight  external  bleeding,  and  uterine  contractions  which 
subsided  may  serve  to  show  the  accoucheur  that  some  disturbance  of  fetation  had 
occurred  at  some  time  during  pregnancy. 

Rarely  coagulation  of  the  blood  in  the  intervillous  spaces  takes  place.  Throm- 
bosis of  the  sinuses  of  the  placental  site  may  be  looked  upon,  in  the  later  weeks,  as 
a  normal  process,  and  preparatory  to  involution  of  the.  uterus.  It  has  been  found 
as  early  as  the  second,  third,  and  fourth  month,  but  it  is  then  pathologic.  It  may 
overstep  the  bounds  of  the  normal  by  going  through  the  uterine  wall  into  the  veins 
of  the  broad  ligaments,  and,  especially  if  these  are  varicose,  may  lead  to  the  develop- 
ment of  phlegmasia  of  the  limbs,  both  before  and  after  delivery. 

Placentitis. — Older  ^vriters  described  an  affection  of  the  placenta  which  we  now 
classify  mider  infarcts,  but  there  does  seem  to  be  an  inflammation  of  the  chorionic 
viUi  which  is  secondary  to  endometritis  {q.  v.). 

Edema. — An  edematous  placenta  may  resemble  a  syphilitic  one,  and  the  micro- 
scope may  have  to  decide.  The  villi  are  club-shaped  and  swollen,  with  irregular 
contour.     Usually  the  syphilitic  placenta  feels  fatty,  while  one  can  squeeze  water 


Hemor- 
rhage into 
an  infarct 


In  mar- 
ginal de 
cidua 


-  Thrombosis  of  uterine 
sinus  extending  into  vessels 
at  side  of  uterus 


Thrombosis  of  uterine  sinus 
Fig.  491. ^Diagram  Showing  Location  of  Hemorrhages  into  Placenta  and  Thromboses, 


from  the  edematous  placenta,  which  is  pale,  thick,  soft,  shaggy,  and  mushy,  with 
torn  serotina.  The  causes  are  maternal  and  fetal  heart  disease,  nephritis,  and 
general  anasarca  from  any  source,  polyhydramnion,  and  fetal  blood  diseases. 
Abortion  is  the  rule.  If  the  child  is  also  edematous,  formidable  dystocia  may 
result. 

Atelectasis. — Sometimes  a  placental  cotyledon  is  completely  infiltrated  with 
fibrous  material,  solid,  dark  red  in  color,  and  hard  to^the  touch.  It  occurs  occasionally 
in  placenta  prtevia,  the  piece  overlapping  the  internal  os  being  in  this  condition, 
and  it  may  make  the  diagnosis  difficult. 

The  fibrous  change  may  be  concrete,  or  may  be  somewhat  diffuse,  giving  the 
whole  placenta  a  fibrous  character.  It  may,  therefore,  interfere  with  the  nourish- 
ment of  the  fetus,  and  prol)ably  has  a  pathology  analogous  to  that  of  white  infarct. 

Calcification. — Not  infrcciuently  the  serotinal  surface  of  the  placenta  is  strewn 
with  white,  sandy  deposits.  These  may  be  discrete  or,  rarely,  may  be  fused  to- 
gether into  little  plates  of  hard,  brittle  masses.  They  are  composed  of  calcium 
carbonate  and  phosphate  and  magnesium  phosphate,  lie  in  the  upper  layers  of  the 


DISEASES    OF   THE    FETAL    ENVELOPS  557 

decidua  scrotina,  especially  around  the  "anclioriiifji;  villi,"  are  due  to  the  deposition 
of  tlu;  salts  in  areas  which  had  undergone  fibrinous  degen(;ration,  and  are,  theref(jre, 
associated  with  white  infarcts;  they  have  no  clinical  significance,  are  not  syphilitic, 
though  they  may  be  found  in  luetic  placentas, — usually  in  the  vessels'  wall, — do 
not  always  indicate  that  the  gestation  has  been  prolonged  (since  they  are  found  in 
abortion.s),  are  not  tubercular,  and  do  not  occur  with  especial  frecjuency  in  any 
particular  condition.  It  has  seemed  to  me  tliat  they  render  the  placenta  stiff, 
which  facilitates  its  separation  and  expulsion,  and  that  usually  no  piece  of  a  cal- 
careous placenta  is  retaint>d. 

Cysts  of  the  Placenta. — On  the  fetal  surface,  underneath  the  amnion  and  just 
under  the  chorial  membrane,  cysts  are  not  seldom  found.  They  vary  in  size  from 
the  microscopic  to  that  of  a  goose-egg,  and  are  oftenest  found  on  ripe  placentas, 
but  have  been  noted  at  all  times  after  the  twenty-second  week,  have  clear  yellowish 
or  cloudy  and  bloody  content,  contain  alljumin,  mucin,  fat,  detritus,  and  various 
sodium  and  chlorin  salts.  Often  a  white  infarct  is  found  underneath  the  cyst,  and, 
on  opening  the  latter,  the  lining  is  seen  to  be  of  soft,  whitish,  shaggy,  necrotic  ma- 
terial resembling  decidua.  This  is  generally  admitted  to  be  degenerated  Langhans' 
cells,  which  are  large,  hydropic,  with  a  big  nucleus  and  all  fatty  degenerated.  It 
is  believed  that  a  few  of  these  cysts  may  be  due  to  degenerated  decidua  or  the  end- 
products  of  large  white  infarctions  or  hemorrhages.  Clinically,  they  are  of  no  im- 
portance. If  a  large  marginal  cyst  ruptured,  one  might  think  the  bag  of  waters 
had  opened  (Seitz). 

Various  tmnors  are  fomid  in  the  placenta — myxoma  fibrosum,  angiomata, 
hj^pcrplasia  of  the  chorionic  villi,  but  especially  chorio-angiomata.  All  are  ex- 
ceedingly rare.  Clinically,  they  are  of  little  importance;  only  rarely  do  tiiey  affect 
the  child  or  the  delivery. 

Literature 

Aichel:  Verb,  der  Deutsch.  Ges.  f.  Geb.  u.  Gyn.,  1901. — Caturani:  Amer.  Jour.  Obst.,  1911,  p.  617.  Literature. — 
Ewing:  Surg.,  G.vn.,  and  Obst.,  April,  1910.  Literature. — Findley:  Amer.  Jour.  Med.  Sci.,  190.3,  p.  4SS. — 
Frank:  Jour.  Amer.  Med.  Assoc.,  1906,  vol.  xlvi,  p.  24S. — Funck:  Annal.  de  Gyn.  et  d'Obst.,  September,  1910. — 
Hoerman:  Monatssch.  f.  Geb.  u.  Gyn.,  1908.  Over  200  literature  references. — Kossman:  Arch.  f.  Gyn.,  vol. 
Hi,  p.  153. — Kroesing:  Arch.  f.  Gyn.  u.  Geb.,  1909,  vol.  Ixxxviii,  H.  3.  Literature. — Marchand:  Zeitschr.  f. 
Geb.  u.  Gyn.,  vol.  xxxix,  p.  215;  ibid.,  H.  3,  pp.  405,  472.  Gives  literature. — Motifor:  Handb.  d.  Geb.,  vol. 
ii,  2,  p.  1067. — Parvin:  Amer.  Jour.  Med.  Sci.,  October,  1892. — Phillips:  Jour.  Obst.  and  Gyn.  British  Em- 
pire, December,  1911.  Chorio-epithelioma  of  Tube. — Sfameni:  Monatsschr.  f.  Geb.,  1909,  vol.  xxvii.  No.  4, 
p.  Go.—Turazza:  Centralbl.  f.  Gyn.,  1893,  p.  948.  With  living  child.— Fei^.-  Handb.  d.  Gyn.,  1898,  vol.  iii, 
No.  2,  p.   539.     Literature  to  date. 


CHAPTER  XLVII 
ANOMALIES  OF  THE  CORD  AND  OF  THE  AMNION 

ANOMALIES  OF  THE  CORD 

Knots. — Since  the  umbilical  vein  is  longer  than  the  arteries,  and  the  vessels 
longer  than  the  cord  itself,  twisting  of  the  vessels  occurs,  and  the  vein  is  twisted 
around  the  arteries.  The  veins  especially,  but  the  arteries  also,  form  loops,  and 
the  jelly  of  Wharton  is  thicker  at  such  places,  causing  nodes  on  the  cord  which  are 
called  false  knots.  These  have  no  clinical  significance.  True  knots  occur  in  the 
cord,  but  they  are  uncommon.  They  are  single  or  complicated,  and  may  even  cause 
the  death  of  the  fetus.  While  they  usually  form  during  labor  as  the  result  of  the 
child  passing  through  a  loop  and  have  no  clinical  importance,  if  they  form  early  in 
pregnancy  the  active  movements  of  the  fetus  may  draw  the  turns  so  tight  that  death 
of  the  child  results. 

Torsion  of  the  cord  is  often  found  in  aborted  fetuses,  but  one  can  seldom  assert 
that  the  torsion  caused  the  death  of  the  child.  As  many  as  380  turns  have  been 
counted  when  the  whole  cord  is  affected.  Occasionally  the  cord  is  twisted — almost 
off — right  at  the  navel,  or  at  any  one  point  of  its  length,  and  in  these  cases  stenosis 
of  the  vessels  with  fetal  death  may  follow.  In  a  given  case  it  may  be  impossible 
to  determine  whether  the  death  of  the  fetus  resulted  from  the  stricture  of  the  cord, 
or  whether  the  torsion  of  the  cord  was  produced  by  the  active  movements  of  the 
fetal  death  agony,  or  whether  the  twisting  occurred  after  the  child's  death.  Prob- 
ably all  three  occur.  In  medicolegal  cases  this  uncertainty  is  to  be  borne  in  mind. 
The  differential  diagnosis  between  torsion  of  the  cord  which  occurred  after  the  fetal 
death  from  that  occurring  before  may  be  made  certain  if  there  are  adhesions  be- 
tween the  coils  of  the  cord,  and  if,  when  the  cord  is  untwisted,  this  is  found  difficult 
and  the  shape  of  the  cord  seems  to  be  permanently  altered. 

Coiling  of  the  cord  around  parts  of  the  fetus  affects  the  child  only  when  it 
produces  an  abnormal  shortness,  or  when  the  coils  are  so  tight  that  the  circulation 
in  the  vessels  is  compromised.  It  is  said  that  such  coiling  around  the  neck  may 
cause  hydrocephalus,  atrophy,  and  cerebral  disease,  by  impeding  the  return  circula- 
tion, and  that  extremities  may  thus  be  amputated.  It  is  more  than  probable  that 
the  fetus  will  die  from  asphyxia,  the  result  of  the  compression  of  the  cord  before 
such  effects  would  be  produced.  Lesser  degrees  of  compression  make  circular 
depressions  in  the  limb  and  sometimes  peripheral  atrophy.  Fracture  of  the  ex- 
tremities may  result  during  labor  when  the  cord  entangles  them.  Twins  in  one 
amnion  usually  have  their  cords  intertwined.  Coiling  of  the  cord  around  the  neck 
is  found  in  fully  one-fifth  of  all  deliveries.  As  many  as  seven  loops  have  been  found, 
and  this  may  make  the  cord  relatively  too  short.  In  order  to  explain  the  coiling  of 
the  cord  around  the  neck  it  is  assumed  that  the  loops  lie  over  the  internal  os,  and 
in  delivery  the  child  passes  through  them.  It  is  more  probable  that,  in  its  active 
movements,  the  child  throws  the  cord  around  the  body  and  down  to  the  neck,  and 
that  the  condition  exists  for  weeks  Ix.'fore  delivery.  One  of  my  patients  was  terri- 
fied by  a  fire  in  an  adjoining  dwelling,  noted  excessive  fetal  movements,  and  then 
aVjorted.  The  left  thigh  of  the  five  months'  fetus  was  caught  in  a  tight  knot  of  the 
cord.  It  is  possible  that  the  mental  shock  caused  hemorrhages  into  the  placenta, 
and  the  dying  child  was  entangled  in  the  cord,  or  the  maternal  impressionists  might 
say  the  child  partook  of  the  mother's  fright  and  by  its  excited  motions  tied  itself 

558 


ANOMALIES    OF   THE    CORD    AND    OF   THE    AMNION 


559 


in  the  cord,  which  caused  its  deatli.  Coils  (jf  cord  around  the  neck  may  interfere 
with  the  mechanism  of  hd)or,  causing  deflexion  attitudes,  delayed  rotation  of  the 
head  or  shoulders,  and  even  shoulder  presentation.  Compression  of  the  cord  be- 
hind the  pubis,  })etwecn  the  neck  and  the  bone,  may  cause  asphyxia  of  the  child, 
which  occurs  especially  in  primipara,  and  is  another  reason  for  carefully  watching 
the  heart-tones  in  the  second  stage  of  labor. 

As  will  again  be  mentioned  in  the  discussion  of  forceps,  the  coiling  of  the 
cord  around  the  neck  and  the  presence  of  a  loop  hanging  down  alongside  the  head 
have  caused  very  many  fetal  deaths.  Compression  by  the  blades  of  the  instrument 
asphyxiates  the  child. 


Fig.  492. — Child  Strangulated  by  its  Cokd  at  Four  Months. 
Case  in  Chicago  Lj-ing-in  Hospital  Service. 


Diagnosis. — During  labor  it  is  sometimes  possible  to  feel  the  cord  in  the  nape 
of  the  neck  by  abdominal  palpation,  and  sometimes  the  funic  souffle  can  be  plainly 
and  constantly  heard  in  this  location.  During  the  forceps  operation  the  fingers 
should  be  passed  all  around  the  head  as  far  as  they  can  reach,  and  a  maneuver, 
which  is  more  successful  than  one  would  think  at  first,  is  to  pass  a  finger  behind  the 
pubis  up  the  nape  of  the  neck  to  the  back.  It  is  possible  to  reach  up  and  discover 
if  the  cord  has  come  within  the  danger  zone.     (For  the  treatment  see  Forceps.) 

Most  authors  advise,  after  spontaneous  delivery  of  the  head,  to  feel  for  the 
cord  around  the  neck.  This  is  not  absolutely  necessary  unless  the  child  seems  to 
be  held  back  by  something.  One  may  be  required  to  cut  the  cord  before  it  is  possible 
to  deliver  the  trunk,  and  this  is  always  advisable  when  it  seems  that  there  will  be 
traction  on  the  placenta — this  to  avoid  abnormalities  in  the  third  stage. 


560      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

Short  Cord. — Cases  are  recorded  where  there  was  no  cord  at  all,  the  fetus  being 
applied  to  the  placenta  through  an  umbilical  hernia.  Bayer  reported  a  cord  10.5 
cm.  and  Naegele  one  of  6.7  cm.  Clinically,  cords  are  either  absolutely  or  relatively 
short,  the  latter  being  those  where  one  or  more  turns  around  the  neck  or  extremities 
make  a  normal  cord  too  short  for  the  mechanism  of  labor. 

A  cord  must  be  long  enough  to  reach  from  the  placental  site  to  the  vulva,  and, 
if  the  placenta  is  located  in  the  fundus,  a  length  of  25  cm.  is  necessary,  not  35  cm., 
as  Kaltenbach  puts  it.  It  must  be  remembered  that  the  uterus  follows  down  the 
child  as  it  expels  it.  Too  short  cord  may  lead  to — (a)  Delay  in  the  second  stage  of 
labor,  the  head  coming  clown  with  difficulty  and  receding  quickly  as  if  it  were  drawn 
back  by  a  rubber  band;  (6)  rupture  of  the  cord  if  the  pains  are  strong,  with  death 
or  asphj^xia  of  the  child;  (c)  tearing  of  the  cord  from  the  placenta;  (d)  tearing  of 
the  placenta  from  the  uterus,  causing  abruptio  placentse  or  pathologic  third  stage; 
(e)  inversion  of  the  uterus;  (/)  painful  uterine  contractions  and  secondary  inertia. 
A  diagnosis  of  too  short  cord  may  not  always  be  made.  In  one  of  my  cases  the 
patient  complained  of  a  dragging  sensation  about  the  navel  during  each  pain,  and  in 
Brickner's  case  there  was  a  desire  to  pass  urine  after  each  uterine  contraction.  In 
another  of  my  cases  a  small  amount  of  urine  was  squeezed  out  with  each  pain. 
Some  authors  have  mentioned  a  depression, — that  is,  partial  inversion  in  the  uterine 
wall,— but  most  often  the  excessive  and  quick  recession  of  the  head  after  the  pain 
has  led  to  the  diagnosis. 

Special  treatment  is  seldom  required  because  of  the  rarity  of  the  affection.  If 
diagnosed,  one  should  watch  the  condition  of  the  child  narrowly  and  deliver  it  on 
the  first  sign  of  asphyxia.  As  soon  as  the  head  is  born  the  cord  is  to  be  cut  between 
two  clamps. 

Long  Cords. — The  longest  cord  found  in  a  service  of  over  15,000  deliveries 
was  120  cm.,  but  one  of  198  cm.  has  been  recorded.  The  average  is  60  cm. — about 
24  inches.  Aside  from  the  tendency  to  prolapse  and  to  coil  about  the  fetus,  they 
do  not  claim  our  interest. 

Rupture  of  the  cord  is  a  curious  accident,  for  it  may  occur  with  a  long  cord, 
and  when  we  can  find  no  reason  for  it.  Stowe,  after  reporting  a  case  of  spontaneous 
rupture  of  the  cord  which  occurred  in  the  Chicago  Lying-in  Hospital  Dispensary 
service,  reports  the  results  of  his  tests  to  discover  the  tensile  strength  of  the  cords. 
They  carried  weights  varying  from  8  to  22  pounds.  In  a  case  of  mine  the  child  was 
delivered,  deeply  asphyxiated,  with  the  cord  broken  eight  inches  from  the  navel. 
The  broken  ends  were  not  jagged,  but  cut  as  if  with  dull  scissors,  and  the  thickness 
at  the  point  of  rupture  was  8  mm.  In  another  case  the  brittle  cord  was  caught  be- 
tween the  blade  of  the  forceps  and  the  head,  and  sharply  severed,  as  with  a  knife. 

Neoplasms  occur  exceedingly  rarely  in  the  cord.  Myxoma,  sarcoma,  and  der- 
moid have  been  reported.  Rupture  of  a  varix  of  the  cord,  with  hematoma,  espe- 
cially^ near  the  belly  of  the  child,  is  occasionally  observed.  Immense  increase  of  the 
jelly  of  Wharton  may  change  the  cord  to  a  heavy,  thick,  glassy  rope — in  one  of  my 
cases  it  was  thicker  than  a  large  thumb.  Cysts,  relics  of  the  ductus  omphalo- 
mesentericus  or  of  the  allantois,  may  rarely  be  found,  and  sometimes  a  cyst  seems 
to  result  from  liquefaction  of  the  Wharton  jelly. 

Syphilis  of  the  cord  has  already  been  mentioned.  The  thickening  of  the  tunica 
media  of  the  vessels  and  calcification,  with  obliteration  of  the  lumen,  found  here, 
have  also  been  found  in  other  conditions,  and,  therefore,  they  are  not  pathog- 
nomonic of  lues. 

Abnormal  Insertion  of  the  Cord. — Ordinarily,  the  cord  is  inserted  at  or  near 
the  center  of  the  i^hicenta.  Eccentric  insertion,  even  attachment  at  the  margin,  is 
not  rare.  Battledore  placenta  has  no  clinical  importance.  When  the  cord  is  at- 
tached to  the  membranes  and  the  vessels  course  a  greater  or  less  distance  between 
the  amnion  and  the  chorion  to  the  body  of  the  placenta  we  speak  of  velamentous 


ANOMALIES    Or   THE    CORD    AND    OF   THE    AMNION 


561 


insertion — inscrtio  vclaniciitosa  (Fig.  493).  I'jnl)ry(jIop;ists  arc  still  at  variance 
as  to  niechaui.sni  of  the  production  of  the  aberrant  insertion  of  the  cord.  Von 
Franque's  idea  that  the  exceptionally  good  nutritional  conditions  of  the  reflexa 
lead  to  the  insertion  of  the  ahdoniinai  pedicle  here  seems  quite  plausible,  but  is 
unproved  (Peiser). 

Velanientous  insertion  is  often  found  witii  other  anomalies  of  the  placenta,  as 
infarcts,  placenta  succenturiata,  bilobata,  and  previa.  It  is  common  with  twins 
and  the  rule  with  triplets.  To  the  child  this  abnormal  insertion  of  the  cord  is 
dangerous  only  when  the  vessels  run  across  the  lower  uterine;  segment;  then  its 
life  may  be  lost  through  hemorrhage,  from  tearing  of  one  or  more  of  the  vessels  when 
the  membranes  rupture,  or  asphyxia  from  compression  of  the  vessels  and  the  cord 
during  the  passage  of  the  head.  Both  twins  may  bleed  to  death  from  the  tearing  of 
one  vessel.     Occasionally  a  diagnosis  may  be  made  before  rupture  of  the  mem- 


Fig.  493. — Author's  Case  of  Velamentous  Insertion  op  Cord. 
Child  passed  through  rent  and  was  asphyxiated,  but  not  anemic. 


branes — the  pulsating  vessels  may  be  felt  inside  the  cervix  coursing  over  the  pouting 
bag  of  waters.  These  vessels  are  not  in  the  forelying  cord,  because  light  pressure 
upward  would  displace  the  latter.  A  slight  but  continuous  hemorrhage  after  the 
rupture  of  the  membranes,  with  weakening  and  rapidity  of  the  fetal  heart-tones,  is 
diagnostic.  Placenta  prtevia  and  other  maternal  causes  of  bleeding  are  easily  elimi- 
nated and  by  exclusion  the  true  condition  recognized. 

Treatment. — If  the  diagnosis  is  made  before  rupture  of  the  membranes,  the 
latter  must  be  delayed  until  dilatation  of  the  cervix  is  complete,  which  is  accom- 
plished by  placing  a  soft  elastic  colpeurynter  in  the  vagina  and  putting  the  woman  in 
the  elevated  Sims  position.  AMien  the  os  is  fully  opened,  the  membranes  are  to  be 
punctured  l^etween  the  vessels  and  delivery  effected  as  rapidly  as  is  consistent  with 
the  safety  of  the  mother. 

Hernias  into  the  cord  are  not  so  very  rare.  This  must  always  be  thought  of 
36 


562      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

while  tjdng  the  cord.  Hernias,  if  operable,  should  be  closed  immediately,  to  avoid 
peritonitis.  Occasionally  the  skin  of  the  belly  runs  up  for  a  varying  distance  on 
the  cord,  called  "skin  navel,"  and  after  the  stump  has  fallen  off  the  retraction  of 
the  center  inverts  this  skin,  making  a  deep  retracted  navel.  Sarcomphalus  is 
likely  to  result  in  such  instances. 


ANOMALIES  OF  THE  AMNION 

Beside  certain  minor  pathologic  findings  on  the  amnion,  as  caruncles,  epithe- 
lioid deposits  containing  lanugo  hairs,  cysts  near  the  insertion  of  the  cord,  scratch- 
marks  from  the  child's  nails,  and  adhesions  to  the  fetus,  the  amnion  presents  two 
important  conditions  for  study — polyhydramnion  and  oligohydramnion,  the  first 
meaning  an  excessive  quantity  and  the  latter  an  abnormally  small  amount  of  liquor 
amnii.  Normally,  the  amount  varies  within  wide  limits,  from  600  to  2000  gm. 
We  do  not  know  the  exact  source  of  the  liquor  amnii,  and,  therefore,  it  is  impossible 
to  give  a  scientific  etiology  of  the  anomalies  of  the  fluid. 

Polyhydramnion,  hydramnion,  or  hydramnios,  is  more  common  than  oligo- 
hydramnion, and  occurs  about  once  in  200  cases.  As  many  as  15  and  30  liters  of 
fluid  have  been  reported,  but  such  cases  are  exceedingly  rare.  In  one  of  my  cases 
we  measured  8  quarts,  and  much  more  escaped  into  the  bed  and  onto  the  floor. 
Ovular  and  maternal  causes  have  been  invoked.  Of  ovular,  the  fetus,  the  cord,  the 
amnion,  and  the  placenta  may  be  involved.  (1)  Malformations  of  the  child,  es- 
pecially those  showing  absence  of  closure  of  fetal  cavities,  harelip,  anencephalus, 
ectopia  vesicae,  spina  bifida,  etc.  Internal  deformities  are  sometimes  associated 
with  the  polyhydramnion,  for  example,  occlusion  of  the  esophagus,  stenosis  of  the 
pylorus.  In  the  former  instance  the  liquid  is  supposed  to  be  due  to  transudation 
from  the  insufficiently  covered  blood-vessels  of  the  deformed  part.  (2)  Diseases  of 
the  child  involving  obstruction  of  its  venous  circulation,  and  causing  stasis,  edema, 
and  exudation,  for  example,  stenosis  of  the  cord,  stenosis  of  the  aorta,  of  the  ductus 
Botalli,  heart  disease,  cirrhosis  of  the  liver,  white  pneumoiiia  (syphilis),  placental 
disease,  obliteration  of  the  placental  blood-vessels,  chorio-angioma.  In  these  cases 
fhe  fetal  kidneys  increase  their  action,  and  there  is  perhaps  more  urine  in  the  liquor 
amnii.  (3)  Hydramnion  in  unioval  twins  is  not  uncommon,  and  one  or  both  of  the 
ova  may  be  affected  equally,  or  one  more  than  the  other,  or  there  may  even  be  oligo- 
hydraimiion  in  one  ovum.  In  homologous  twins,  when  one  child  is  stronger  than 
the  other,  its  heart  forces  blood  through  the  intermediate  or  "third"  circulation 
into  the  vascular  system  of  the  other,  causing  enlargement  of  the  latter's  heart, 
increased  kidney  action,  and  even  transudates  from  its  vessels.  (4)  Increase  of  the 
fetal  urine  may  cause  hydramnion,  but  we. know  no  cause  for  the  former.  Jaggard 
reported  a  fetus  with  deficient  kidneys  and  oligohydramnion  (Wilson). 

Older  writers  spoke  of  an  amnionitis,  and  later  investigators  have  found  in- 
flammatory and  degenerative  changes  in  the  amnial  epithelium.  Ahlfeld  believes 
that  an  early  amnionitis  produces  adhesions  to  the  fetus,  with  resulting  deformities, 
such  as  craniorachischisis,  gastroschisis,  amputation  of  the  extremities,  etc.  The 
amnion  offers  promise  of  great  results  from  scientific  investigation. 

Maternal  diseases  arc  seldom  the  cause  of  polyhydramnion:  (1)  All  those 
affections  which  make  general  anasarca — cardiac,  lung,  liver,  and  kidney;  (2) 
syphilis,  leukemia,  chronic  anemia — in  such  cases  the  fetus  usually  has  hydrops 
universalis. 

Clinical  Course. — Two  varieties  are  distinguishable — the  acute — very  rare — and 
the  chronic,  the  commoner.  Acute  hydramnion  is  graver,  and  usually  leads  to 
abortion.  It  begins  during  the  fourth  or  fifth  month,  and  rapidly  expands  the 
uterus  to  colossal  size,  pressure  symptoms  ])eing  early  and  pronounced.  There  are 
pain  in  the  abdomen,  back,  and  thighs,  feeling  of  great  distention,  dyspnea,  espe- 


ANOMALIES    OF   THE    CORD    AND    OF   THE    AMNION  5G3 

cially  in  primiparif,  with  attacks  of  suffocation  when  the  attempt  to  lio  down  is 
made,  nausea  and  voiiiitinfi;,  and  symptoms  referal>le  to  tlio  kidney  of  pregnancy  or 
even  of  nephritis.  Emaciation  maybe  marked,  fever  present;  edema  of  the  legs, 
thighs,  and  even  the  alxlomcn,  with  enormous  (Hstcntion  of  the;  latter,  will  be  found. 
The  uterus  may  l)e  larger  than  at  term,  the  belly  so  tight  and  tender  that  palpation 
is  rendered  negative,  but  fluctuation  is  usually  obtainable.  Stria)  gravidarum 
cover  the  skin,  and  often  minute  hemorrhages  bestrew  it;  fetal  parts  are  not  palpable, 
and  the  heart-tones  may  be  jnaudible.  Vaginally,  the  cervix  is  found  high  up, 
effaced,  and  the  os  usually  opened.  As  a  rule,  acute  hydramnion  terminates  in 
ab(M'tion  before  the  sixth  month,  or  the  symptoms  Ijecome  so  threatening  that  the 
attentlant  nmst  interfere.  Twins  are  often  found  in  such  cases,  and  a  spontaneous 
cure  may  follow  if  one  of  them  should  die. 

Didgnosis. — If  a  diagnosis  of  pregnancy  had  already  been  made,  the  rapid  en- 
largement of  the  uterus  with  abdominal  symptoms  will  be  easily  explained.  H^'da- 
tidiform  mole  causes  not  such  rapid  growth  of  the  uterine  tumor,  and,  further,  it  is 
almost  always  complicated  by  hemorrhages.  Generally,  the  first  duty  is  to  diag- 
nose pregnancy,  which  is  usually  not  difficult  if  all  the  aids  are  called  upon.  Con- 
tractions occurring  in  the  abtlominal  tumor  on  one  occasion  enabled  me  to  diagnose 
the  condition  when  all  other  findings  were  equivocal.  Ovarian  cyst  oftenest  recjuires 
differentiation,  but  in  this  condition  the  uterus  is  usually  found  below  the  large 
fluctuating  tumor,  the  cervix  is  closed  and  hard  (open  and  soft,  with  palpable  mem- 
branes in  hydramnion),  and  the  symptoms  and  other  signs  of  pregnancy  are  absent. 
Ascites  shows  the  characteristic  area  of  tympany  around  the  navel,  which  changes 
with  position.  Encysted  (tubercular)  ascites  was  once  mistaken  for  polyhydram- 
nion.  In  critical  cases,  where  a  diagnosis  must  be  made,  it  is  justifiable  to  use  the 
uterine  sound  because,  if  the  case  really  is  acute  hydramnion,  the  puncture  of  the 
membranes  is  the  proper  treatment. 

Treatment  of  acute  hydramnion  is  abortion,  Ijy  letting  off  the  waters,  which 
must  be  done  slowly  to  avoid  shock,  the  case  being  then  left  to  nature,  and  other 
interference  being  made  only  on  special  indication. 

Chronic  Hydramnion. — This  differs  from  the  acute  in  that  the  course  is  much 
less  stormy— it  does  not  lead  so  often  to  abortion,  though  premature  labor  is  fre- 
quent. It  is  commoner  and  a  little  more  amenable  to  treatment.  It  may  occur  in 
ectopic  gestation,  which  renders  diagnosis  very  difficult.  Causation  and  symptoms 
are  the  same  as  in  the  acute  form,  but  the  latter  are  less  marked  and  of  longer  dura- 
tion. Enormous  distention  of  the  uterus  may  occur,  wdth  resulting  cardiac  distress 
and  kidney  insufficiency.  The  patient  may  be  annoyed  by  false  laljor  pains  for 
weeks  before  delivery.  The  diagnosis  lies  most  often  between  hydramnion  and 
twins,  but  it  must  be  remembered  that  they  are  often  associated.  In  one  of  my 
cases  the  bag  of  waters,  felt  over  the  internal  os,  was  relaxed,  while  the  uterus,  felt 
abdominally,  w^as  very  tense,  a  fact  which  Remy  and  Ahlfeld  noted,  and  which 
they  used  for  the  diagnosis  of  hydramnion  of  the  upper  twin.  Fluctuation  is 
demonstrable  only  in  the  hydramniotic  sac;  it  does  not  pass  through  the  septum 
between  the  twins. 

The  prognosis  of  acute  hydramnion  is  good  for  the  mother,  because  abortion 
usualh'  terminates  the  case  early.  In  general  the  prognosis  is  not  bad,  but  one 
should  remember  the  dangers — kidney  lesions,  cardiac  collapse,  respiratory  failure, 
hydroperitoneum,  and  hydropleura.  Labor  may  bring  added  troubles — for  ex- 
ample, a  tedious  first  stage,  sometimes  lasting  days,  prolapse  of  the  cord  w^hen  the 
membranes  rupture  and  the  sudden  rush  of  the  waters  takes  place;  abnormal 
presentations  and  positions  of  the  child,  weak  labor  pains,  the  last  three  recjuiring 
operative  interference;  atonia  uteri  and  postpartum  hemorrhage,  which  often  is 
hard  to  stop.  The  sudden  rush  of  the  waters,  besides  causing  the  mentioned  anoma- 
lies, may  leave  so  small  a  uterine  cavity  that  abruptio  placentae  results,  or  the  heart 


564      THE  PATHOLOGY  OF  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

cannot  stand  the  shock  of  the  sudden  diminution  of  intra-abdominal  tension.  Fi- 
nally, the  cause  of  the  polyhydramnion  may  have  a  bearing  on  the  prognosis,  for 
example,  syphilis,  anemia,  heart  and  kidney  lesions. 

For  the  child,  the  prognosis  is  bad  in  acute  hydramnion,  but  in  the  chronic 
forms  it  is  fairly  good.  An  expression  of  opinion  should  be  guarded,  because  of  the 
frequency  of  prematurity  and  of  fetal  deformities,  which  may  make  extra-uterine 
existence  impossible.  In  the  higher  degrees,  the  mother  being  very  cyanotic,  the 
child  or  children  may  die  of  asphyxia  before  delivery,  and  many  succumb  during 
operative  procedures  necessitated  by  prolapse  of  the  cord,  etc. 

Treatment. — Syphilis,  anemia,  renal  and  cardiac  disease,  of  course,  are  to  be 
appropriately  treated,  though  much  success  is  not  attained.  When  the  symptoms 
become  marked,  the  patient  should  stay  in  bed,  on  an  antinephritic  diet,  and  should 
be  carefully  watched.  Should  the  heart  begin  to  suffer  or  the  kidneys  prove  de- 
fault, labor  is  to  be  induced,  the  best  method  being  to  let  off  the  excessive  waters 
through  a  small  trocar,  such  as  is  used  for  ovarian  cysts.  It  is  important  to  let  the 
waters  off  slowly  to  avoid  shock  from  sudden  decrease  of  intra-abdominal  tension, 
and  to  prevent  the  prolapse  of  the  cord  or  extremities.  Delivery  of  the  child  should 
also  be  slow,  to  enable  the  uterus  to  get  a  better  hold  on  itself  by  retraction  of  its 
fibers.  Preparations  for  postpartum  hemorrhage  are  to  be  made  beforehand,  and 
the  placenta  removed  on  the  first  indication,  after  which  the  uterovaginal  tract  is 
to  be  firmly  packed  with  gauze. 

Oligohydramnion. — Decrease  of  the  amount  of  liquor  amnii  is  rare,  and  in  such 
cases  there  may  be  a  few  spoonfuls  of  thick,  viscid  or  cloudy,  yellowish-green  fluid, 
insufficient  to  fill  the  interstices  between  the  fetal  parts  and  the  uterus.  If  the  con- 
dition occurs  early  in  fetation,  it  results  in  more  or  less  adhesion  of  the  amnion  to 
the  fetus,  causing  deformities,  for  example,  hemicephalus,  cranioschisis,  gastro- 
schisis,  spina  bifida,  amputation  of  extremities,  curvatures,  ankylosis  of  joints,  and 
skin  defects.  If  the  liquor  amnii  is  lacking  in  the  later  months,  the  skin  of  the  child 
becomes  dry  and  leathery,  the  fetal  body  is  cramped  together,  club-foot,  drop-wrist, 
skin  defects  on  the  shoulders,  trochanters,  malleoli  (decubitus),  curvature  of  the 
spine,  shortening  of  the  muscles,  such  as  wry-neck,  talipes  calcaneus,  etc.,  are  found 
— all  the  result  of  limitation  of  the  confines  of  the  child  and  of  pressure  of  the  uterine 
wall  on  its  body. 

These  same  conditions  are  found  in  extra-amniotic  development  of  the  child  and 
in  extra-uterine  pregnancy. 

Nothing  is  definitely  known  of  the  causation  of  oligohydramnion.  Jaggard's 
case  of  absence  of  urethra  and  kidney  has  been  referred  to.  Oligohydramnion  can 
affect  one  twin,  there  being  an  excess  of  fluid  with  the  other. 

During  labor,  which  is  often  premature,  painful  uterine  contractions,  weak 
pains,  protracted  first  stage,  a  tendency  to  abruptio  placentae,  and  increase  in  the 
dangers  to  the  child  have  been  noted. 

Literature 

Brickner:  Amer.  Jour.  Obstet.,  1902,  vol.  xlv,  p.  512. — Pi-lner:    Monatssohr.  f.  Geb.  u.  Gyn.,  1898,  vol.  viii,  p.  619. — 

Wilson:  Amer.  Jour.  Ob.stet.,  1SS7,  vol.  xx,  p.  1. 


SECTION  VI 
THE  PATHOLOGY  OF  LABOR 


An  obstetric  case  is  a  surgical  case,  with  more  than  the  usual  surgical  aspects. 
Older  writers  used  to  speak  of  eutocia  and  dystocia,  the  former  meaning  normal,  the 
latter  abnormal,  labor.  No  two  authorities  are  agreed  as  to  where  eutocia  ends 
and  dystocia  begins.  Most  authors  ])elieve  that  labor  in  the  human  female  borders 
very  closely  on  the  pathologic,  l)ut  I  am  convinced  that,  today,  measured  by  our 
present  standards,  labor  cannot  be  called  a  normal  function.  To  mention  only  one 
reason  for  so  considering  it,  the  almost  invariable  injury  to  the  pelvic  floor  may  be 
cited.  No  other  function  of  the  body,  normally  executed,  is  attended  by  perma- 
nent damage  to  structure.  Should  such  damage  occur,  we  call  the  process  patho- 
genic and  pathologic.  I  believe  that  the  notion  that  labor  is  normal  is  a  fallacy, 
and  that  this  fallacy  is  fundamentally  responsible  for  the  still  high  mortality  and 
morbidity  which  attend  the  parturient  function.  Taking  for  granted  that  parturi- 
tion is  normal,  the  State  allows  ignorant  midwives  and  half-instructed  medical 
students  to  assume  the  heavy  responsibilities  of  its  conduct.  Since  the  public  is 
taught  to  believe  that  labor  is  physiolo^c,  it  refuses  to  recognize  the  dignity  of  the 
science  and  the  high  degree  of  art,  of  obstetrics,  and,  as  a  result,  the  field  of  its  prac- 
tice is  not  made  inviting  to  the  best  men  of  the  profession.  Such  a  state  of  affairs 
naturally  explains  why  20,000  women  die  every  year  in  our  country  from  the  effects 
of  childbirth,  why  nearly  every  mother  carries  the  marks  of  injury  inflicted  during 
labor,  and  why  a  hundred  thousand  infants  are  annually  lost  during  delivery. 

It  is  best  to  regard  every  labor  case  as  a  severe  operation.  Like  the  surgeon, 
the  obstetrician  should  consider  the  strength  of  the  patient  in  standing  the  shock, 
the  asepsis  and  antisepsis,  the  nature  and  technic  of  the  operation,  and,  finally,  all 
the  complications  which  are  hkely  to  arise. 

So,  during  labor,  it  is  necessary  and  our  duty  to  have  a  clear  knowledge  of  the 
patient's  condition,  especially  of  the  heart,  lungs,  kidnej's,  and  blood;  second,  we 
must  know  accurately  what  is  going  on  during  the  labor,  that  is,  we  must  be  thor- 
oughly acquainted  with  the  mechanism  of  the  particular  labor,  the  strength  of  the 
powers,  the  greatness  of  the  resistances,  and  the  relation  between  them;  third,  we 
must  be  aware  of  all  possible  complications  and  the  particular  ones  likely  to  arise 
in  this  particular  case,  and  know  how  to  prevent  and  treat  them;  and,  finally,  we 
must  know  and  practise  the  strict  principles  of  asepsis  and  antisepsis,  that  the 
latest  standards  demand.  To  meet  all  these  ol)ligations  is  the  duty  of  the  obstetri- 
cian, and  a  conscientious  man  will  find  little  time  for  idling  at  a  labor  case.  It  re- 
quires studious  regard  of  the  patient  during  her  pregnancy,  and  gettmg  her  into  the 
best  possible  condition  for  the  ordeal  of  parturition.  It  requires  a  prompt  response 
to  the  call  to  the  labor,  a  careful  and  painstaking  examination  on  arrival,  and  a 
proper  valuation  of  all  the  conditions  found.  It  requires  attentive  conduct  of  the 
case  from  the  beginning  to  the  end,  and  a  preparedness  for  doing  the  usual  work  of 
a  delivery,  plus  far-reaching  provision  and  ability  for  all  emergencies. 

In  general,  the  abnormalities  of  a  labor  may  be  classed  under  three  heads: 
(1)  Anomalies  of  the  powers;  (2)  disproportion  between  the  passage  and  the  pass- 
engers;   (3)  comiDlications  on  the  part  either  of  the  mother  or  of  the  fetus. 

565 


566  THE    PATHOLOGY    OF    LABOR 

When,  in  the  course  of  his  study  of  a  labor  case,  the  accoucheur  notes  that  one 
or  the  other  of  the  three  irregularities  is  present  or  threatens,  he  decides  that  he 
must  do  something  to  save  the  mother  or  the  child  from  disaster — in  other  words, 
he  finds  an  indication  for  interference.  An  "indication,"  therefore,  is  a  reason  for 
interference  in  the  course  of  a  given  case.  However,  certain  circumstances,  char- 
acters, or  phases  of  the  case  may  cause  us  to  modify  the  indication;  in  other  words, 
the  accoucheur  must  consult  the  conditions  of  the  case  in  determining  the  course  of 
procedure.  A  "  condition,"  therefore,  is  a  prerequisite  or  requirement  which  governs 
the  incUcation.  For  example,  in  eclampsia  the  indication  is  for  immediate  delivery. 
The  state  of  the  cervix  is  one  of  the  conditions  which  will  determine  what  mode  of 
dehvery  will  be  selected.  The  study  of  the  case,  and  the  determination  that  this  or 
that  remedy  or  course  of  procedure  is  required,  we  call  "placing  the  indication." 
After  this  the  conditions  are  consulted.  If  they  are  all  fully  met,  the  line  of  procedure 
is  carried  out;  if  not,  the  indication  is  to  be  revised  until  it  does  meet  and  satisfy 
all  the  conditions,  or,  if  the  indication  is  imperative,  the  conditions  are  forced  to 
meet  it.  It  is  here  that  the  judgment  of  the  accoucheur  comes  to  the  test,  and, 
speaking  generally  and  reflectively,  I  affirm  that  there  are  no  situations  in  all  medi- 
cine and  surgery  that  require  broader  knowledge,  finer  discernment,  more  logical 
reasoning,  and  more  courageous  purpose  for  their  control  than  do  the  problems  of 
obstetrics. 


CHAPTER  XLVIII 
ANOMALIES  OF  THE  POWERS 

In  the  first  stage  of  hilxjr  tlie  uterus  does  all  the  work.  Regularly,  with  in- 
creasing frequency  and  strength,  its  muscle  contracts,  slowly  reaching  an  acme 
and  then  relaxing.  In  this  way  the  lower  uterine  segment  is  developed,  the  hydro- 
static bag  of  waters  formed,  the  cervix  effaced,  and  the  os  dilated.  In  the  second 
stage  the  larger  part  of  the  work  is  done  by  the  abdominal  muscles.  The  uterus  by 
this  time  is  well  drawn  up  over  the  child  and  can  exert  but  little  power.  While  in 
some  instances  the  uterus  expels  the  child  unaided,  its  main  action  in  this  stage  is 
forcing  the  presenting  part  against  the  pelvic  floor,  which,  reflexly,  elicits  the  action 
of  the  abdominal  muscles — the  bearing-down  efforts.  In  discussing  this  subject, 
therefore,  we  will  consider,  first,  anomalies  of  the  uterine  and  second  those  of  the 
abdominal  action. 

Anomalies  of  the  Uterine  Action. — The  pains  may  be  too  weak  or  too  strong, 
too  seldom  or  too  frequent,  too  short  or  too  long,  and  they  may  be  irregular  in  time 
and  in  character,  too  painful,  or,  rarely,  painless.  Even  normally,  much  variation 
may  be  noted  as  regards  the  time,  rhythm,  and  strength  of  the  labor  pains  in  differ- 
ent women.  Knowledge  of  the  character  of  the  pains  in  preceding  labors  will 
enaljle  us  to  predict  the  kind  of  uterine  action  in  subsequent  deliveries,  since  they 
are  usually  much  alike,  but  exceptions  are  not  rare. 

False  pains  are  the  contractions  of  pregnancy,  which,  toward  the  end  of  gesta- 
tion, become  perceptible,  even  painful,  to  the  gravida.  They  are  especially  marked 
at  the  time  of  lightening,  and  may  force  the  head  down  into  the  pelvis.  According 
to  Schatz,  they  recur  with  a  certain  periodicity,  the  intervals  being  less  by  one-half 
as  term  approaches.  All  the  usual  symptoms  of  an  actual  labor  pain  may  be  pres- 
ent, that  is,  pain,  hardening  of  the  uterus,  regularity,  even  dilatation  of  the  cervix 
and  rupture  of  the  membranes.  Most  authors  regard  the  last  two  as  indicative  of 
the  beginning  of  actual  labor.  Indeed,  it  is  often  impossible  to  say  when  pregnancy 
ends  and  labor  starts,  but  these  points  may  help  in  the  diagnosis:  false,  or  preg- 
nancy, pains  are  of  even  intensity,  while  true  pains  grow  stronger  apace;  they 
cease  after  a  day  or  so;  they  are  out  of  the  time  of  the  expected  labor,  and  if  their 
type,  i.  e.,  whether  they  appear  at  intervals  of  three,  four,  or  six  weeks,  is  known, 
they  will  recur  on  the  days  which  would  correspond  to  the  end  of  one-half  of  the 
previous  interval;  while  the  cervix  may  open,  it  is  not  shortened  nor  effaced,  the 
membranes  rarely  rupture,  and  the  bloody  show^  does  not  appear.  False  pains  are 
not  strengthened  by  pituitrin  (Hofbaucr).  It  is  important  to  recognize  the  false 
pains  and  treat  them  as  such,  because  if  the  woman  were  considered  to  be  in  labor, 
when  actually  she  is  not,  much  unnecessar}'  and  harmful  examination  and  inter- 
ference might  be  instituted.  Treatment  consists  of  rest  in  bed,  narcotics,  and  ex- 
pectancy. The  author  does  not  agree  with  those  who  would  allow  such  a  case  to 
continue  far  beyond  the  normal  term  of  pregnancy.  (See  Prolonged  Pregnane}' 
and  Induction  of  Labor  at  Term.) 

Weak  Pains. — Inertia  uteri,  atonia  uteri,  or  uterine  atony  may  show  itself  in, 
first,  infrequent  contractions,  w^eak  contractions,  and  too  short  contractions;  usually 
the  three  are  combined.  Clinically,  we  nmst  describe  the  condition  as  it  affects 
the  first  stage,  or  the  dilatation  of  the  cervix;  the  second  stage,  the  expulsion  of  the 
fetus;   and  the  third  stage,  or  the  period  of  the  after-birth.     In  the  first  stage  labor 

567 


568  THE    PATHOLOGY    OF   LABOR 

is  unduly  prolonged,  the  pains  are  weak,  at  long,  irregular  intervals,  and  last  only  a 
few  seconds.  Sometimes  they  intermit  for  a  few  hours  or  days,  reminding  one  of 
the  false  pains  just  considered.  After  a  rest,  uterine  action  is  resumed,  but  usually 
with  more  force.  Dilatation  of  the  cervix  may  require  several  days,  and  the  patient 
is  exposed  to  the  dangers  of  sepsis  and  exhaustion.  Should  fever  arise,  which  is 
especially  likely  if  the  bag  of  waters  is  ruptured,  the  pains  start  up  with  vigor  and 
terminate  the  labor,  if  this  is  possible.  Ordinarily,  the  child  is  in  no  danger  at  this 
time.  As  long  as  the  bag  of  waters  is  intact,  serious  trouble  is  unlikely.  Should 
it  rupture  early,  the  uterus  may  retract  firmly  on  the  fetus,  and  for  the  mother  there 
is  then  danger  of  infection  of  the  cavity  of  the  uterus.  Either  the  germs  wander  up- 
ward or  are  carried  up  by  the  too  frequent  examinations.  In  two  cases  of  the 
author  the  children  came  to  the  world  already  infected,  one  with  gonorrheal  oph- 
thalmia and  one  with  gastro-intestinal  sepsis. 

During  the  second  stage  weak  uterine  pains  are  responsible  for  weak  abdominal 
action,  because  the  presenting  part  is  not  forced  against  the  perineum  strongly 
enough  to  arouse  the  abdominal  muscles.  Expulsion  is  slow  or  stopped,  causing 
danger  to  the  mother  from  pressure  necrosis  of  the  pelvic  viscera,  which  may 
eventuate  in  fistulas.  The  child  in  utero  is  endangered  by  asphyxia.  In  the  third 
stage  weak,  infrequent,  or  short  pains  are  grave,  because  of  imperfect  separation  of 
the  placenta,  retention  of  membranes,  and  hemorrhage  from  insufficient  closure  of 
the  vessels  at  the  placental  site. 

Etiology.- — Primarily  weak  pains  may  be  due  to  poor  general  health,'  chronic 
wasting  disease,  tuberculosis,  or  anemia,  though  in  acute  affections  the  uterus 
generally  acts  well.  The  nervous  mechanism  may  be  disturbed,  the  muscle  being 
poorly  innervated,  or  the  nervous  balance  being  imperfect.  A  shock  may  frighten 
the  pains  away,  or  fear  of  an  operation  hasten  them.  In  hyperesthetic  women  the 
suffering  they  cause  may  be  inhibitory,  and,  contrary  to  what  would  be  expected, 
morphin  will  sometimes  strengthen  weak  pains.  Local  causes  are :  infantile  uterus, 
fibroids,  and  other  tumors  in  or  near  the  uterus;  peritoneal  adhesions,  which  inter- 
fere with  the  muscle  action;  full  rectum  and  bladder,  which  act  like  the  last;  ab- 
normal position  of  the  uterus;  retroflexion  or  anteversion  (pendulous  abdomen); 
disease  of  the  uterine  wall;  scars  from  previous  operations;  chronic  metritis,  with 
increase  of  fibrous  and  decrease  of  muscular  tissue;  endometritis;  too  frequent 
child-bearing,  with  overstretching;  old  primiparity;  conditions  of  the  ovum  which 
overdistend  the  uterus,  for  example,  polyhydramnion,  twins;  physometra;  ab- 
normal positions  of  the  child — breech,  shoulder,  face,  occipitoposterior,  which  pre- 
vent it  from  pressing  on  the  great  cervical  ganglion;  generally  contracted  pelvis; 
adhesion  of  the  membranes  around  the  os,  which  act  in  the  same  way,  a  poorly 
shaped  bag  of  waters  being  formed.  Secondary  weak  pains  are  due  to  fatigue  from 
overwork  and  to  retraction  of  the  contractile  portion  of  the  uterus  above  the  child. 
Sometimes  they  are  clue  to  stricture  of  the  uterus  {vide  infra) . 

The  diagnosis  of  atony  of  the  uterus  is  easy — the  organ  does  not  harden  firmly 
with  the  pain,  and  the  contraction,  timed  with  a  watch  and  feeling  the  fundus  with 
the  hand,  lasts  only  a  few  seconds.  There  is  no  progress  in  labor,  very  little  suffer- 
ing, and  the  pains  have  no  effect  on  the  fetal  heart-tones.  An  important  part  of 
the  diagnosis  is  the  determination  of  the  point  when  the  mother  and  child  begin  to 
be  endangered.  For  the  child,  this  is  usually  late  in  the  second  stage,  is  clue  to 
asphyxia  from  the  reduction  in  size  of  the  placental  area,  and  is  discovered  by  aus- 
cultation. For  the  mother,  it  depends  largely  on  the  cause,  the  worst  cases  being 
those  of  weak  pains  in  the  presence  of  disproportion  between  the  head  and  the  pelvis. 
Here  the  parts  beneath  the  zone  of  compression  become  edematous,  sometimes 
bloody,  later  anemic,  necroses  begin,  and  in  all  cases  the  tissues  lose  their  bacteri- 
cidal power,  which  invites  infection.  SweUing,  transudation,  edema,  fetid  dis- 
charge, pain,  nausea  and  vomiting,  fever,  etc.,  indicate  the  time  for  interference. 


ANOMALIES    OF   THE    POWERS  569 

Prognosis. — This  dcpontls  on  the  cause.  The  {greatest  danRors  arc  sepsis  from 
too  long  wuitinft",  from  too  many  internal  examinations  and  manii)uiations,  and  the 
injuries  infHcted  hy  too  early  and  umieeessary  oix'ratinji;. 

Trealnienl  should  be  varied  with  the  cause,  and  is  medical  or  mechanical,  (^ne 
of  the  best  remedies  is  to  put  the  patient  to  sleep,  and  morphin,  %  grain  hypoder- 
mically,  or  20  grains  sodium  bromid,  may  be  used.  Morpliin  is  safe  for  the  child 
onl}'  early  in  the  first  stage  of  lal)or.  The  effect  is  better  if  the  parturient  is  given 
a  full  warm  bath  beforehand.  While  in  the  tub,  the  genitals  are  protected  against 
the  access  of  the  infected  bath-water  by  means  of  a  large  pad  of  cotton.  After  a 
good  sleep  the  patient  usually  has  regular,  vigorous  pains.  Ergot  is  never  used,  and 
quinin  seldom.  Though  some  practitioners  report  success  with  the  latter  drug,  my 
own  experience  has  l^een  negative,  and  several  times  it  seemed  to  cause  the  pre- 
mature discharge  of  meconium  and  annoying  postpartum  oozing.  Sugar  in  half- 
ounce  doses  has  occasionally  seemed  to  help.  Latterly,  pituitrin,  introduced  by 
Hofbauer,  15  minims  hypodermically  every  three  hours  for  three  doses,  has  been 
used  with  success  in  pure  atonia  uteri.  In  my  experience  it  does  strengthen  the 
pains,  but  there  is  a  slight  danger  of  asphyxia  of  the  child  and  postpartum  hemor- 
rhage. On  this  account  I  start  with  5  minims  and  give  a  larger  dose  only  if  re- 
quired. If  a  stimulant  is  desired,  strychnin,  -^-jj  grain  every  three  hours,  and  hot 
coffee  may  be  used.  Much  patience  is  to  be  exercised,  and  suggestion,  with  mental 
and  moral  supi^ort,  must  be  given  the  parturient.  In  many  instances  a  large  dose  of 
castor  oil  will  i)rove  effectual. 

Mechanical  measures  are :  hot  sitz-bath;  hot- water  bag  to  the  fundus;  uterine 
massage;  letting  the  patient  change  her  position  or  walk  about;  electricity  to  the 
uterus  (useless  in  my  experience);  the  electric  vibrator  applied  evenlj^  over  the 
fundus;  a  hot  soapsuds  enema  (very  effective);  hot  vaginal  douches  (115°  F.), 
repeated  every  three  hours  (not  recommended) ;  insertion  of  a  bougie  into  the  lower 
uterine  segment;  application  of  a  small  colpeurynter  above  the  cervix,  and  traction 
on  it  so  as  to  irritate  the  cervical  ganglion;  packing  the  cervix  or  vagina  or  both 
with  gauze;  separation  of  the  membranes  around  the  internal  os  and  lower  uterine 
segment,  to  form  an  effective  hydrostatic  bag  of  waters;  and  puncture  of  the  mem- 
branes and  allowing  the  liquor  amnii  to  escape,  which  permits  the  uterine  fibers  to 
shorten  and  obtain  a  better  grasp  on  the  child. 

Occasionally,  in  a  primipara,  the  head  will  be  deeply  engaged,  but  the  cervix  is 
far  back  in  the  hollow  of  the  sacrum  and  very  thin.  The  membranes  are  tightly 
stretched  over  the  head,  and  there  are  no  forewaters.  By  pulling  the  cervix  gently 
to  the  middle  of  the  pelvis,  separating  the  membranes  around  the  lower  uterine 
segment  for  two  inches,  and  pushing  up  the  head  a  little  to  allow  some  liquor  amnii 
to  run  dovm.  and  make  a  pouch,  the  mechanism  of  labor  is  started  right  and  the 
pains  improve  at  once.  The  practitioner,  after  carefully  studying  the  asjDects  of 
the  individual  labor,  will  have  to  select  the  remedy  which  offers  the  best  hope  of 
stimulating  the  uterus.  Internal  manipulations  should  be  avoided  as  far  as  pos- 
sible, and  expectancy  carried  to  the  point  of  threatened  danger. 

Anomalies  of  the  Abdominal  Powers. — Weakness  of  the  abdominal  powers 
may  l)e  primary  or  secondary.  Either  the  woman  has  poorly  developed  abdominal 
muscles,  the  result  of  tight  lacing  or  insufficient  exercise,  or  the  muscles  are  pre- 
vented from  contracting  by — (1)  Inflammatory  conditions  in  the  belly;  for  ex- 
ample, appendiceal  abscess;  (2)  hernias;  (3)  cardiac  and  pulmonary  disease  with 
dyspnea;  (4)  tumors  in  the  abdomen — fibroids,  cysts;  full  bladder;  tympany; 
fat.  Women  with  pendulous  belly  have  insufficient  abdominal  action  because  the 
diastatic  recti  cannot  get  a  purchase  on  the  uterus,  which  has  fallen  forward  be- 
tween them.  Comatose  and  narcotized  women,  the  reflexes  being  abolished,  do 
not  bear  dowTi,  but  when  the  coma  is  not  deep,  the  abdominal  muscles  act  reflexly 


570 


THE    PATHOLOGY    OF   LABOR 


and  sometimes  powerfully,  as  may  be  seen  in  eclampsia  and  obstetric  anesthesia. 
Hypersensitive  women  sometimes  will  refuse  to  bear  down  because  it  hurts  too 
much,  and  in  such  cases  anesthesia  to  the  obstetric  degree,  by  abolishing  the  pain, 
will  apparently  strengthen  the  abdominal  muscles.  Sometimes  the  parturient 
actually  does  not  know  how  to  use  the  abdominal  muscles,  and  needs  to  be  taught 
how  to  bear  do\^^l  effectively.  Again,  she  bears  down  strongly  enough,  but  the 
antagonistic  muscles  of  the  pelvic  floor  contract  spasmodically  and  hold  the  head 
back.  The  woman  must  bp  shown  how  to  relax  the  outlet  while  bearing  down. 
Secondary  weak  abdominal  action  arises  either  from  exhaustion,  the  woman  having 
used  up  her  stock  of  strength  in  fruitless  bearing-down  efforts  in  the  first  stage, 
when  they  could  do  no  good  and  much  harm,  or  the  resistances  of  the  delivery  have 
proved  too  much  for  her.  She  may  have  had  too  little  reserve  power,  or  the  weak 
uterine  contractions  have  been  unable  to  evoke  sufficiently  powerful  response  in 


Fio.  494. — Physician  Instructing  Pakturient  how  to  Use  her  Powers  to  Best  Advantage. 


the  abdominal  muscles.  Voluntary  bearing-down  efforts  are  never  so  strong  nor 
so  effectual  as  those  elicited  by  the  uterine  contractions.  Curiously,  sometimes  a 
weak  uterine  pain  will  produce  a  strong  bearing-down  effort.  A  prolonged  first 
stage  is  thus  sometimes  followed  ])y  a  quick  second  stage,  but  in  such  cases  atony 
of  the  uterus  in  the  placental  period  is  often  to  be  anticipated. 

Prolongation  of  the  second  stage  is  the  result  of  insufficient  abdominal  action, 
and  ordinarily  neither  patient  runs  much  risk  unless  the  delay  exceeds  five  hours. 
Most  text-books  exaggerate  the  dangers  of  simple  weakness  of  the  expulsive  powers. 
This  condition  must  ]m  sharply  differentiated  from  resistant  outlet  with  strong 
pains.  Owing  to  the  pressure  exerted  by  the  head  on  the  pelvic  viscera,  fistulas  may 
possibly  result,  though  they  usually  do  not,  the  vulva  becomes  edematous  and  fri- 
able, and  aid  may  have  to  be  rendered  simply  because  of  the  delay  and  the  depressing 


ANOMALIES    OF   THE    POWERS 


571 


cl'l'ect  on  the  womuu's  nervous  system.  For  the  cliild,  such  u  stoppuK<!  in  the  lal>or 
may  become  dungerous  from  asphyxia,  the  placental  area  l^eing  diminished  since 
th<'  uterus  has  retracted;  tiie  caput  succedaneuni  Ix-comes  very  large,  which,  inci- 
dentall>',  indicates  that  the  fetus  is  sufTeriiig  from  cerebral  congestion,  and  the  cord, 
if  it  is  in  tiie  ])elvis,  may  suffer  injurious  pressure. 

Treatment. — First  in  the  order  of  procedure  is  a  careful  diagnosis  of  the  cause 
of  tiie  delay  in  labor,  which  includes  the  determination  of  the  location,  the  station, 
or  the  degr(>e  of  engagement  of  the  head  or  presenting  part.  Weak  uterine  contrac- 
tions in  this  stage  rccjuire  tiie  same  treatment  as  in  the  first  stage  {q.  v.).  In  cases 
of  intlaumuitory  conditions  in  the  bell>-,  and  in  cardiac  and  respiratory  diseases, 


I'ln.  105. — KxAOf.EKATF.n   I.itiiotdmy   rn^rTinx. 


the  woman  should  not  ])e  allowed  to  bear  down  too  much,  but  extraction  is  to  be 
performed.  Pendulous  belly  is  treated  with  a  binder.  (See  p.  400.)  If  the  patient 
is  tired  out,  a  short  respite  is  given  her  by  means  of  light  ether  anesthesia,  after 
which  she  may  work  to  better  advantage.  Ether  given  to  dull  the  pain  in  the 
stretching  perineum  may  remove  the  inhibition  on  the  abdominal  muscles.  A 
change  of  position  from  side  to  back,  or  back  to  side,  or  to  the  sitting  posture,  or 
even  a  short  walk,  may  be  useful.  A  multipara,  however,  may  not  go  far  from  the 
bed.  Ergot  is  never  to  be  given  to  stimulate  the  uterus.  A  valuable  help  is  the 
instruction  of  the  parturient  as  to  the  best  way  to  bear  down,  and  the  physician,  in 
a  sterile  gowm,  may  sit  on  the  edge  of  the  bed,  and,  grasping  the  woman's  hands, 
with  each  pain  show  her  how  to  get  the  most  out  of  her  efforts  (Fig.  -49-4).  Another 
plan  which  has  been  of  inestimable  service  in  my  practice  is  to  place  the  woman  in 


572 


THE    PATHOLOGY    OF   LABOR 


the  exaggerated  lithotomy  posture  (Fig.  495).  The  thighs  support  the  abdominal 
muscles  and  thus  strengthen  them;  an}'  tendency  to  pendulous  belly  is  corrected; 
the  fetus  is  straightened  out,  the  levator  ani  tightened  (which  facilitates  anterior 
rotation  of  the  occiput),  and  the  outlet  of  the  bony  pelvis  is  enlarged. 

By  putting  the  patient  in  a  squatting  Indian  attitude  against  either  a  wall  or 
the  bed,  as  King  recommends  so  highl}',  the  same  results  are  obtainable,  but  it  is 
not  so  eas3'  nor  so  comfortable  (Fig.  355).  A  hot  enema  may  hasten  delivery  by  un- 
loading the  bowel  and  by  stimulating  the  forces.  If  the  head  is  well  down  on  the 
perineum,  Kristeller's  expression  may  be  employed  (Fig.  496).  Both  hands  are 
evenly  spread  over  the  fundus,  and  during  the  pains  gently  applied,  but  firm  pressure 
is  exerted  in  the  axis  of  the  inlet.  As  the  contraction  of  the  uterus  diminishes,  the 
force  applied  is  to  lessen.  It  is  impractical  to  keep  up  the  pressure  between  pains. 
Kristeller's  expression  is  not  without  clangers — rupture  of  the  uterus,  abruptio 
placentae,  injury  to  the  abdominal  viscera,  and  for  this  reason  it  should  seldom  be 


•»-^^' 


Fig.  496. — Kristeller  Expression. 


used  in  multiparse,  never  when  there  is  the  least  sign  of  thinning  of  the  lower  uterine 
segment,  and  always  with  only  moderate  force. 

If  the  head  is  so  low  that  the  forehead  has  passed  the  coccyx,  Ritgen's  man- 
oeuver  may  be  used,  that  is,  pressing  the  head  out  with  two  fingers  working  from 
the  rectum.  While  the  objection  on  the  score  of  infection  could  be  removed  by  the 
use  of  rubber  gloves,  there  is  still  danger  of  injury  to  the  rectum,  and  cracks,  fissures, 
infiltrates,  bruises,  with  subsequent  stricture,  are  to  be  considered.  By  placing  the 
two  fingers  outside,  on  the  perineum,  one  on  each  side  of  the  coccyx,  with  the  flat- 
tened rectum  between  thcnn,  sometimes  one  can  obtain  sufficient  purchase  on  the 
forehead  to  aid  materially  in  the  delivery  (Fig.  497).  This  operation  may  be 
advantageously  combined  with  episiotomy.  Incision  of  the  perineum  is  a  very 
useful  operation,  and,  if  all  that  is  needed  to  complete  the  labor  is  overcoming  the 
resistance  of  the  vulvar  outlet,  episiotomy  shows  brilliant  results.  Indeed,  the 
author  often  performs  it  to  save  the  pelvic  floor  from  excessive  stretching. 

If  encouragement  and  instruction  of  the  parturient  and  the  above  measures 
fail,  forceps  are  to  be  applied,  and  easily  75  per  cent,  of  the  forceps  operations  in 
America  are  done  for  indications  of  this  nature. 


ANOMALIES    OF   THE    POWERS 


673 


The  above  remarks  apply  to  the  treatment  of  weakness  of  the  abdominal 
muscles,  when  the  second  stage  is  well  on,  and  the  head  deeply  engaged  in  the 
pelvis — even  visil)le  in  the  vulva.  If  the  head  is  not  engaged,  but  still  above  the 
inlet,  the  case  is  much  more  formidable.  "What  was  said  regarding  tlu;  treatment 
of  weak  pains  in  general  applies  here.  Unless  the  head  can  be  gotten  to  enter  the 
pelvis  by  the  usual  nutans,  a  high  forceps  operation  or  version  and  extraction  will 
be  r('(iuired,  both  of  which  arc  dangerous,  under  such  circumstances,  because  of  the 
frequency  and  extent  of  the  necessarily  inflictetl  lacerations,  and  the  usually  severe 
and  sometimes  intractable  atony  of  the  uterus  postpartum.  Manual  removal  of 
the  placenta  is  often  necessitated,  which  adds  to  the  danger  of  infection.  Hof- 
meier  recommended  pressing  the  head  into  the  pelvis  from  the  outside,  using  two 
hands,  and  under  favorable  special  conditions  this  may  succeed.  The  Walcher 
posture  has  been  used,  but  with  only  moderate  success.  (Sec  Treatment  of  Con- 
tracted Pelves.)  In  some  cases  the  squatting  posture  favors  the  passage  of  the 
head  through  the  inlet,  especially  with  pendulous  abdomen.     Should  operative 


Fig.  497 


-Ritgen's  Manceits'ek,  with  Two  Fingers  at  Either  Side  of  Rectum. 
Drawn  from  a  photograph. 


delivery  be  imperatively  demanded,  all  preparations  must  he  made  to  avoid  the 
above-named  dangers. 

Myoclonia  Uteri,  or  Cramp  Pains. — When  the  action  of  the  uterus  is  irregular, 
painful,  and  inefficient,  even  though  the  force  apparently  exerted  is  normal  or  even 
greater  than  normal,  we  speak  of  cramp  pains  or  myoclonia  uteri.  The  condition 
is  closely  allied  to  tetanus  or  spasmus  uteri,  about  to  be  considered.  Labor  is  very 
painful  and  prolonged;  the  women  feel  that  the  pains  do  no  good,  and  become 
nervous,  highly  excited,  and  sometimes  even  delirious.  The  constant  suffering, 
with  inappreciable  progress  in  the  labor,  throws  the  i^arturicnt  into  a  sort  of  frenzy. 
In  the  second  stage  these  pains  are  of  less  significance,  ])ut  if  the  first  stage  was  much 
prolonged,  atonia  uteri  may  have  resulted  and  artificial  delivery  maj'  be  needed 
because  labor  has  stopped.  The  danger  of  cramp  pains,  besides  their  bad  effect  on 
the  morale  of  the  parturient,  lies  in  asphA-xia  of  the  child,  and  in  the  possible  in- 
juries and  infections  from  the  operations  rendered  necessary  by  the  delay.  Cases 
of  real  myoclonia  uteri  are  rare:   most  of  them  are  instances  of  strictura  uteri. 

Tetanus  Uteri;    Strictura  Uteri. — "When  the  uterus  passes  into  a  state  of  tonic 


574  THE    PATHOLOGY   OF   LABOR 

contraction,  we  speak  of  tetanus  uteri.  If  the  spasm  involves  only  one  zone  of  the 
organ,  the  term  strictura  uteri  is  applied.  Older  writers  believed  the  condition  was 
frequent,  and  called  it  hour-glass  contraction  of  the  uterus.  Jaggard  denied  its 
existence,  but  there  is  no  doubt  that  it  occurs,  and,  in  the  author's  experience,  not 
rarely.     A  spasm  of  the  external  os  is  also  described,  but  this  is  very  uncommon. 

The  causes  of  cramp  pains,  tetanus,  and  strictura  are  much  alike,  an  unstable 
nervous  sj^stem  being  the  most  frequent  predisposing  factor.  Locally,  any  irritant 
to  the  cervix  or  uterine  wall  will  evoke  tempestuous  action,  for  example,  too  fre- 
quent examinations,  especially  if  combined  with  attempts  to  dilate  the  cervix; 
chronic  metritis  and  cervicitis;  the  improper  use  and  application  of  hydrostatic 
bags;  premature  attempts  at  delivery  through  an  ill-dilated  cervix;  irritation  of 
the  uterine  wall  by  the  hand,  bougies,  douches;  and  rupture  of  the  membranes  and 
escape  of  the  liquor  amnii,  which  permit  the  uterine  wall  to  apply  itself  too  firmly 
on  the  irregular  and  knobby  fetal  body.  It  will  be  noticed  that  the  remedies  recom- 
mended for  the  treatment  of  atony  of  the  uterus  may  send  the  organ  into  tempestu- 
ous action  or  cause  stricture.  Obstructed  labor  produces  a  condition  analogous  to 
tetanus  uteri,  but  here  the  uterus  is  moderately  firm  all  the  time,  and  the  contrac- 
tions are  regular  and  powerful — sometimes  sufficiently  so  as  to  burst  it.  A  uterus  in 
tetanic  spasm  vdW  not  rupture,  but  operations  undertaken  during  the  contraction 
will  tear  it  if  too  much  force  is  used.     (See  Contracted  Pelvis.) 

Ergot,  in  the  olden  times,  was  frequently  responsible  for  tetanus  uteri,  but 
now,  since  it  has  been  discarded  as  the  result  of  almost  universal  condemnation  by 
obstetric  authorities,  one  rarely  meets  such  a  case,  except  perhaps  in  the  practice 
of  midwives. 

Tetanus  uteri  completely  stops  labor;  the  woman  complains  of  continuous 
pain;  the  child  dies  as  the  result  of  asphyxia,  the  contracted  uterus  preventing  the 
oxj^genation  of  the  fetal  blood,  and  soon,  because  of  the  same  circulatory  disturb- 
ance, infection  of  the  uterus  and  contents  occurs.  When  sepsis  begins,  the  pulse 
and  temperature  mount  rapidly,  the  skin  becomes  dry,  the  face  cyanotic  or  red,  and 
great  tenderness  in  and  around  the  uterus  is  noticeable.  The  liquor  amnii  takes  on 
a  bad  odor,  is  discolored, — a  cloudy  green  or  gray, — ^the  vulva  reddens  and  swells, 
while  any  abrasions  on  the  labia  become  covered  with  a  gray  exudate.  Gas  may 
accumulate  in  the  uterus,  paralyzing  it,  after  which  the  organ  balloons  out — that 
is,  tympania  uteri  develops.  In  such  cases  the  bacterium  coli  is  usually  found. 
Unless  relief  is  brought,  the  woman  dies  of  sepsis  or  exhaustion,  or  both. 

Strictura  Uteri. — A  spasm  of  a  zone  of  circular  fibers  of  the  uterus  may  imprison 
the  fetus.  Sometimes  the  constriction  is  around  the  child's  neck,  as  in  Fig.  498, 
and  sometimes  around  the  trunk  or  breech,  a  groove  around  the  arms  and  chest 
having  been  demonstrable  in  a  case  delivered  at  the  Chicago  Lying-in  Hospital. 
Ordinarily,  the  contraction  of  the  remainder  of  the  uterus  is  not  strong  enough 
to  rupture  the  lower  uterine  segment,  which  is  in  spasm,  nor,  indeed,  to  overcome  the 
resistance  of  the  constricting  ring.  Therefore  labor  comes  to  a  standstill,  and  we 
find  the  same  clinical  picture  as  in  tetanus  uteri  (g.  v.),  though  not  so  aggravated  nor 
so  quickly  fatal.  The  contractions  are  irregular  both  in  frequency  and  in  strength, 
are  very  painful,  and  the  woman  is  frenzied  l)y  the  delay  in  labor  in  spite  of  con- 
stant and  prolonged  suffering.  The  lower  part  of  the  uterus  is  hard,  the  fundus 
soft  (between  pains),  and  the  lower  al)domen  is  very  tender.  Attempts  at  version 
may  be  rendered  futile  by  the  stricture  if  they  do  not  rupture  the  uterus.  In  one 
of  my  cases  the  whole  fetus  was  locked  in  above  the  stricture,  which  was  so  narrow 
that  I  could  not  insert  more  than  three  fingers  (Fig.  499). 

Strictures  are  oftenest  found  in  primiparse  of  neurasthenic  type  and  in  women 
in  whom  the  bag  of  waters  ruptures  early  in  labor.  After  a  while  progress  ceases, 
the  head  remains  high  up  and  in  the  transverse  diameter,  the  cervix  becomes  ede- 
matous, and  the  vagina  hot  and  dry.     Attempts  to  rotate  the  head  succeed  easily. 


ANOMALIES    OF   THE    POWERS 


575 


but  the  occiput  turns  (luickly  hack,  as  on  a  pivot,  the  shoulders  ])eing  hjcked  in 
position  l)y  the  uterine  spasm. 

In  the  third  sta^e,  strictura  uteri,  or  h()ur-<z;lass  eont raclion,  is  of  irrcni  sig- 
nificance, heing-  a  fre(iuent  cause  of  jxMpartuin  hcinorrliage  with  incarceration 
of  the  placenta,  and  even  produciug  anomalies  of  ulciine  contraction  after  the 
placenta  is  delivered. 

Diagnosis. — T{>tanus  uteri  is  easily  determined  from  the  board-like  consistence 
of  the  organ,  the  continuous  pain,  and  suspended  labor.  Spasm  of  Bandl's  ring 
is  suspected  in  all  cases  of  cramp  pains,  irregular  and  painful  uterine  action,  ex- 


FiG.  498. — Contraction-ring  Around  Child's  Xeck. 


cessively  slow  dilatation  of  the  cervix,  in  the  absence  of  disease  of  the  latter,  but  it 
can  be  positively  diagnosed  only  when  the  ring  is  palpable  internally  or  abdominally. 
Tetanus  uteri  must  be  differentiated  from  the  simple  emptying  of  the  organ  of  the 
liquor  amnii  and  the  passive  application  of  its  walls  to  the  child.  In  tetanus  the 
uterus  is  very  hard,  ovoid,  and  the  fetal  parts  are  not  palpable,  while  the  hand  intro- 
duced from  below  can  only  Avith  the  greatest  difficulty,  and  sometimes  onl}'  ^nth  the 
risk  of  a  rupture  of  the  wall,  be  passed  up  to  the  fundus.  In  simple  retraction  the 
uterine  wall  is  firm  but  pliable,  the  uterus  has  the  shape  of  the  fetus,  and  varies  ac- 
cording to  the  attitude  of  the  latter;  fetal  parts  are  readily  felt,  and  the  hand  is 
easily  passed  up  to  the  fundus  and  version  or  other  manipulations  performed.     In 


576 


THE    PATHOLOGY    OF   LABOR 


obstructed  labor,  the  child  being  dehvered  largely  into  the  lower  uterine  segment, 
the  contracting  and  retracted  fundus  uteri  may  be  thought  to  be  in  tetanus.  Here 
the  shape  of  the  tumor,  the  hard  fundus,  the  soft,  dilated  lower  uterine  segment, 
regularl}''  recurring  pains,  and  the  internal  exploration  will  clear  the  diagnosis. 

Treatment. — Irregular  and  cramp  pains  and  stricture  of  the  uterus  require 
sedatives,  first  among  which  is  the  influence  of  a  confident  and  capable  physician 
and  nurse.  Proper  encouragement  "^^dll  help  the  nervous,  excited  woman  to  become 
quieted.  A  prolonged  hot  bath,  followed  by  a  hot  drink  of  lemonade  containing  3 
drams  of  alcohol,  will  often  be  productive  of  gentle  perspiration,  sleep,  and  calm. 
Early  in  the  first  stage  a  small  dose  of  morphin  may  be  given.  Sodium  bromid  up 
to  60  grains  may  be  exhibited,  but  chloral  at  all  times  and  morphin,  except  as  above 
stated,  are  [dangerous,  the  first  because  of  its  cytolytic  influence  on  the  liver,  the 
latter  because  of  its  narcotic  effect  on  the  baby.     Green,  of  Boston,  recommends 


Fig.  499. — Strictura  Uteri.     Star  Indicates  Location  of  Navel. 


scopolamin-morphin  for  the  nervous,  apprehensive  parturient.  Change  of  posi- 
tion from  back  to  side,  the  elevated  Sims,  or  the  knee-chest,  and  walking  about  may 
be  tried.  Prolonged  warm  salt  solution  douches  are  sometimes  useful.  The  vagina 
is  filled  with  the  solution,  the  labia  held  together  for  a  few  minutes,  and  then  the 
water  is  allowed  to  escape,  such  a  procedure  being  repeated  for  thirty  minutes  at  a 
time.  Vaginal  examinations  are  restricted,  and  all  attempts  to  dilate  the  cervix 
omitted. 

If  the  uterus  is  tetanically  contracted,  it  will  seldom  respond  to  the  above 
treatment  and  delivery  is  indicated.  A  prime  requisite  for  any  and  all  intra- 
uterine manipulations  in  tetanus  uteri  is  profound  anesthesia.  Ether  is  to  be 
preferred  because  the  patient  must  be  brought  close  to  the  danger-line  of  narcosis, 
and  the  operation  must  not  be  l^egun — not  even  the  hand  introduced  until  the  uterus 
has  relaxed.     In  very  rare  instances  a  prolonged,  deep  chloroform  narcosis  failed 


ANOMALIK.S    Ol'    THE    I'OWEUS  577 

to  quiet  the  uterus;    tlelivery  from  hclow  provccl  impossible,  and  cesarean  section 
had  to  1)0  performed. 

Spasm  of  the  Cervix;  Strictura  Cervicis. — Many  authors  deny  the  existence 
of  spasmodic  rifi;idity  of  the  cervix.  I'ieux  proved  that  there  are  practically  no 
muscular  fibers  in  the  cervix  around  the  external  os  near  term.  Nevertheless,  a 
few  cases  in  the  author's  experience  have  shown  that  occasionally  the  cervix  will 
contract,  either  in  front  of  the  presenting  part  or,  more  conunonly,  around  the  neck 
after  the  head  is  through  it,  or  after  the  body  is  delivered  in  breech  presentation, 
and  thus  create  an  obstacle  to  delivery.  Most  of  the  cases  of  so-called  rigidity 
of  the  cervix  are  not  spasmodic,  but  anatomic,  due  to  some  alteration  of  structure. 
The  causes,  diagnosis,  and  treatment  are  on  the  same  lines  as  those  of  stric- 
tura uteri.  Stricture  of  tlie  cervix  around  the  after-coming  head  is  often  more 
apparent  than  real,  though  the  effect  is  serious,  just  the  same.  The  slender  body 
slips  througli  the  unprepared  cervix,  but  the  head  is  arrested.  Such  a  cervix,  not 
dilating  with  gentle  efforts,  may  have  to  be  incised. 

Precipitate  Labors — Too  Strong  Pains. — Too  strong  uterine  action  and  too 
strong  abdominal- action  are  sometimes  observed,  and  they  lead  to  the  too  rapid 
delivery  of  the  child.  Since  the  abdominal  action  is  mostly  refiexly  excited  by  the 
uterine  pains,  when  the  latter  are  strong,  the  former  will  also  be  strong.  Then,  too, 
even  after  long  labor,  the  first  stage  having  Ijeen  very  slow,  characterized  Ijy  either 
atonia  or  myoclonia  uteri,  when  the  head  finally  has  reached  the  perineum,  its 
presence  here  may  evoke  such  powerful  abdominal  action  that  labor  is  finished 
entirely  too  quickly. 

Precipitate  labor  is  the  forcible,  violent  expulsion  of  the  child  in  a  period  of  time 
disproportionate  to  that  normally  reciuired  for  the  safe  overcoming  of  the  resis- 
tances. Sometimes  the  woman  has  pains  for  several  hours,  but  does  not  recognize 
them  as  true  labor  pains,  and  sends  for  the  accoucheur  too  late.  These  labors 
should  not  he  called  precipitate.  Many  cases  are  on  record  where  the  uterus, 
without  warning,  suddenly  became  violently  active  and  expressed  the  child  in  a 
few  minutes  to  an  hour.  The  woman  may  be  thus  overtaken  on  the  street  and  not 
have  time  to  run  to  shelter.  In  her  excitement  she  may  forget  to  lie  down,  and  the 
child  may  fall  to  the  ground,  the  cord  breaking.  In  a  case  in  the  dispensary  service 
of  the  Chicago  Lying-in  Hospital  the  mother  was  l>ing  down  and  the  child  was 
hurled  against  the  foot  of  the  bed,  the  cord  breaking,  ])ut  the  child  was  not  injured. 
In  another  from  the  same  service  the  child  fell  to  the  floor  and  died  from  a  fractured 
skull.  Very  important  are  these  cases  from  a  medicolegal  point  of  view,  since  the 
mother,  if  she  was  delivered  alone,  may  be  accused  of  having  killed  the  child.  The 
best  authorities  (Freyer)  are  now  agreed  that  the  excitement  and  pain  incident  to 
such  an  event  can  produce  a  state  of  mental  aberration  which  may  persist  during  the 
last  few  minutes  of  labor,  and  for  a  variable  period  after  it,  certainly  long  enough 
for  the  child  to  drown  in  the  mass  of  blood,  feces,  urine,  liquor  amnii,  and  meco- 
nium, in  which,  under  such  circumstances,  it  is  likely  to  be  born.  The  actual  causes 
of  too  strong  pains  and  precipitate  labor  are  not  known.  Heredity,  habit,  neuras- 
thenia, multiparity,  large  pelvis,  small  child,  cervicitis,  and  old  cervical  and  perineal 
lacerations  have  been  cited  as  predisposing  factors.  Various  uteri  have  varying 
contractile  power — just  as  men  have  greater  or  less  musculature  and  better  or 
worse  muscle,  and,  usually,  the  conduct  of  the  uterus  in  a  given  labor  may  be  an- 
ticipated to  be  like  its  action  in  pre\'ious  deliveries. 

Dangers  of  Precipitate  Labor. — Fortunately,  these  are  not  so  great  as  one  would 
expect.  In  the  author's  experience  these  accidents  have  occurred:  complete  and 
incomplete  lacerations  of  the  perineum,  clitoris  tears,  laceration  of  the  cervix, 
postpartum  hemorrhage,  rupture  of  the  uterus  with  fatal  hemorrhage,  puerperal 
sepsis,  fracture  of  the  child's  skull,  intracranial  hemorrhage,  drowning  of  twins  in 
the  chscharges,  and  rupture  of  the  cord.  It  must  be  said  that  these  are  very  rare, 
37 


578  THE    PATHOLOGY    OF   LABOR 

with  the  exception  of  mild  and  moderately  severe  perineal  tears,  and  represent 
isolated  instances  from  private  practice  and  the  large  service  of  several  hospitals. 
Other  authors  have  noticed  postpartum  hemorrhage,  but  not  fatal,  emphysema  of 
the  neck,  fracture  of  the  sternum,  hsematoma  vulvge.  Hirst  records  an  instance  of 
marvelous  endurance  on  the  part  of  the  infant.  A  woman  on  an  express  train 
going  40  miles  an  hour  dropped  the  infant  through  the  water-closet,  and  it  was  picked 
out  of  the  snow  an  hour  later,  alive  and  uninjured.  Winckel  records  20  children 
delivered  in  winter  and  exposed  for  hours  without  harm.  These  facts  are  excep- 
tional— many  children  have  died  from  cold  and  injury. 

Treatment. — If  the  pains  are  coming  on  tempestuously,  one  following  the  other 
in  rapid  succession,  the  woman's  face  becoming  turgid,  and  the  bearing-down  efforts 
prolonged  and  powerful,  the  accoucheur  must  do  something  to  prevent  the  too  rapid 
expulsion  of  the  child  and  the  injury  to  the  soft  parts.  The  patient  is  to  be  turned 
on  the  side,  and  ether  given  until  the  uterine  action  has  moderated.  Admonitions 
to  the  woman  to  not  bear  down  are  usually  useless,  because  she  cannot  help  it.  If 
the  head  is  coming  through  the  vulva  in  spite  of  mild  measures,  it  should  be  allowed 
to  come.  Under  no  circumstances  should  an  attempt  be  made  forcibly  to  hold  the 
head  back  with  a  view  to  saving  the  perineum.  The  danger  of  rupture  of  the  uterus 
thus  arises,  the  conditions  thus  artificially  produced  resembling  obstructed  labor. 
Episiotomy  is  to  be  performed  if  there  is  time.  Care  is  to  be  exerted  to  save  the 
rapidl}^  emerging  child  from  injury.  After  precipitate  labors  it  may  be  necessary 
to  make  an  internal  examination  to  find  if  there  are  deep  injuries.  External  and 
internal  hemorrhage  and  the  general  aspects  of  the  case  will  decide  this  point.  In 
cleaning  up  a  case  where  the  child  has  been  delivered  without  the  usual  aseptic 
preparations,  the  open  vulva  is  to  be  treated  on  the  same  principles  as  a  compound 
fracture.  A  physician  called  in  emergency  to  a  partus  prsecipitatus  should  not 
express  the  placenta  unless  there  be  hemorrhage,  but  should  institute  proper 
arrangements  for  the  conduct  of  the  third  stage,  or  provide  for  the  transportation 
of  the  patient  to  a  hospital  or  home.  Pending  the  arrival  of  the  woman's  own 
accoucheur,  he  should  do  only  that  which  is  absolutely  necessary  for  the  safety  of 
the  mother  and  child,  and  should  turn  the  case  over  to  him  upon  his  arrival. 

Literature 

Freyer:  Die  Ohnmacht  bei  der  Geburt,  Springer,  Berlin,  1887. — Hofbauer:  "Pituitrin,"  Zentralbl.  f.  Gyn.,  January, 
1911,  No.  4. — Jardine:  Jour.  Obst.  and  Gyn.  British  Empire,  July  1,  1911.— Kossa.'  "Contraction  Ring  and 
Mechanism  of  Labor,"   Monatsschr.  f.  Geb.  u.  Gyn.,  1900,  vol.  xii,  p.  457. 


CHAPTER  XLIX 
ANOMALIES  OF  THE  PASSENGERS 

Classification. — Under  this  caption  are  to  be  considorod  irregularities  of  the 
mct'hanisni  of  labor  due  to  the  child.  While  those  due  to  the  placenta  might  belong 
here,  it  is  best  to  take  them  uj)  with  the  study  of  jiostpartum  hemon-hage.  Anoma- 
lies of  the  mechanism  of  labor  are  due  to  errors  of  attitude,  of  presentation,  and  of 
position  of  the  child,  and  also  to  the  overgrowth  of  the  fetal  body  as  a  whole  or  as 
a  part.  Before  taking  up  this  branch  of  the  subject  the  student  is  advised  to  read 
what  was  said  a])out  the  mechanism  of  normal  labor,  for  the  following  pages  will 
deal  mainly  with  descriptions  of  the  factors  of  lal)or  gone  wrong.  For  ciuick  and 
clear  orientation  regarding  the  relations  of  the  fetus  to  the  mother,  and  the  various 
movements  executed  in  the  mechanism  of  labor,  a  pelvis  and  fetal  head  are  almost 
absolutely  necessary,  though  the  little  models  and  paper  manikins  on  the  market 
will  aid  very  much.  It  is  also  necessary  to  have  clear  notions  regarding  the  terms 
used  in  describing  all  phases  of  the  subject. 

"Attitude"  or  posture  means  the  relation  of  the  parts  of  the  fetus  to  each  other; 
"presentation"  is  the  part  of  the  fetus  which  lies  over  the  os,  or  is  bounded  by  the 
girdle  of  resistance,  and  "position"  means  the  relation  of  any  given  arliitrarj-  point 
in  the  prcscniting  part  to  the  four  quadrants  of  the  mother's  pelvis.  The  name  of 
this  arbitrary  point  is  the  "point  of  direction."  It  might  also  be  called  the  "de- 
nominator." To  a  certain  extent  attitude  determines  presentation;  for  example, 
when  the  head  lies  over  the  inlet,  not  in  its  usual  condition  of  flexion,  but  with  the 
chin  extended,  face  presentation  results.  If  the  head  is  less  deflexed,  brow  presenta- 
tion, and  if  only  partly  deflexed,  the  vertex  being  felt  over  the  os,  median  vertex 
presentation  is  diagnosed.  These  might  be  grouped  together  as  "deflexion  at- 
titudes." In  addition  to  these,  the  result  of  errors  of  attitude,  there  are  abnormal 
presentations  produced  by  errors  of  polarity  of  the  fetus,  such  as  breech  and  shoulder 
presentation.  Other  anomalies  of  attitude  are  prolapse  of  the  feet  in  ]:)reech  pres- 
entation, of  the  arm  in  head  presentation,  of  the  cord  in  all  presentations,  etc. 
Just  as  in  occipital  presentations,  each  of  the  abnormal  presentations  may  lie  in 
different  positions.  Following  Baudelocque  and  Hodge,  six  positions  were  dis- 
tinguished in  occipital  presentations— O.L.A.,  O.L.T.,  O.L.P.,  O.D.A.,  O.D.T., 
O.D.P. — and  six  may  be  described  for  most  of  the  abnormal  presentations,  though 
not  all  are  observed  in  practice;  for  example,  Sac.L.A.,  S.L.T.,  S.L.P.,  S.D.A., 
S.D.T.,  and  S.D.P.  In  breech  presentation  S.L.A.  and  S.D.P.  are  the  ones  almost 
exclusively  observed. 

Finally,  errors  in  rotation  of  the  presenting  part  occur;  either  rotation  ceases 
before  its  completion,  or  the  presenting  i^art  turns  backward  into  the  sacrum,  caus- 
ing severe  dystocia.  It  is  thus  evident  that  an  almost  infinite  variety  of  combina- 
tions of  presentations  and  errors  of  attitude  and  position  may  be  presented  to  the 
accoucheur  for  study,  and  when  it  is  considered  that,  in  addition,  a  contracted  pelvis, 
a  large  child,  twins,  or  monsters  may  coexist,  not  to  mention  all  superadded  com- 
plications incidental  and  accidental  to  parturition,  one  must  concede  that  truly 
formidable  prol)lems  of  deep  complexity  are  offered  for  solution. 

Unusual  Mechanisms  of  Head  Labors. — In  order  will  be  discussed  errors  of 
rotation  in  occipital  presentations  and  the  deflexion  attitudes — median  vertex, 
forehead,  brow,  and  face  presentation. 

579 


580  THE    PATHOLOGY    OF   LABOR 

Persistent  Occipitoposterior  Position. — Normally,  when  labor  starts  with 
O.D.P.  or  O.L.P.,  anterior  rotation  occurs,  and  ijthe  delivery  terminates  as  in 
O.L.A.  and  O.D.A.  Sutugin,  of  Russia,  believes  that  in  the  majority  of  cases  the 
head  enters  the  pelvis  in  the  transverse  diameter,  which  agrees  with  my  experience. 
After  it  has  passed  the  inlet  the  occiput  turns  either  toward  the  front  or  the  back — 
almost  always  toward  the  pubis.  Should  the  occiput  turn  toward  the  sacrum,  or 
should  the  head  enter  the  pelvis  in  an  oblique  with  the  occiput  behind,  an  occipito- 
posterior position  results.  In  rare  instances  the  head  may  enter  the  pelvis  with 
the  occiput  pointed  directly  behind,  or  the  occiput  may  rotate  into  the  hollow  of  the 
sacrum  after  engagement.  These  are  called  occipitosacral  positions,  and  will  be 
considered  later. 

In  still  rarer  instances  the  head  enters  and  passes  through  the  pelvis  with  the 
occiput  directly  anterior,  and  no  rotation  is  needed  in  the  mechanism  of  its  delivery. 
Prolapse  of  an  arm  was  the  cause  of  this  anomaly  in  the  one  instance  the  author 
observed. 

Since,  in  the  large  majority  of  cases  of  occipitoposterior  position,  anterior  ro- 
tation finally  occurs,  a  search  into  the  cause  of  its  persistence  is  necessary:  (a)  Flat 
pelvis  in  minor  degrees,  the  occiput  meeting  resistance  first  and  deflexion  occurring; 
(h)  primary  brachycephalia,  the  two  head  levers  being  of  the  same  length  and  flexion 
not  occurring;  (c)  pendulous  abdomen,  the  convex  back  of  the  fetus  fitting  better, 
to  the  posterior  arched  wall  of  the  uterus;  (d)  large  pelvis,  small  child,  the  natural 
mechanism  of  labor  of  balanced  resistances  becoming  inoperative;  (e)  prolapse  of 
an  arm  in  front  of  the  occiput — if  it  lay  behind  the  occiput,  anterior  rotation  would 
be  facilitated;  (/)  anything  that  would  mechanically  prevent  anterior  rotation  of 
the  head,  or  that  would  hold  back  the  child's  trunk  and  thus  keep  the  back  posterior, 
for  example,  the  placenta,  tumors  in  the  wall  of  the  uterus,  scars  in  the  uterus  which 
give  the  lower  uterine  segment  an  irregular  shape,  a  full  rectum  or  bladder,  etc.; 
(g)  exhaustion  of  the  powers  before  rotation  has  been  completed;  in  such  cases 
"arrest"  of  rotation  occurs  at  any  point  in  the  transit  of  the  occiput;  (h)  vices 
of  configuration  of  the  bony  pelvic  cavity,  for  example,  poorly  developed  spines  of 
the  ischia — funnel  pelvis;  (i)  abnormal  pelvic  floor,  which  gives  a  wrong  bend  to 
the  parturient  canal  or  does  not  form  a  good  gutter.  Not  all  the  causes  are  known 
or  understood.  Given  a  cause,  the  child  soon  becomes  molded  to  the  abnormal 
position,  the  uterus  adapts  itself  to  the  child,  and  the  conchtion  is  less  easily  cor- 
rected as  labor  goes  on. 

Course. — Two  varieties  are  distinguishable:  first,  those  where  the  head  re- 
mains high  up  and  will  not  engage,  and  those  where  the  head  enters  the  pelvis  with 
the  occiput  behind.  In  the  first  class,  which,  fortunately,  are  rare,  labor  comes  to 
a  standstill,  and  occasionally  a  brow  presentation  develops,  a  little  deflexion  occur- 
ring. In  the  second  type  the  occiput  sinks  in  either  the  transverse  or  one  of  the 
obliques,  and  comes  to  the  second  parallel  plane  of  Hodge.  Now  four  terminations 
are  possible:  (1)  Under  strong  pains  the  occiput  sweeps  forward  through  the  135 
degrees  and  comes  to  lie  under  the  pubis  (commonest) ;  (2)  it  comes  forward  more  or 
less,  usually  to  the  transverse  diameter,  and  stops — "deep  transverse  arrest";  (3)  it 
may  come  down  in  the  transverse,  and  the  head  may  even  ])e  delivered  in  the  trans- 
verse, the  occiput  rolling  out  under  one  of  the  descending  rami  pubis;  (4)  it  may 
rotate  backward  to  the  hollow  of  the  sacrum,  becoming  an  occipitosacral  position. 
If  the  head  rotates  backward  into  the  sacrum,  nature  manages  the  delivery  in  two 
ways:  First,  extreme  flexion  occurs,  and  the  pains  force  the  head  downward  and 
backward  against  the  perineum,  which  is  much  overstretched  and  nearly  always 
torn;  descent  is  continued  until  the  forehead  stems  behind  the  pubis  and  the  oc- 
ciput has  escaped  either  over  or  through  the  torn  perineum,  the  perineal  region 
coming  to  lie  on  the  nape  of  the  neck;  now  the  face  appears  from  behind  the  pubis, 
extension  occurring  (Fig.  500).     Secondly,  as  the  head  descends  deflexion  occurs. 


ANOMALIES    OF   THE    PASSENGERS  581 

the  forohoad  takes  the  lead  and  becomes  the  point  of  direction,  and  descent  con- 
tinues until  tlie  brow  appears  in  the  vulva,  tlie  glabella  stems  behind  the  pubis, 


Fig.  500. — Occipitosacral.     First  Mechanism,  Flexion. 


and  now  the  occiput  appears  over  the  perineum,  which  is  more  endangered  than  in 
the  first  instance;  lastly,  the  face  comes  from  behind  the  pubis  (Fig.  501).  In  this 
form  it  is  almost  impossible  clinically  to  differentiate  the  mechanism  from  that 


Fig.  501. — Occipitosacral.     Secoxd  Mechanism,  Partial  Extension. 

of  brow  presentation.     External  rotation  or  restitution  of  the  occiput  to  the  rear 
is  the  rule,  the  face  looking  upward,  but  when  the  shoulders  start  to  come,  thej" 


582 


THE    PATHOLOGY    OF   LABOR 


usually  descend  in  an  oblique  or  even  in  the  sagittal  diameter,  and  then  the  face 
turns  slightly  toward  one  side. 

jMolding  of  the  head  with  the  first  mechanism  is  that  of  extreme  dolichocephaly 
(Fig.  502),  the  occiput  being  more  than  usually  pointed,  while  with  the  second 
mechanism  the  shape  of  the  head  resembles  more  that  of  the  brow  presentation 
(Fig.  503) .  In  multiparse  naturally  the  head  does  not  suffer  as  much  distortion  as 
in  primiparie.  The  caput  succedaneum  in  the  first  mechanism  is  found  over  the 
sagittal  suture,  anterior  to  the  small  fontanel;  in  the  second  mechanism  it  lies  over 
the  large  fontanel.     Lateral  asymmetry  of  the  head  is  usually  absent. 

Clinical  Course  and  Diagnosis. — In  occipitoposterior  positions  labor  is  generally 
slower  and  longer,  the  pains  being  weak  and  irregular  both  as  to  time  and  as  to 
strength.  Such  pains  may  serve  to  draw  the  accoucheur's  attention  to  the  condi- 
tion. Early  rupture  of  the  bag  of  waters  is  frequent,  and  in  general  things  do  not  go 
smoothly.     The  head  stays  high  up  longer  than  in  anterior  positions,  requires 


Fio.  .",02. 


-MOLDI-VG     IN     OCCIPITOSACRAL. 
ANIS.VI. 


First  Mech- 


FiG.    503. — Molding    in    Occipitosacral. 
Mechanism. 


Second 


stronger  pains  to  bring  it  well  down  in  the  pelvis,  and,  after  anterior  rotation  has 
started,  the  uterus  and  abdominal  pressure  may  prove  unequal  to  the  task  of  forcing 
the  head  all  the  way  round,  labor  coming  to  a  standstill  with  arrested  rotation. 
Dilatation  of  the  cervix  is  incomplete  Ijccause  the  head  does  not  fit  well  into  the 
pelvis,  and  it  does  not  press  equally  on  the  internal  os  all  around.  Spontaneous 
delivery  in  occipitoposterior  positions  requires  great  uterine  and  abdominal  effort, 
because — (1)  The  head  traverses  the  pelvic  floor  with  its  largest  diameters.  Instead 
of  the  small  suboccipitol^regmatic  and  suboccipitofrontal  planes,  the  occipitofrontal 
and  the  occipitomental  planes  pass  through  the  vulva.  (2)  When  the  chin  is  strongly 
flexed  on  the  sternum,  the  nape  of  the  neck  is  stretched  and  the  child  forms  a  solid, 
unbendable  cylinder,  which  cannot  accommodate  itself  to  the  angular  birth-canal. 
The  birth-canal,  therefore,  has  to  either  stretch  or  tear,  to  allow  the  cylinder  to  pass 
through.  (3)  The  back  and  the  head  have  to  pass  through  the  pelvis  together 
(Fig.  500).     Perineal  lacerations  are  the  rule  unless  the  child  is  small  or  the  woman 


ANOMALIES    OF   THE    PASSENGERS 


583 


multiparous.  They  arc  tluc  to  the  fact  that  the  head  passes  through,  presenting 
Uirgcr  phiMcs  than  usual,  and  also  to  the  fact  that  the  perineum  is  much  and  forciljly 
dislocated  downward — torn  off,  in  fact,  from  its  hony  and  vaginal  attachments. 

Abdominally,  in  thin  w(jmen,  the  diagnosis  may  sometimes  be  made  by  a 
glance — over  the  pubis  there  is  a  distinct  lioUow.  Palpation  reveals  the  shoulder 
far  back  from  the  median  line,  and  the  forehead  can  usually  be  felt  over  the  op- 
posite ramus  pubis.  The  heart-tones  are  deep  in  the  flank  and  (hstant  from  the  ear, 
although  if,  as  sometimes  occurs,  there  is  a  moderate  deflexion  of  the  head,  the  chest 
is  pushed  forward  against  the  abdominal  wall  and  the  heart-tones  are  very  loud  and 
ilistinct.  They  are  then  on  the  same  side  as  the  forehead,  opposite  to  that  on  which 
the  back  may  be  felt,  and  this  finding  may  give  rise  to  erroneous  diagnoses  of  face 
presentation  or  of  occii)ut  presentation,  the  accoucheur  believing  the  occiput  is  on 
the  side  other  than  the  one  truly  present.  Internally,  early  in  labor  the  head  is 
felt  high  up,  usually  partly  defiexed,  the  small  fontanel  being  higher,  or  on  a  level 
with  the  large,  which  is  nearer  the  center  of  the  pelvis.  Unless  the  pelvis  is  con- 
tracted or  the  belly  pendulous,  the  head  is  synclytic.  If  anterior  rotation  is  going 
to  occur,  flexion  takes  place  with  descent.     The  palpating  finger  will  discover  the 


Fig. 


504. — Touch  Picture  of  Occipitosacral  Posi- 
tion.    First  Mechanism. 


Fig.  505. — Touch  Picture  of  Occipitosacral  Posi- 
tion.    Second  Mechanism. 


tendency  of  the  small  fontanel  to  turn  to  the  front  during  the  pains,  or  will  find  it 
easy  to  push  the  occiput  in  this  direction.  If  posterior  rotation  is  to  be  the  mech- 
anism, the  head  descends  in  moderate  extension,  this  attitude  of  the  child  having 
been  called  "military,"  that  is,  the  head  is  set  squarely  on  the  shoulders.  As  the 
occiput  turns  into  the  hollow  of  the  sacrum,  the  finger  feels  the  small  fontanel 
deeply  on  the  rectmn,  and  the  large  one  behind  the  pubis,  the  sagittal  suture  rumiing 
nearly  anteroposteriorly  and  from  above  forward,  do^\'nward,  and  backward.  If 
the  first  mechanism  of  delivery,  that  of  extreme  flexion,  is  the  one  selected  by  nature, 
the  large  fontanel  is  felt  just  under  the  pubis;  if  the  second,  that  of  extension,  the 
large  fontanel  lies  in  the  center  of  the  pelvis,  and  the  glabella  will  be  felt  behind  the 
pul)is  (Figs.  504  and  505).  Owing  to  the  usually  large  caput  succedaneum,  it  is 
not  always  easy  to  outline  the  sutures,  and  mider  these  difficulties  the  finger  is  to 
be  passed  to  the  side,  until  the  ear  is  found,  when  the  direction  of  the  tragus  will 
bring  clarity.  Not  seldom  the  accoucheur  is  surprised  by  the  head  being  delivered 
with  the  occiput  over  the  perineum,  when  he  was  anticipating  a  normal  mechanism. 
Pwgnofiis. — ]Vlortality  and  morbidity  are  higher  for  both  mother  and  child  in 
occipitoposterior  positions.  For  the  mother,  exhaustion  and  sepsis  from  prolonged 
labor,  and  the  frequently  necessary  operations,  ^vith  the  almost  inevitable  lacera- 


58-4  THE    PATHOLOGY    OF    LABOR 

tions,  are  to  be  feared.  Postpartum  hemorrhage  from  secondary  inertia  uteri  is 
not  rare.  For  the  child,  asphyxia  and  the  operative  dehvery  bring  danger,  and 
without  doul^t,  in  the  author's  opinion,  more  children  are  lost  from  this  complica- 
tion than  are  lost  from  the  effects  of  contracted  pelvis. 

Treatment. — When  the  head  is  high,  "floating"  above  the  pelvis,  "caput 
ballitabile,"  it  is  best  not  to  interfere.  A  complete  examination  is  to  be  made  to 
determine  the  existence  of  a  contracted  pelvis  or  other  anomaly  which  may  require 
treatment  for  its  own  sake,  and  also,  if  possible,  the  cause  of  the  occipitoposterior 
position.  During  the  usually  prolonged  first  stage  the  woman  should  walk  around, 
and  when  lying  down,  should  recline  on  the  side  on  which  the  occiput  lies.  By  this 
means  the  breech  is  thrown  over  to  the  side,  the  spinal  column  is  straightened,  the 
occiput  is  forced  down,  flexion  increased,  and,  therefore,  rotation  favored.  Some- 
times a  change  to  the  side  position  will  strengthen  uterine  action.  Rupture  of  the 
bag  of  waters  retards,  rather  than  hastens,  labor  in  these  positions,  both  by  inter- 
fering wdth  the  mechanism  of  labor  and  by  removing  the  hydrostatic  cervical  dilator, 
and  besides  loss  of  the  liquor  amnii  makes  version,  if  the  case  comes  to  it,  much 
more  difficult  or  even  impossible.  Watchful  expectancy  is  the  treatment  until  an 
indication  for  interference  arises.  If  the  labor  drags  on,  and  danger  to  either 
mother  or  child,  while  not  imminent,  is  to  be  anticipated,  dilatation  of  the  cervix 
may  be  hastened  by  the  use  of  a  colpeurynter.  If  the  head  remains  high  long  after 
complete  dilatation,  it  may  be  advisable  to  anesthetize  the  woman,  change  the  posi- 
tion to  one  anterior,  impress  the  head  into  the  pelvis  by  combined  manipulation  or 
draw  it  down  with  forceps,  and  then  leave  the  case  to  nature.  In  primiparse  this 
method  is  far  more  preferable  than  version,  which  almost  always  kills  the  babies  and 
always  lacerates  the  mother. 

After  the  head  has  engaged,  watchful  expectancy  is  still  practised,  because  the 
vast  majority  of  cases  terminate  in  anterior  rotation,  or  at  least  in  rotation  to  or 
beyond  the  transverse  diameter,  and  thus  become  easy  forceps  operations.  Change 
in  posture,  even  the  knee-chest,  may  be  tried,  but  most  of  the  time  the  woman 
should  lie  on  the  side  to  which  the  occiput  points.  Hodge's  manoeuver  may  be 
helpful — upward  pressure  on  the  sinciput  during  pains.  This,  by  increasing  flexion, 
favors  rotation.  Tarnier  advised  direct  rotation  of  the  head  with  the  fingers  or 
half-hand,  operating  from  behind  the  ear,  at  the  same  time  pressing  the  forehead  to 
the  rear  from  the  outside.  Older  writers,  among  whom  Hodge  may  be  mentioned, 
recommended  the  vectis  for  these  cases.  Objections  to  all  these  manoeuvers  may 
be  urged  on  the  score  of  danger  of  infection  and  inefficiency.  In  multiparae  they 
occasionally  succeed,  and  may  shorten  the  labor  somewhat.  At  all  events,  they 
should  not  be  persisted  in,  and  much  force  may  not  be  used,  but  if  an  indication 
arises  for  interference,  it  is  best  to  make  the  manual  correction  of  the  malposition 
under  anesthesia,  as  is  described  in  Chapter  LXIX.  Failing  the  last,  recourse  is  to 
be  had  to  forceps. 

Occipitosacral  positions  often  require  assistance.  If  the  head  is  descending  in 
flexion,  the  perineum  is  not  endangered  as  much  as  when  the  forehead  comes  down. 
In  either  case  a  deep  episiotomy  is  indicated  unless  the  patient  is  a  multipara.  (See 
Chapter  on  Forceps.) 

Internal  Super-rotation.- — In  roomy  pelves,  or  when  the  child  is  small,  anterior 
rotation  of  tlie  occiput  may  l)e  exaggerated,  the  small  fontanel  passing  beyond  the 
middle  line  to  the  opposite  side  of  the  pelvis.  An  O.L.A.  may,  in  the  course  of  labor, 
become  an  O.D.A.  The  accoucheur  will  l)e  surprised  to  find  the  back  on  one  side 
and  the  occiput  on  the  other,  but  sometimes  the  back  rotates  too  and  the  attendant 
will  imagine  his  first  diagnosis  was  wrong.  Indeed,  occasionally  the  head  will  rotate 
through  the  hollow  of  the  sacrum  from  an  O.L.P.  to  an  O.D.P.,  and  the  back,  which 
at  first  was  on  the  left,  later  lies  on  the  right,  side.  In  internal  super-rotation  the 
head  in  the  course  of  delivery  may  turn  back  again,  or  may  escape  in  an  oljlique 


ANOMALIES    OF   THE    PASSENGERS 


585 


diameter  of  the  outlet,  the  hack  pointing  to  the  side  opp(jsite  that  of  the  occiput,  but 
sometimes  the  trunk  follows  the  rotation  of  the  head,  and  may  escape  with  the  hack 
looking  directly  upward,  or  even  to  the  side  to  wliich  the  occiput  had  rotated.  A 
turhinal  movement  is  thus  imparted  to  the  child. 

Again,  though  the  head  conu^s  out  in  the  normal  mechanism,  the  shoulders 
may  super-rotate,  the  hack  coming  (jut  (jn  the  side  opposite  that  to  which  the  occiput 
originally  pointed.  A  knowledge  of  these  variaticms  of  the  mechanism  of  delivery 
is  necessary  for  the  proper  conduct  of  the  end  of  the  second  stage.  As  a  general 
rule  nature  needs  no  help.  When  the  delivery  of  the  trunk  is  too  slow,  the  woman 
should  he  askcnl  to  hear  down;  a  moderate  pressure  may  be  exerted  on  the  fundus, 
but  traction  on  the  child  is  made  onlj'  when  absolutely  necessary.  In  doing  this 
the  accoucheur  should  aid  and  supplement  the  mechanism  evidently  intended  by 
nature.  For  examjile,  if,  after  delivery  of  the  head,  external  restitution  does  not 
occur,  but  the  shoulders  show  a  tendency  to  turn  in  a  cUrection  opposite  to  that  wliich 
was  expected,  the  attendant  should  favor  the  movement,  because  if  he  sought  to 
impress  a  contrary  one,  the  child  would  stop  in  its  rotation  and  the  back  would 


Fig.  506. — Deflexion  At- 
titude. Median  Ver- 
tex, "Military." 


Fig.  507. — Deflexion  At-  Fig.  508. — Deflexion  At- 
titude. Forehead  titude.  Brow  Pke- 
Presentation.  sentation. 


Fig.  509. — Deflexion  Attitude. 
Face  Present.vtion.  De- 
flexion Completed. 


come  out  transversely,  with  injury  to  the  perineum  or  fracture  of  the  child's  clavicle, 
or,  indeed,  the  delivery  of  the  body  would  be  arrested,  requiring  strong  traction  in 
order  to  free  it. 

Deflexion  Attitudes. — Often,  during  an  examination  early  in  labor,  the  head  is 
found  lying  over  the  inlet  with  the  large  fontanel  lower  than  the  small,  or  even  with 
the  root  of  the  nose  and  the  eyes  palpable.  After  regular  uterine  action  is  estab- 
lished, or  if  the  parturient  adopts  a  favorable  posture,  the  small  fontanel  will  sink 
and  labor  will  assume  a  normal  mechanism.  Should  the  cause  of  the  abnormal  atti- 
tu(l(>  of  the  child  persist,  the  body  of  the  child  will  remain  in  the  wrong  jiosture,  the 
uterus  will  fix  the  trunk  and  adapt  itself  permanently  to  the  abnormal  conditions, 
a  pathologic  mechanism  resulting.  All  degrees  of  deflexion  of  the  head  may  be 
found,  but  it  would  be  useless  and  confusing  to  descrilie  them  all.  Clinically,  four 
of  these  deflexion  attitudes  deserve  mention  as  distinct  presentations,  having  a 
clearly  defined  course  and  mechanism.  Named  in  the  order  of  the  degree  of  de- 
flexion, they  are:  (1)  Median  vertex  presentation,  or  "military"  attitude;  (2)  fore- 
head presentation;  (3)  brow  presentation;  (4)  face  presentation.  In  all  these  the 
trmik  of  the  child  passes,  in  a  varying  degree,  from  its  natural  condition  of  flexion 


586 


THE   PATHOLOGY    OF   LABOR 


or  C  shape  to  one  of  extension  or  S  shape,  face   presentation  representing  the 
greatest  change  (Figs.  506-509). 

Causation. — All  cases  of  deflexion  attitudes  cannot  be  explained  by  one  cause, 
and  often  several  factors  combine  to  produce  the  abnormal  presentation.  In 
general,  primary  and  secondary  factors  may  be  distinguished,  i.  e.,  those  active 
during  pregnancy  and  those  showing  in  labor.  The  primary  factors  are  anything 
that  wall  cause  a  straightening  of  the  child's  trunk,  as  tumors  of  the  fetus,  tumors  of 
the  uterus  pressing  in  the  fetal  back,  a  congenitally  long  uterus  which  cannot  adapt 
itself  well  to  a  curved  fetal  back,  obliquity  of  the  uterus,  tumors  of  the  neck  of  the 


Fig.  510. — Showing  Correction  of  Face  PRESENT.iTioN  by  Posture. 


fetus,  as  goiter,  a  short,  deep-chested  child  which  does  not  allow  the  chin  to  flex 
fully,  and  the  spontaneous  nutatory  movements  of  the  child.  Should  the  pains 
come  on  when  the  infant  happens  to  have  his  head  extended,  the  lower  uterine 
segment  may  lock  the  child  in  this  position.  Baudeloeciue  called  attention  to  the 
wrong  direction  of  the  uterine  forces  when  the  uterus  was  oblique  to  the  inlet — if 
the  back  falls  over  to  the  side  of  the  occiput,  the  chin  extends,  and  if,  now,  uterine 
action  commences,  the  fetal  axis  pressure  is  exerted  in  the  direction  of  the  chin, 
increasing  the  extension,  even  to  the  production  of  a  face  presentation.  Anen- 
cephali  usually  present  by  the  face — snout  labors  (Ahlfeld).  Congenital  dolicho- 
cepbalus  (Hecker) — elongation  of  the  head — may  favor  face  presentation.     Poly- 


ANOMALIES    OF   THK    PASSENGERS 


587 


liydrainuiun,  by  coulVniiij;-  a  liii>;h  ilcj^riH;  of  iiiol>ilily  (jii  tlic  lotus,  is  a  predisposing 
factor.  Secondary  causes  are:  (1)  Those  conditions  whicli  prevent  or  delay  en- 
<>;;i<;<'nieiit  of  tiie  head,  as  contracted  pelvis,  larfi;e  head  (face  babies  are  often  large), 
pencUilous  belly,  tumors  occupying  the  lower  uterine  segment,  as  the  placenta,  or 
narrowing  the  inlet— the  full  rcchiui,  full  l)lad(ler;  (2)  rupture  of  the  bag  of  waters 
when  the  head  happens  to  be  in  extension;  (3)  occipitoposterior  positions;  (4)  a 
cause  of  deflexion  attitudes  not  generally  appreciated  is  weak  labor  pains.  With  a 
normal  pelvis  the  cervix  exerts  a  certain  influence  on  the  mechanism  of  luljor.  The 
head  presiMiting  to  it  with  the  broad  flat  vertex  will,  under  strong  vis  h  tergo,  adai)t 
itself  so  as  to  bring  the  longest  diameter  of  its  ovoid  into  a  position  parallel  w^ith  the 
axis  of  the  passage,  so  that  it  can  go  through  with  the  least  friction.  With  weak  pains 
the  head  will  not  apply  itself  to  the  cervix  and  thus  come  under  the  latter's  influence. 
Nearly  always  the  cause  of  deflexion  is  maternal,  and  operates  during  labor, 
but  the  author  would  emphasize  the  role  that  the  child  plays.  Nutatory  move- 
ments are  often  felt  during  vaginal  examination,  and  it  is  easy  to  understand  that, 
should  labor  come  on  f)r  the  membranes  rupture  while  the  child  has  the  chin  ex- 


FiG.  511. — Median  Vertex  Presentation.     Military  Attitude. 


tended  the  attitude  will  be  fixed,  and  the  deflexion  may  become  exaggerated  as 
labor  progresses.  For  example,  in  occipitoposterior  presentation  a  slight  extension 
will  throw^  the  forehead  over  the  inlet.  Should  the  patient  turn  on  the  side  to 
which  the  venter  of  the  fetus  points,  the  trunk  ^\'ill  fall  over  to  that  side  and  the 
brow  will  sink  lower,  and  if  pains  come  on  strongly,  the  bregma  will  stem  on  the 
edge  of  the  inlet  and  a  full-face  presentation  result.  Often  early  in  labor  the  ex- 
amining finger  feels  the  lirow  or  the  forehead  high  over  the  inlet,  but  by  proj^erly 
placing  the  patient — that  side  to  which  the  occiput  points — the  breech  will  fall 
into  the  flank,  the  occiput  "will  sink,  and  flexion  result.  These  passing  deflexion 
attitudes  should  not  mislead  to  hasty  interference. 

Mechanism  of  Labor  in  Median  Vertex  Presentation. — ]\Iost  authors  do  not 
recognize  this  form  of  anomaly,  but  Baudelocriue,  \'elpcau,  and  Hodge  have  de- 
scribed it,  and  Hirst,  among  other  modern  writers,  mentions  it.  I  believe  it  is  a 
frequent  cause  of  dystocia.  AVhen  the  deflexion  is  only  moderate,  the  child  pre- 
senting with  its  head  in  the  "military"  attitude,  labor  is  very  similar  to  that  in 
occipitoposterior  positions.  As  the  point  of  direction,  or  denominator,  the  occiput 
is  still  employed,  although  sometimes  in  abnormal  mechanisms  the  forehead  de- 


588 


THE    PATHOLOGY    OF   LABOR 


scends  and  becomes  the  point  of  direction — a  fact  of  great  importance  in  the  forceps 
operation. 

Engagement  of  the  head  is  slow,  because  the  largest  plane,  the  occipitofrontal, 
is  presented  to  the  inlet.  Descent  continues  with  the  large  and  small  fontanels  on 
the  same  level, — that  is,  flexion  remains  absent, — and  with  the  sagittal  suture  in  the 
transverse,  until  the  median  vertex  reaches  the  pelvic  floor  (Fig.  511).  Now  four 
terminations  are  possible:  (1)  Flexion  occurs,  the  occiput  rotates  anteriorly  under 
the  pubis,  and  labor  terminates  normally;  (2)  delivery  takes  place  with  the  sagittal 
suture  in  the  transverse  diameter — requires  strong  pains,  large  pelvis,  small  child, 
the  perineum  being  much  endangered;  (3)  the  occiput  rotates  into  the  hollow  of 
the  sacrum,  the  forehead  turns  to  the  pubis,  and  the  mechanism  is  similar  to  occipito- 
posterior  positions,  second  mechanism,  deflexion;  (4)  labor  comes  to  a  standstill 
■^-ith  the  head  in  the  transverse  diameter,  deep  in  the  pelvis,  and,  unless  art  is  called, 

the  mother  and  child  may  die.  These  last 
cases  can  hardly  be  distinguished  from 
arrested  rotation  in  occipitoposterior  posi- 
tions. They  are  both  "deep  transverse 
arrest,"  and  require  the  same  treatment. 
Molding  in  median  vertex  presentation 
closely  resembles  that  of  forehead  presenta- 


FiG.  .512. — Molding  in  Median  Vertex  Presen- 
tation. 


Fig 


-Touch    Picture 

TION 


Median    Vertex    Presenta- 
O.L.T. 


tion.  The  caput  succedaneum  is  on  one  parietal  bone,  close  to  the  posterior  third 
of  the  sagittal  suture  (Fig.  512). 

Clinical  Course. — Labor  is  longer  and  tedious.  The  pains  are  weak  and  in- 
frequent, because  the  presenting  part  does  not  press  firmly  against  the  cervix. 
Dilatation  is  slow,  and  the  cervix  must  be  opened  wider  to  allow  the  head,  presenting 
its  biggest  planes,  to  pass  through.  After  the  head  reaches  the  pelvic  floor  the  pains 
usuall}^  become  augmented,  and  one  of  the  terminations  mentioned  occurs,  but  in 
all  cases  strong  pains  are  needed.  These  may  fail,  and  the  assistance  of  art  is  often 
required. 

Diagnosis. — Abdominally,  the  usual  points  for  determining  presentation  and 
position  are  to  be  sought,  and  the  examiner  will  notice  that  the  trunk  of  the  child 
is  very  straight,  the  fundus  applied  to  the  ensiform,  the  heart-tones  near  the  median 
line,  and  heard  over  a  large  area — distant  in  O.L.T. ,  louder  in  O.D.T.  The  shoulder 
is  in  the  median  line,  just  above  the  pubis.  Internally  (Fig.  513),  the  finger  dis- 
covers the  two  fontanels  on  the  same  level,  the  sagittal  suture  running  across  the 
pelvis.     Usually  the  head  is  synclitic,  but  anterior  asynclitism  has  been  observed, 


ANOMALIES    OF   THE    PASSENGERS  589 

especially  in  peiKluluu.s  aljthjiiicn  aiul  Hat  pelves.  Naturally,  the  findings  change 
as  the  various  mechanisms  unfold. 

Trcdhniid—  This  is  the  same  as  that  of  occi))it()post('rior  i)ositions. 

Forehead  Presentations. — Tlicse  are  primary  or  secondary.  Primary  f(jre- 
head  mechanisms  are  very  rare  because,  if  the  deflexion  has  proceeded  thus  far,  the 
forces  (jf  labor  almost  always  complete  the  process,  a  face  or  at  least  a  brow  presenta- 
tion resulting.  The  forehead  is  the  point  of  direction — it  takes  the  lead,  descent 
occurs,  usually  in  one  of  the  obliques,  until  the  presenting  part  reaches  the  pelvic 
floor.  Now  tliree  mechanisms  occur:  (1)  Under  strong  pains  and  late,  flexion  of 
the  head,  descent  of  the  occiput,  and  anterior  rotation  of  the  latter  under  the  pubis 
(rare);  (2)  anterior  rotation  of  the  forehead  under  the  pubis  while  the  occiput 
turns  behind,  the  glabella  stemming  under  the  arch,  the  occiput  coming  over  the 
perineum,  in  all  respects  similar  to  the  second  mechanism  of  occipitoposterior 
positions;    (3)  cessation  of  progress  with  the  forehead  on  the  perineum. 

Secondary  forehead  presentations  are  the  result  of  deflexion  of  the  head  and 
descent  of  the  forehead  in  occipitoposterior  positions,  to  which  the  reader  -is  re- 
ferred for  a  description  of  the  mechanism  and  for  diagnosis  and  treatment. 

Primary  forehead  presentations  closely  resemble  the  brow,  but  an  internal 
examination  will  show  the  large  fontanel 
in  the  line  of  direction  (Fig.  514).  The 
configuration  of  the  head  is  shown  in  Fig. 
503,  and  the  caput  succedaneum  over  the 
bregma  exaggerates  the  tower-like  raising 
of  the  vault  of  the  cranium.  In  the  treat- 
ment of  primary  forehead  presentations  it 
must  be  remembered  that  often,  in  the  be- 
ginning of  labor,  the  forehead  is  to  be  felt 
over  the  inlet,  but  w'hen  the  head  enters, 
flexion  occurs  and  the  occiput  comes 
down,  rotating  anteriorly.  By  keeping 
the  patient  on  the  side  on  which  the  occi- 
put lies,  flexion  and  descent  of  the  head 
are  favored.  King  advises  the  squatting 
posture,  claiming  that  the  pressure  of  the 

. ,  .    ,  •       ,     ,  1  11  1        ,  Fig.  514. — Touch  PicrrRE  ix  Forehe.\d  Present.^- 

thighs  agamst  the  abdomen  and  uterus  tion. 

affects  the  position  of  the  child.     If  it  is 

desired  to  exert  pressure  on  the  back  of  the  child,  the  woman  kneels  on  one  knee,  the 
other  foot  resting  flat,  and  the  corresponding  thigh  being  pressed  firmly  against 
the  abdomen,  where  the  back  hes  (Fig.  654).  Should  the  forehead  not  change  its 
location,  labor  does  not  progress,  and  the  case  is  to  be  treated  as  a  brow  presenta- 
tion, with  which,  indeed,  it  is  often  confused  in  practice. 

Brow  Presentation. — Transitory  presentation  of  the  brow  in  the  beginning  of 
labor  is  occasionally  observed,  and  as  the  head  engages  in  the  pelvis  descent  of 
the  occiput  occurs,  and  a  more  normal  mechanism  results.  j\Iore  frequently  the 
deflexion  is  completed,  and  a  face  presentation  is  produced.  Brow  presentation  is 
distinctly  pathologic,  and  if  the  child  is  normal  or  above  normal  in  size,  becomes 
very  formidable.  Small  or  macerated  fetuses  may  pass  through  the  pelvis  spon- 
taneously, though  labor  is  usually  difficult  and  much  prolonged. 

The  frequency  of  brow  presentation  is  variously  given — perhaps  once  in  3000 
cases  is  as  near  accurate  as  is  possible  to  get.  In  the  ^Moscow  maternity  brow  pres- 
entation occurred  101  times  in  130,768  labors.  Its  causes  come  under  the  general 
etiology  of  deflexion  attitudes,  but  the  frequency  of  contracted  pelvis  must  be 
emphasized  (in  45  per  cent,  of  the  above-mentioned  cases),  and  this  may  explain, 
in  part,  the  extraordinary  difficulties  encountered  when  the  child  is  above  normal  in 


590 


THE    PATHOLOGY    OF   LABOR 


size.  The  posture  of  the  child  is  shown  (Fig.  508).  It  will  be  noticed  that  the  S 
shape  of  the  back  is  more  marked  than  in  forehead,  but  less  than  in  face  presen- 
tation, which,  however,  it  closely  approaches. 


Fig.  515. — Mechanism  in  Brow  Presentation.    Brow  Rotated. 

Mechanism. — The  point  of  direction  is  the  brow,  and  although  six  positions  are 
theoretically  possible,  two  are  most  commonly  observed  in  nature, — frontolseva 


Fig.  51G. — Mechanism  in  Brow  Presentation.     Brow  in  Tran.sverse  Diameter.     Not  Rotated. 

anterior  and  frontodextra  posterior.  During  the  progress  of  labor,  of  course,  the 
brow  will  be  felt  in  other  pelvic  diameters,  that  is,  it  is  found  at  any  point  of  its 
arc  of  rotation.     Descent  of  the  head  is  slow,  and  starts  only  after  complete  dilata- 


ANOMALIES    OF   THE    PASSENGERS 


591 


tion,  with  the  rui)turG  of  tlic  moinbranos.  Sinco  tlic  preparation  of  tho  cervix  is 
poor,  delay  in  the  first  stafi;e  is  the  rule.  Unless  tho  attitude  is  to  change  to  either 
a  face  or  an  occiput  ])resentation,  the  brow  descends  in  tiie  middle  of  the  ])elvis,  the 
head  holding  itself  midway  between  flexion  and  extension.  During  the  descent 
the  frontal  suture  usually  takes  the  transverse  diameter  and  is  synchtic  (Fig.  51  (i), 
unless  the  ])elvis  is  flat.  When  the  pelvic  floor  is  reached,  the  bnnv  rotates  to  the 
front,  and  the  occii)ut  to  the  IhjHovv  of  the  sacrum.  The  factors  ])r(jducing  tliis  ro- 
tation are  the  same  as  those  operative  in  normal  cases — the  pelvic  floor,  the  guidance 
of  the  converging  rami  pubis,  and  the  accommodation  of  the  fetal  cylinder,  which 
is  easily  flexible  only  in  certain  directions — to  the  bent  l)irth-canal  (Sellheim). 
In  the  brow  attitude  the  f(^tal  cylinder  can  l)end  best  in  its  sagittal  diameter.  The 
sagittal  diameter,  therefore',  is  brought  to  correspond  with  the  sagittal  diameter  of 
the  pelvis.  The  brow,  therefore,  comes  down  and  turns  to  the  front  until  the  face 
rests  behind  the  pu])is.  In  the  rima  vulvae  the  brow,  covered  by  a  large  caput  suc- 
cedaneum,  first  ai)p(^ars;  then,  under  very  strong  expulsive  pains,  by  a  movement 
of  flexion,  the  large  fontanel,  the  vertex, 
and  the  occiput  successively  pass  over 
the  perineum,  the  nape  of  the  neck  com- 
ing to  rest  upon  it,  after  which  the  eyes, 
nose,  mouth,  and  chin  come  from  l)e- 
hind  the  pubis  with  one  movement. 
Sometimes  the  brow  is  delivered  up  to 
the  mouth  before  the  occiput  escapes. 


-TorcH    PicTrnE  iv  Bno-n-   Presextatiox 
(Fr.D.A.). 


Fig.  518. — >roLDiKG  ik  Brow  Presentation. 


and,  rarely,  the  head  may  escape  with  the  frontal  sutvu'o  in  the  transverse  diameter  of 
the  outlet;  that  is,  internal  anterior  rotation  has  not  occurred.  It  will  be  seen  that 
the  accomplishment  of  such  a  mechanism  must  be  slower,  harder,  and  more  dan- 
gerous to  mother  and  child  than  any  other.  The  perineum  is  almost  always  lacer- 
ated, and  often  tears  high  up  into  the  rectum,  because  the  largest  diameters  are 
offered  to  the  outlet.  Clinically,  it  is  very  difficult,  at  this  stage,  to  distinguish  a 
brow  presentation  from  terminal  occipitosacral  and  forehead  mechanisms  If  the 
chikl  is  large,  operation  is  almost  always  necessary  to  effect  dehvery. 

Diagnosis. — Abdominally,  the  findings  are  the  same  as  in  face  cases  (q.  v.). 
Internally  (Fig.  517),  the  liregma  is  the  lowest  point, occupies  the  center  of  the  pelvis, 
the  large  fontanel  being  palpalile  on  one  side,  the  root  of  the  nose  and  orbital  ridges 
on  the  other.  The  nose,  mouth,  and  chin  are  high  up.  out  of  reach  unless  the  pa- 
tient is  anesthetized,  to  allow  deep  insertion  of  the  four  fingers.  The  frontal  suture 
runs  in  the  transverse  diameter  or  a  little  obliquely,  and  the  amount  of  the  facial 


592  THE    PATHOLOGY    OF   LABOR 

line  which  is  palpable  determines  the  degree  of  deflexion.  In  true  brow  presenta- 
tion the  nose  is  not  to  be  felt,  the  orbital  ridges  being  on  a  level  with  the  posterior 
border  of  the  large  fontanel,  the  two  demarcating  the  girdle  of  resistance. 

JMolding  is  characteristic  (Fig.  518),  the  head  having  acquired  a  three-cornered 
outline.  The  face  is  flattened  out,  the  distance  from  chin  to  top  of  forehead  very- 
great,  and  this  is  exaggerated  temporarily  by  the  large  caput  succedaneum. 

The  treatment  of  brow  presentation  must  be  active  unless  it  seems  certain  that 
spontaneous  correction  will  occur.  To  favor  flexion  the  patient  is  put  on  the  side 
to  which  the  occiput  points,  but  if  this  does  not  speedily  bring  about  the  desired 
result,  it  is  best  to  correct  the  presentation  under  ether  before  the  head  engages  and 
molchng  commences.  Before  the  rupture  of  the  bag  of  waters,  nothing  but  the 
use  of  posture  need  be  done.  When  the  cervix  is  fully  dilated,  the  membranes  may 
be  punctured,  the  head  flexed  and  led  into  the  pelvis  either  by  the  two  hands  or  the 
forceps,  after  which  the  case  is  left  to  nature.  (See  Operative  Obstetrics.)  Should 
it  be  impossible  to  change  the  brow  into  an  occipital  presentation,  which  is  most 
desirable,  the  attempt  may  be  made  to  obtain  a  full  face  presentation,  and,  failing 
this,  version  is  to  be  performed. 

After  the  engagement  of  the  head  in  brow  presentation  all  manoeuvers  are 
rendered  more  difficult  and  dangerous.  It  is  astonishing,  however,  what  may  be 
accomplished  under  deep  anesthesia.  When  the  abdomen  and  uterus  are  fully 
relaxed,  it  is  often  easy  to  push  the  head  out  of  the  pelvis,  flex  or  extend  it,  and 
draw  it  back  in  proper  attitude  and  position.  Version  at  this  stage  is  very  risky, 
because  the  lower  uterine  segment  is  usually  much  stretched  in  brow  cases,  and, 
further,  version  is  always  to  be  avoided  in  primiparse  if  possible.  Should  version 
be  out  of  the  question  and  manual  correction  fail,  the  attendant  has  two  alternatives 
— a  cutting  operation,  as  abdominal  delivery  or  hebosteotomy,  and  expectancy,  in 
the  hope  that  strong  pains  will  so  mold  the  head  to  the  pelvis  that  it  will  finally  go 
through  or  can  be  delivered  by  forceps.  If  the  child  is  large  or  the  pelvis  small,  the 
latter  process  is  not  to  be  expected,  and  if  the  mother  and  baby  are  in  perfect  condi- 
tion, the  accoucheur  should  seriously  consider  the  other  procedures  as  primary 
operations. 

What  has  been  said  acquires  greater  force  in  labors  with  the  brow  in  posterior 
position.  Here  spontaneous  delivery  is  impossible  unless  the  infant  is  very  small, 
which  is  also  true  of  face  presentation.  Symphysiotomy  has  been  performed  by 
H.  F.  Lewis  and  Montgomery  for  the  relief  of  dystocia  due  to  brow  presentation. 
Since  some  degree  of  pelvic  contraction  is  frequent  in  such  cases,  symphysiotomy 
or  even  cesarean  section  must  always  be  taken  into  consideration.  Should  nature's 
efforts  suffice  to  bring  the  head  well  down  onto  the  perineum,  the  additional  power 
required  for  delivery  may  be  applied  by  the  forceps.  (See  Operative  Obstetrics.) 
Forceps  operations  in  brow  cases  are  nearly  always  very  difficult,  and,  should  the 
hazard  be  too  great,  craniotomy  is  to  be  performed. 

Face  Presentation. — When  the  deflexion  is  carried  to  its  highest  degree,  the 
full  face  comes  to  lie  in  the  line  of  direction,  or  is  bounded  by  the  girdle  of  resistance 
and  is  felt  by  the  examining  finger.  This  is  face  presentation,  and  it  occurs,  in 
round  numbers,  about  once  in  200  cases.  In  face  presentation  the  chin  is  the  point 
of  direction  or  denominator,  and  the  six  positions  of  presentation  may,  in  individual 
cases,  be  distinguished.  Mentodextra  transversa  is  the  most  frequent,  mentolaeva 
anterior  the  next,  mentodextra  posterior,  dextra  anterior,  lava  transversa,  and  Iseva 
posterior  in  order.  The  various  statistics  show  differing  frequencies  of  the  several 
positions,  but,  in  general,  face  positions  occur  in  the  order  of  the  frequency  of  the 
occipital  positions  from  which  they  were  developed;  for  example,  since  O.L.T.  is 
the  usual  position  which  the  head  takes  on  entering  the  pelvis,  the  deflexion  of  the 
chin  will  bring  the  face  down  in  M.D.T. 

As  a  rule,  face  presentations  are  fully  developed  only  after  labor  has  been  in 


ANOMALIES    OF   THE    PASSENGERS 


593 


active  progress  for  sonic  time,  and  most  often  a  l)ro\v  i)resentation  can  he  discov- 
ered eai'ly  in  the  first  stajijc,  but  in  two  cases  I  distinctly  felt  the  full  face  lyiuf^  over 
the  inlet  in  the  last  month  of  pregnancy,  an  observation  which  was  also  made  by 
LaChapelle,  Naegele,  Fieux,  and  others. 

Mechanism. — Figs.  519  and  520  show  the  attitude  or  postun;  of  the  fetus  in 
two  of  the  common  positions.  The  head  is  completely  extended  on  the  back,  the 
forehead  is  flattened,  and  the  occijiut  long  drawn  out.  The  neck  is  stretched;  some- 
times there  are  cracks  in  the  skin  from  overstretching.  The  chest  is  protruded  and 
is  convex.     The  back  is  sharply  incurved  to  receive  the  occiput,  while  the  breech 


Fig.  519. — F.\ce  Presen-tation.     M.L.A. 


is  turned  to  the  Imck.     The  fetus  is  lengthened,  while  its  axis  takes  the  shape  of  the 
letter  S. 

At  the  beginning  of  labor  the  head  lies  high,  with  moderate  anterior  asynclitism, 
the  anterior  malar  bone  and  orbit  being  nearer  the  middle  line  and  lower.  Instead 
of  flexion,  as  descent  begins,  we  observe  an  exaggeration  of  the  extension,  the  chin 
becomes  more  accessible,  and  the  brow  recedes  a  little.  Descent  occurs,  with  the 
facial  line  usually  in  the  transverse  diameter  of  the  pelvis.  In  IM.L.A.  the  chin 
points  to  the  obturator  foramen,  that  is,  lies  in -the  left  anterior  quadrant  of  the 
pelvis;  in  M.D.P.  the  chin  points  to  the  right  posterior  quadrant,  and  the  facial 
line  runs  in  the  right  oblique  diameter  of  the  inlet.  Anterior  rotation  of  the  chin, 
the  third  movement,  does  not  begin  until  the  face  is  well  a]:)plied  to  the  pelvic  floor 
and  is  brought  about  by  the  same  factors  as  operate  in  O.L.A.  The  greatest  flexi- 
bility of  the  fetal  cylinder  in  face  attitudes  lies  in  the  sagittal  plane,  but  in  a  direction 
3S 


594 


THE    PATHOLOGY   OF   LABOR 


opposed  to  that  of  occipital  attitudes.  In  occipital  presentations  the  fetal  cylinder 
can  accommodate  itself  best  to  the  angular  birth-canal  by  breaking  at  the  fetal  neck 
and  the  occiput  bending  backward — that  is,  extension  occurring.  In  face  presenta- 
tions the  same  bending  occurs,  but  reversed,  and  the  chin  flexes.  In  order,  there- 
fore, for  the  fetal  cylinder  to  accommodate  itself  easiest  to  the  birth-canal,  it 
rotates  so  as  to  bring  the  chin  forward  under  the  pubis  (Fig.  521).  Anterior  rota- 
tion must  have  begun  before  the  face  reaches  the  second  parallel  plane  of  Hodge, 
because  the  head,  if  normal  in  size,  cannot  enter  the  pelvis  with  the  chin  behind. 
This  would  bring  the  occiput  and  the  upper  chest  and  shoulder  region  into  the  inlet 
at  the  same  time,  and,  under  normal  conditions,  progress  in  this  fashion  would  be 


Fig.  520. — Face  Presentation.     M.D.P. 


impossible.  Under  the  exceptional  combination  of  large  pelvis,  small  child,  and 
strong  pains,  labor  may  progress  and  terminate  spontaneously  with  the  chin  pos- 
terior. Usually  in  those  cases  of  spontaneous  labors  with  the  chin  behind,  the  head 
entered  the  pelvis  with  the  chin  transverse  or  anterior,  and,  after  engagement,  the 
chin  rotated  to  the  hollow  of  the  sacrum,  the  shoulders  entering  in  one  of  the 
obliques.  Further,  mentosacral  positions  terminating  happily  for  mother  and  child 
are  so  exceedingly  rare  that,  for  practical  purposes,  it  is  best  to  consider  them  as 
absolutely  pathologic  and  as  always  requiring  interference  from  art. 

Anterior  rotation  being  completed,  or  nearly  so,  the  chin  comes  to  lie  behind 
the  pubis  near  to  the  urethra,  the  forehead  is  behind  the  fourchet,  and  the  occiput 
occupies  the  hollow  of  the  sacrum.     The  fourth  movement  is  not  extension  as  in 


ANOMALIES    OK   THE    PASSENGERS 


595 


O.L.A.,  but  flexion  (Fip;.  522),  the  hyoid  l)onc  of  the  fetus  being  applied  to  the 
posterior  surface  of  tlie  pubis,  the  chin,  nioutii,  nose,  eyes,  forehead,  and  occiput 


Fig.  521. — Mechanism  in  Face  Pkesbntation.     Face  in  Tkansverse  Diameter.     Not  Rot.\ted. 

appearing  successively  over  the  perineum,  the  chin  flexing  toward  the  sternum,  but 
riding  on  top  of  the  symphysis  pubis.     Internal  anterior  rotation  may  be  completed 


Fig.  522. — Mechanism  in  F.'v.ce  Presentation.     Flexion  Beginning. 

only  as  the  head  passes  through  the  vulva.  External  restitution  occurs  as  usual,  the 
chin  turning  back  to  the  position  it  occupied  in  utero,and  dehvery  of  the  trunk  takes 
place  according  to  general  principles. 


596 


THE    PATHOLOGY    OF   LABOR 


Fig.  523.- 


-Face  Appearing  at  ^'ULVA  after  Episi- 

OTOMY. 

Photograph.     Wesley    Hospital. 


Abnormal  mechanisms  can  occur  in  the  rotation.     (1)  Deep  arrest  of  rotation, 

the  face  coming  deeply  into  the  pelvis,  and 
even  pressing  firmly  on  the  perineum,  but 
not  turning  to  the  front,  the  facial  line 
resting  in  the  transverse  diameter.  Under 
favorable  conditions — large  pelvis,  small 
child,  relaxed  pelvic  floor  (multipara),  and 
strong  pains — the  head  may  escape  in  this 
position,  the  flexion  of  the  chin  taking 
place  over  one  descending  ramus  pubis. 
Otherwise,  unless  aid  is  rendered,  labor 
ceases,  and  both  mother  and  child  will  die. 
(2)  The  second  anomaly  is  where  the  chin 
remains  at  the  sacro-iliac  joint,  or  even 
rotates  into  the  hollow  of  the  sacrum. 
These  are  called  persistent  chin  posterior 
positions,  and  are  very  formidable 
(Fig.  525).  It  has  already  been  shown 
that  the  head  cannot  enter  the  pelvis  with 
the  chin  behind,  and  it  is  easy  to  see  how 
difficult  labor  will  be  should,  after  engage- 
ment, the  mentum  turn  back  toward  the 
sacrum,  Then'the  broad  occiput  and  the 
chest  must  pass  the  inlet  together,  which 
is  possible  only  under  most  favorable  conditions.  Rarely,  nature  terminates  these 
cases,  first,  by  anterior  rotation  even  as  late  as  this;  second,  by  delivering  the 
head  as  a  brow  presentation 
with  posterior  rotation,  the  oc- 
ciput coming  down  from  behind 
the  pubis,  and,  third,  the  face  is 
forced  down  and  out  in  the  ab- 
normal position,  without  regard 
to  the  soft  parts,  which  are  torn 
most  extensively  in  all  direc- 
tions. Should  none  of  these  oc- 
cur and  art  be  absent,  the  baby 
dies  from  asphyxia  and  the 
mother  from  ruptured  uterus 
or  exhaustion. 

Clinical  Course. — Labor  in 
face  presentation  is  usually 
longer — by  three  or  four  hours 
in  primipara3  and  one  or  two 
hours  in  multiparae.  Since  the 
soft  face  does  not  press  so  hard 
nor  so  evenly  as  the  occiput  on 
the  cervix,  the  pains  are  weaker, 
especially  in  the  first  stage. 
Dilatation  of  the  cervix  is,  there- 
fore, delayed,  and  this  is  often 
enhanced  by  the  early  rupture 
of  the  bag  of  waters,  which  is 
favored  by  the  maladaptation  of 
the  presenting  part  on  the  cer- 


».^^ 


Fig.  524. — Face  being  Delivered. 
Photograph.     Wesley  Hospital. 


ANOMALIES    OF   THE    PASSENGERS 


597 


vix,  ullovving  tlic  full  force  of  tho  p;oncral  intra-utcrinc  pressure  to  act  on  the  mem- 
branes. The  cause  of  the  face  presentation,  for  example,  contracted  pelvis,  tumors, 
))lacenta  pra'via,  may  also  be  responsible;  for  other  anomalies.  Encasement  of  the 
liead  is  slow,  but  anterior  rotation  comes  on  suddenly  and  is  usually  Vjuickly  accom- 
plished, as  is  also  the  delivery.  Piiinipara3  less  often  have  face  presentations,  and 
nat  urally  in  them  the  mechanism  is  slower  and  more  arduous.  Owin^  to  the  extreme 
lengtheninji;  of  the  fetal  ovoid  the  lower  uterine  segment  is  put  on  the  stretch,  which 
must  be  remembered  during  the  treatment. 

Diagnosis. — A])dominally,  the  ovoid  is  longitudinal  and  very  long,  the  flanks 
being  quite  flat.  The  shape  of  the  uterus  alone  may  sometimes  suffice  to  make  a 
diagnosis.  Over  th(>  inlet  the  head  is  felt,  and  in  the  fundus  the  breech  with  small 
parts,  the  latter  unusually  easily  outlined.     It  is  often  difficult  to  map  out  the 


Fig.  525. — Face  Presentation.     Chin  Rotated  to  Hollow  of  Sacruii. 


back;  what  first  impresses  one  as  being  the  dorsal  plane  not  having  the  proper 
consistence  and  not  showing  the  triangular  area  pictured  in  Fig.  302.  This  is  the 
chest  of  the  infant,  and  in  one  case  I  could  feel  the  child's  heart  beat,  which  has 
also  been  found  l\v  others.     The  back  may  occasionalh'  be  felt  b}^  deep  pressure. 

Above  the  inlet,  to  one  side,  is  felt  a  hard,  round  prominence,  the  occiput,  and 
this  is  separated  from  the  back  by  a  deep  furrow.  On  the  other  side  the  inlet  is 
empty,  but  if  the  patient  is  docile  and  the  abdominal  wall  relaxed,  with  deep 
pressure  the  fingers  may  come  upon  the  horseshoe-shaped  jaw.  Great  importance 
is  to  be  attached  to  the  finding  of  the  feet,  the  heart-tones,  and  the  chest  all  on 
the  same  side.  If  on  the  other  side,  over  the  inlet,  a  large,  hard  prominence  is 
felt  with  a  sharp  groove  above  it,  the  diagnosis  of  face,  or  at  least  brow,  presentation 
is  assured.     The  heart-tones  are  unusually  loud. 

Vaginally,  early  in  labor  the  pelvis  is  empty,  the  bag  of  waters  is  large,  square, 


598 


THE    PATHOLOGY   OF   LABOR 


at  least  not  of  the  watch-crystal  form  observed  in  occipital  presentations.  One 
can  feel  how  it  receives  the  full  force  of  the  uterine  contraction  during  the  pains. 
High  up,  even  in  primiparae,  and  generally  quite  movable,  the  brow  is  felt,  and  also 


526. — Touch 


Face    Presentation. 


Fig.  527.— Touch  Picture.     M.D.P. 


the  anterior  orbit,  if  not  the  root  of  the  nose.  As  soon  as  the  bag  of  waters 
ruptures  there  is  usually  no  difficulty  in  recognizing  the  eyes,  nose,  mouth,  and  jaw. 
Onh'  late  in  labor,  when  the  caput  succedaneum  has  disfigured  the  parts,  does  the 
face  feel  like  the  breech.    An  irregular  surface,  one  with  prominences  and  depressions, 


Fia.  528. — Diagram.    Occiput  Engaged. 


is  felt  by  the  finger,  which  at  once  notifies  the  examiner  that  the  vertex  does  not 
present.  The  facial  line  lies  in  the  transverse  or  the  oblique  diameter  (Figs.  526 
and  527),  turning  as  rotation  progresses.  In  differential  diagnosis  breech  presen- 
tation, brow,  and  lesser  degrees  of  deflexion,  and  anencephalous  monsters  must  be 


ANOMALIES    OK   TIIK    PASSENGERS 


599 


considcrt'd.     An}'  j)r:ictili(jiuT  who  will  lu^ld  tiui  pos-sihilit^'  of  such  confusion  in 
mind  will  easily  avoid  errors.     If  the  face  is  so  swollen  that  the  landmarks  are 


Fig.  529. — Diagram.     Face  not  yet  Exgaged. 


obliterated,  two  points  will  always  remain — the  saddle  of  the  nose  and  the  gums. 
If  the  child  is  alive,  it  may  suck  the 
finger.  An  important  point  in  the 
diagnosis  is  the  determination  of  the 
degree  of  engagement.  The  head  is 
engaged  only  when  the  biparietal 
diameter  has  passed  the  inlet.  In 
occipital  presentations  the  parietal 
bosses  have  just  sunk  below  the 
plane  of  the  inlet  when  the  lowest 
part  of  the  head,  the  vertex,  comes 
to  lie  in  a  line  drawoi  from  one  ischi- 
atic  spine  to  the  other.  In  face  pres- 
entation, however,  when  the  brow 
or  the  root  of  the  nose,  that  is,  the 
lowest  portion  of  the  presenting 
part,  comes  to  lie  in  this  line,  the 
parietal  bosses  are  still  several  centi- 
meters above  the  plane  of  the  inlet 
(Figs.  528  and  529).  Only  when 
the  face  is  deep  down  on  the  pelvic 
floor  may  we  say  that  the  head  is 
engaged. 

When   making   internal   exam- 
inations in  face  cases  great   care  is  to  be  taken  to  avoid  the  introduction  of 
vaginal  mucus  into  the  eyes  of  the  child.     If  gonorrheal,  a  blinding  ophthalmia 


Fig.  .530. 


Front  View  of  Child  Deuvered  in  Face  Pres- 

EXT.\TION. 

Chicago  Lj-ing-in  Hospital. 


600 


THE    PATHOLOGY    OF   LABOR 


may  thus  be  caused.     Similar  precautions  are  advisable  with  the  use  of  antiseptic 
solutions. 

Plostic  Changes. — If  the  labor  has  been  prolonged  after  rupture  of  the  mem- 
branes, the  face  is  horribly  disfigured  (Figs.  530  and  531).  Over  the  anterior  cheek 
and  eye  the  caput  is  always  found,  and  the  whole  face  is  involved,  the  eyes  bulge  out, 
the  lids  are  swollen,  a  mucoserous  discharge  escaping  from  them;  the  mouth  is  held 
open  by  the  tumid  lips,  the  tongue  sometimes  protrudes,  and  the  child  may  not  be 
able  to  nurse  for  several  days.  Minute  hemorrhages  under  conjunctiva  and  skin, 
sometimes  with  bullae,  intense  venous  congestion,  the  tumefaction  of  the  thyroid, 

and  the  cracks  in  the  skin  of 
the  neck  already  mentioned, 
give  the  child  a  most  dis- 
couraging appearance.  The 
shape  of  the  head  is  extremely 
dolichocephahc,  the  occiput 
being  long  drawn  out,  and 
there  may  even  be  a  saddle- 
shaped  depression  near  the 
large  fontanel.  The  child  lies 
in  its  crib  on  the  side,  with 
the  head  extended,  the  back 
straight,  and  may  keep  this  at- 
titude for  at  least  two  weeks. 
The  mother  may  be  reassured 
that  the  child's  features  will 
soon  regain  their  proper  ap- 
pearance. 

Prognosis  of  Face  and 
Brow  Presentations. — Without 
question  both  face  and  brow 
presentations  must  be  con- 
sidered pathologic.  The  mor- 
tality is  higher  in  both  because 
of  the  longer  labor,  the  greater 
danger  of  infection,  the  fre- 
quently necessary  operative 
interventions,  and  also  those 
unnecessarily  undertaken. 
While  the  majority  of  face 
cases  will  terminate  spontan- 
eously or  with  a  little  help 
from  art,  brow  presentation  is 
always  dangerous. 

For  the  child  the  mor- 
tality is  also  higher,  which  is  due  to — (1)  Prolonged  labor  and  cerebral  compression; 
(2)  compression  of  the  neck  against  the  pul^is,  interfering  with  the  return  circulation 
from  the  head;  (3)  compression  of  the  trachea  and  larynx  against  the  pubis,  with 
suffocation  or  even  fracture;  (4)  injury  from  forceps  or  other  operation,  done  to  effect 
delivery.  Fully  four  times  as  many  children  die  from  face  presentation  as  in  occi- 
pital, and  fully  ten  times  as  many  in  brow.  It  would  be  interesting  to  follow  up 
these  children  to  see  if  the  extreme  molding  which  the  brain  suffered  affects  their 
mentality  in  any  way  in  later  life. 

Treatment. — Not    all    face    presentations    reciuire    special    treatment.     The 
majority  terminate  spontaneously  and  happily  for  the  mother  and  babe,  without 


Fig.  53L 


-Child  Delivered  in  Face  Presentation. 
Chicago  Lying-in  Hospital. 


ANOMALIES    OF   THE    PASSENGERS  GOl 

the  assistance  of  art.  Moscliicjii  (a.  d.  l()(Jj  rccoiniiiciKlcd  tiiat  all  such  j)r('S('nta- 
tions  be  chaiigotl  to  occipital;  Mauriceau  (16G3)  and  de  la  Motte  (1721)  taught  the 
same.  Paul  Portal  (KkSo)  and  Deleuryo  (1770)  took  the  opposite  side,  and  loft 
thcni  to  nature.  Baudelocijue  (a.  d.  1810)  advised  inmuHliate  interference,  a 
teachin};'  which  is  still  felt,  in  spite  of  i\\c  efforts  of  modern  ol)stetricians  to  dispel 
it.  Perhaps  the  fact  that  Hodge,  and  more  recently  Schatz,  recommended  it,  does 
nmch  to  explain  the  present  frequency  of  operative  measures  in  face  cases.  In 
1789  Z(dl(>r,  from  40  cases,  and  in  1791  Boer,  in  Vienna,  from  an  experience  of  80 
cases,  showed  that  these  presentations  may  safely  be  left  to  nature,  79  of  Bcjer's  80 
cases  having  terminated  sjiontaneously  with  only  4  fetal  deaths.  .laggard,  of 
Chicago  (died,  189G),  declared  in  the  strongest  terms  that  watchful  expectancy 
should  be  the  treatment  of  face  presentation.  No  one  nowadays  claims  that  it  is 
good  ])ractice  to  correct  every  face  ])resentation,  but  when  the  cases  are  carefully 
differentiated,  many  will  be  found  where  the  interests  of  mother  and  child  are  best 
served  by  early  interference. 

Before  Engagement. — If  discovered  during  pregnancy  or  early  in  labor,  it  may 
ho.  possible  to  alter  the  attitude  of  the  child  by  Schatz's  method  of  al)dominal 
manipulation.  During  labor  all  measures  which  preserve  the  ]jag  of  waters  are 
to  be  employed,  for  example,  the  side  position,  abstention  from  bearing-down 
efforts  by  the  patient,  and  care  during  examinations  by  the  accoucheur.  It  may 
be  very  advisable  to  put  a  colpeurynter  in  the  vagina,  filling  it  moderately.  If  the 
head  is  found  in  transition  from  vertex  to  face,  the  woman  should  lie  on  the  side 
to  which  the  occiput  points;  if  the  face  presentation  is  fully  formed,  she  should 
lie  on  that  side  which  will  favor  descent  and  anterior  rotation  of  the  chin,  that  is, 
the  side  to  which  the  chin  points.  As  a  rule,  in  the  absence  of  special  indications, 
watchful  expectancy  is  the  treatment  to  be  pursued,  and  the  general  practitioner 
will  do  best  for  his  patient  if  he  gives  her  plenty  of  time  to  force  the  head  well  down 
into  the  pelvis  and  onto  the  perineum.  Then  he  may  w^ait  as  long  as  six  hours  for 
internal  anterior  rotation,  and  almost  always  his  patience  will  be  rewarded  by  either 
a  spontaneous  delivery  or  sufficient  descent  and  anterior  rotation  that  the  forceps 
may  be  easily  and  safely  applied. 

If  the  position  is  one  with  the  chin  in  the  transverse  diameter,  or,  better  still, 
in  the  anterior  quadrants  of  the  pelvis,  this  is  the  invariable  treatment,  in  the 
absence  of  other  indication,  but  if  the  chin  is  posterior  to  the  transverse  cUameter 
of  the  pelvis,  a  more  active  conduct  may  be  advisable,  in  the  interests  of  the  child 
antl  in  the  hope  of  reducing  the  lenglh  of  the  labor  and  its  attendant  distress  and 
clangers.  If  the  head  remains  high  with  the  chin  posterior,  in  spite  of  good  pains, 
the  malpresentation  may  be  changed  manually  to  one  of  the  occiput,  or  podalic 
version  may  be  performed.  There  is  no  unanimity  of  opinion  among  the  authori- 
ties regarding  the  selection  of  these  procedures.  Baudelocque,  Schatz,  Thorn, 
and  Hodge  prefer  the  manual  correction,  as  do  most  modern  writers.  Bumm 
prefers  version.  The  writer  has  had  almost  uniform  success  ^^^th  the  conversion 
of  face  presentation  to  occipital,  the  only  cases  in  which  his  efforts  failed  being 
those  in  which  labor  had  progressed  too  far,  extreme  molding  of  the  head  had  taken 
place,  and  the  uterus  had  become  strictured  around  the  child's  neck.  Chin  pos- 
terior positions  are  particularly  favorably"  altered  by  conversion  into  occiput  pres- 
entations, because  an  anterior  occiput  is  obtained,  for  example,  jNI.D.P.  becomes 
an  O.L.A.,  and  M.L.P.  an  O.D.A.  (For  the  methods  of  manual  correction  see  Chap- 
ter LXX.)  Should  it  he  impossible  to  correct  the  presentation,  podalic  version  may 
be  done,  and,  failing  in  this,  craniotomy  would  be  necessary. 

AJtcr  Engagement. — When  the  head  is  engaged  in  the  pelvis  -uith  the  chin  in 
the  transverse  diameter  or  even  anterior  to  it,  given  a  strict  indication  for  delivery, 
forceps  is  the  operation  of  choice.  Before  apphdng  the  instrument  an  attempt  is 
to  be  made  to  complete  the  rotation  of  the  chin  to  the  front  by  manipulation  with 


602  THE    PATHOLOGY    OF   LABOR 

the  fingers  or  half  hand.  A  purchase  is  obtained  on  the  posterior  malar  and 
frontal  bones,  and,  during  the  pains,  the  fingers  make  gentle  traction  upward  and 
for^yard,  trjdng  to  bring  the  chin  under  the  pubis,  aiding  the  manceuver  by  pressure 
on  the  occiput  from  the  outside  over  Poupart's  ligament.  Occasionally  a  little 
pressure  on  the  chin  to  exaggerate  extension  and  slight  traction  forward  will  help 
rotation.  If  rotation  can  be  thus  completed,  nature  may  terminate  the  case,  or, 
at  least,  the  forceps  operation  becomes  at  once  easier,  simpler,  and  safer. 

Should  the  chin  lie  behind  the  transverse  diameter,  or  have  even  turned  toward 
the  sacrum,  the  family  is  to  be  advised  that,  with  the  usual  methods  of  delivery,  a 
dead  child  is  almost  a  certainty,  and  if  the  mother  and  child  are  in  prime  condition, 
the  question  of  cesarean  section  is  to  be  considered.  When  the  conditions  are  not 
ideal  for  an  abdominal  delivery,  the  accoucheur  should  try  to  change  the  chin 
posterior  to  an  occiput  anterior,  even  though  the  head  is  engaged.  Under  deep 
anesthesia  so  much  relaxation  of  the  uterus  occurs  that  a  surprising  degree  of  mobil- 
ity is  conferred  on  the  fetus.  It  is  then  possible,  and  if  it  is  done  gently  it  is  safe, 
to  push  the  head  up  and  out  of  the  pelvis  sufficiently  far  to  enable  the  author's 
method  of  manual  conversion  to  be  practised.  Naturally,  the  operation  requires 
the  greatest  circumspection,  but  the  end  will  justify  the  risk,  and  the  latter  is  very 
little  in  competent  hands.  If  conversion  fails  or  appears  too  hazardous,  manual 
rotation  of  the  chin  through  an  arc  of  three-fourths  of  the  half-circle  is  to  be  at- 
tempted. Unless  the  chin  can  be  brought  into  the  anterior  half  of  the  pelvis,  forceps 
are  a  most  dangerous  and  destructive  instrument,  being  at  the  same  time  inefficient. 
Craniotomy  is  a  more  humane  operation,  and  has  hardly  a  higher  fetal  mortality 
than  the  forceps  used  in  such  instances.  Hodge  lauds  the  use  of  the  vectis  in  these 
cases,  but  modern  accoucheurs  hardly  know  the  instrument.  In  the  treatment  of 
face  presentation  the  forceps  are  to  be  employed  only  when  absolutely  unavoidable. 
Before  doing  a  craniotomy  on  a  living  child  with  the  chin  posterior  a  gentle  attempt 
with  the  forceps  is  justifiable,  but  it  must  stop  short  of  maternal  injury.  For  these 
impacted  cases  pubiotomy  has  been  recommended.  In  all  face  deliveries,  spon- 
taneous and  operative,  the  fact  must  be  remembered  that  the  diameters  and  circum- 
ferences presented  to  the  pelvic  floor  outlet  are  not  so  favorable  as  in  occipital  de- 
liveries, and  that  the  pelvic  floor  is  pushed  further  downward  and  torn  from  its  bony 
attachments.  Deep  episiotomy,  sometimes  going  through  the  pillar  of  the  levator 
ani,  is  almost  always  needed,  and  is  to  be  strongly  recommended.  After  the  conver- 
sion into  an  occipital  presentation,  unless  there  is  an  urgent  indication  for  delivery, 
the  case  should  be  left  to  nature.  A  spontaneous  delivery  may  now  occur — at  all 
events  the  head  will  be  molded  by  a  few  hours'  labor  into  a  favorable  shape,  and 
brought  low  into  the  pelvis,  sometimes  even  onto  the  perineum,  making  the  eventual 
forceps  delivery  easy  and  safe. 

Every  face  and  brow  case  demands  a  comprehensive  diagnosis  of  all  adjuvant 
conditions  which  may  govern  the  methods  of  treatment.  As  such  may  be  men- 
tioned contracted  pelvis,  placenta  prsevia,  tumors,  eclampsia,  etc. 

It  is  advisable  to  observe  the  children  carefully  for  several  days,  since  edema 
of  the  glottis  may  occur.  Fracture  of  the  larynx  has  resulted  from  too  forcible 
pressure  of  the  trachea  against  the  pubis,  a  point  worth  remembering  while  con- 
ducting the  delivery.  The  scratch-marks  on  the  face  require  antiseptic  treatment. 
The  tumefaction  of  the  eyelids  will  subside  quickly  under  a  warm  boric  solution 
dressing. 


rHAPTl-:R  L 
ANOMALIES  OF  THE  PASSENGERS  fContinwed) 

BREECH  PRESENTATION 

In  al)Out  3  per  cent,  of  ctiscs  the  eliikl  i)n'sents  itself  for  delivery  with  the 
breech  as  the  advancing  portion  of  its  l)ody.  Most  authors  consider  breech  pres- 
entations eutocia,  but  since  thv  fetal  mortality  is  three  times  as  high  as  in  O.L.A., 
and  the  maternal  morbidity,  from  lacerations  and  sepsis,  decidedly  greater,  the 
author  believes,  with  Eden  and  others,  that  they  should  be  considered  dystocia. 

Breech  pr(\sentation  is  the  first  of  the  errors  of  polarity  of  the  fetus  to  be  dis- 
cussed, the  normal  polarity  being  a  parallelism  of  the  fetal  axis  with  the  long  axis 


Fig.  532. — Breech  Presfnt.^tion.     S.L.A. 

of  the  mother,  the  cephalic  pole  presenting  at  the  inlet.  Reversal  of  the  normal 
polarity  is  breech  presentation;  lack  of  parallelism  between  the  two  axes  produces 
the  varieties  of  transverse  presentation. 

Etiology. — Little  is  positively  known  of  the  causes,  because  neither  the  mother 
nor  the  babe  may  show  anything  unusual,  but  the  presentation  has  been  more 
frequently  found  in  the  following  conditions:  (1)  Abnormally  shaped  uteri,  especi- 
ally uterus  arcuatus  and  subseptus;  (2)  anj-thing  that  will  prevent  engagement  of 
the  head,  as  contracted  pelvis,  tumors,  placenta  praevia;  (3)  polyhydranmion,  the 

603 


604 


THE    PATHOLOGY    OF   LABOR 


child  being  very  free  to  move  around;    (4)  multiparity,  which  acts  in  the  same  way; 
(5)  on  the  part  of  the  fetus,  hydrocephalus,  tumor  of  the  neck  or  head,  making  the 


Fig.  533. — Breech  Presentation.     S.D.P. 


Fig.  534. — Single  Breech  Presentation. 


ANOMALIES    (JF    'I'lIK    PASSENGERS 


605 


cephalic  polo  lar<i;<'r  than  the  caudal,  and  thus  rcndcriiiji;  it  better  adapt a})le  to  the, 
lar^"<'  fundus  uteri;  (())  prematurity,  a  very  conunon  predisposinj;-  cause;  (7)  twin 
pregnancy. 

]?re(>('h  presentation  is  very  fre(|uent  about  the  seventh  month  of  pregnancy, 
but  it  usually  clianges  to  a  head,  and  the  process  may  he  repeated  several  times, 
even  up  to  a  lew  da>s  before  labor. 

Mechanism  of  Labor. — There  are  several  varieties  of  breech  presentation, 
depending  on  the  attitude  or  posture  of  the  child:  (1)  Complete  or  doul)le  breech, 
where  the  infant  maintains  th(^  same  attitude*  as  in  vertex,  but  with  reversed  polarity. 


Fig.  535. — .Y-ray  of  Nine  Months'  Pregnancy.     S.D.P.     Bheech  Presentation  (Dr.  J.  B.  Murphy's  case). 


Here  the  buttocks,  with  the  feet  alongside  them,  present  at  the  internal  os  (Figs, 
532  and  533).  (2)  Incomplete  breech,  where — (a)  One  foot  or  two  feet  have  pro- 
lapsed into  the  vagina — single  or  double  "footling"  presentation;  (6)  where  one  or 
both  knees  have  thus  prolapsed;  and  (c)  where  the  legs  are  extended  against  the 
trunk  and  the  feet  lie  against  the  face,  sometimes  called  "single"  breech  presenta- 
tion (Fig.  534).  These  are  all  errors  of  attitude  and  increase  the  dangers  to  mother 
and  child. 

In  conformity  with  the  system  employed  in  the  other  presentations  it   is 
possible  here,  too,  to  distinguish  six  positions  of  the  presentation,  but  in  practice 


606 


THE   PATHOLOGY   OF   LABOR 


two  are  mostly  observed, — S.L.A.  and  S.D.P., — though  in  the  latter  usually  the 
back  tends  somewhat  more  to  the  side  than  behind.  The  point  of  direction  is  the 
sacrum,  and  in  following  the  mechanism  of  labor  the  genital  crease  is  used  for  the 
purpose  of  orientation,  in  the  same  way  that  the  facial  line  and  the  sagittal  suture 
are  used  for  other  presentations. 

Mechanism  of  Breech  Presentation. — With  very  little  variation  the  mechanism 
of  labor  is  the  same  whether  the  complete  breech  presents  or  there  is  an  error  of 
attitude,  as  footling  or  single  breech.  For  purposes  of  study  sacrolseva  anterior 
(S.L.A.)  w\\\  be  selected.  The  movements  of  the  breech  and  lower  trunk,  of  the 
shoulders  and  of  the  head,  must  be  considered,  those  of  the  shoulders  and  head 
being  more  constant  and  important. 

Even  in  primiparse  the  breech  remains  high  up  until  labor  is  quite  well  advanced, 
often  until  dilatation  of  the  cervix  is  completed  and  the  bag  of  waters  ruptured. 
The  feet  accompany  the  buttocks,  but  at  a  slight  distance,  being  held  back  by  the 
cervix  or  pelvic  brim.     Descent  is  slow  in  primiparse  because  the  soft  breech  cannot 


Fig.  536. — Mechanism  of  Breech  Labor.     S.D.P.     Lateroflexion  at  Outlet. 


wedge  itself  into  the  vagina  so  firmly  as  does  the  head,  and,  further,  when  the  l)«ad 
presents,  the  upper  vagina  and  the  bases  of  the  broad  ligaments,  with  the  pelvic 
connective  tissues,  are  already  dilated  and  prepared  by  the  descent  of  the  broad 
cephalic  wedge  in  the  latter  weeks  of  pregnancy.  Flexion,  the  second  movement, 
takes  place  as  soon  as  the  breech  strikes  the  perineum;  the  posterior  buttock  is 
hold  back;  the  anterior  one  stems  under  the  pubis  (Fig.  536).  This  movement  is 
always  associated  with  the  third — internal  anterior  rotation.  In  S.L.A.  the  breech 
descends  in  the  left  oblique,  that  is,  the  bisiliac  diameter  lies  in  the  left  oblique 
diameter  of  the  pelvis,  the  genital  crease  lying  in  the  right,  the  anterior  hip  pointing 
to  the  right  iliopubic  tubercle,  and  lacing  a  little  lower  than  the  posterior.  This  is 
anterior  asynclitism,  and  is  analogous  to  the  obliquity  of  Naegele.  Anterior 
rotation  occurs  by  the  anterior  hip  rotating  to  the  front  from  the  right  anterior 
quadrant  of  the  pelvis,  the  sacrum  looking  directly  to  the  left  side,  the  other  buttock 
turning  behind,  the  genital  fissure  now  lying  in  the  transverse.  The  causes  of  this 
movement  are  the  same  as  in  the  other  presentations  ({/.  v.).     The  fourth  move- 


A.NOMALIK.S    (JF    Till-:    PASSENGERS 


007 


mcnt  is  continued  hitcroflcxloti;  the  anterior  hip  stems  under  the  pubis,  the  pos- 
terior hip  rolls  over  the  perineum,  the  whoh;  pelvis  risinj^  uj)  (n'er  the  pubis,  a  tight 
pelvic  Hoor  increasing  this  elevation.  External  restitution ,  the  fifth  movement,  is 
not  constant.  Usually  the  anterior  hip  turns  again  to  the  right  side,  and  the 
sacrum  comes  directly  anterior,  but  sometimes  the  l^ack  remains  in  the  transverse 
and  the  shoulders  come  out  in  this  position.  X<jw  the  legs  drop  down  and  tlie  back 
again  lies  in  the  oblicjue  (Fig.  5:^7). 

The  movements  of  the  shoulders  are  precisely  similar  to  those  of  the  breech. 
Descent  occurs  with  the  bisacromial  diameter  in  the  left  obliciue.  If  no  attempt 
to  aid  delivery  by  traction  from  below  is  made,  the  arms  lie  folded  closely  against 
the  chest.  Stronger  pains  and  more  abdominal  muscular  exertion  are  needed  for 
delivery  of  the  slioulder-girdle.  The  anterior  shoulder  rotates  in  the  right  anterior 
quadrant  of  the  pelvis  toward  the  pubis  and  stems  behind  it,  while  by  a  process  of 
lateroflexion  the  posterior  shoulder  and  arm  are  delivered.  Then  comes  the  an- 
terior shoulder  from  l)ehind  the  pul)is,  and  if  no  assistance  is  given,  the  body  drops 
down  with  the  neck  against  the  perineum,  the  nape  against  the  subpubic  ligament. 


Fig.  537. — Delivery  of  Breech  to  Navel.     S.D.P. 

If  the  head  is  arrested  high,  the  fifth  movement,  external  restitidion,  now  takes  place, 
the  back  rotating  again  to  the  side.  If  the  head  follows  the  body  closely  and  sinks 
into  the  pelvis,  the  back  may  rotate  to  the  front. 

When  the  shoulders  are  passing  the  vulva,  under  normal  circumstances  the 
head  has  entered  the  inlet.  If  the  inlet  is  contracted,  the  head  is  held  back,  and 
the  stretching  of  the  neck  permits  the  escape  of  the  shoulder-girdle,  l)ut  not  com- 
pletely, unless  the  soft  parts  are  pushed  back  a  little  around  the  fetal  neck  and  up 
into  tjie  bony  pelvis.  When  the  head  is  well  flexed  on  the  sternum,  the  same 
diameters  are  opposed  to  the  girdle  of  resistance  as  in  O.L.A.,  but  in  inverted  order. 
A  difference  is  also  seen  in  the  shape  of  the  wedge — in  occipital  presentation  the 
blunt  occiput  advances;  in  head-last  deliveries  the  narrow  planes  from  the  neck  to 
the  biparietal  go  first,  a  fact  which  explains  in  part  why  the  head  goes  through  the 
pelvis  easier' and  quicker  when  it  comes  out  last.  Descent,  flexion,  anterior  rota- 
tion of  the  occiput  to  the  front,  occur  in  order  (Fig.  538),  all  explained  by  the  usual 
mechanisms.  The  sagittal  suture  enters  in  the  right  oblique,  just  as  it  does  in 
O.L.A.  When  the  chin  has  rotated  to  the  hollow  of  the  sacrum,  flexion,  the  fourth 
movement,  occurs,  the  nape  of  the  neck  being  the  center,  and  the  chin,  face,  and 


608 


THE    PATHOLOGY    OF   LABOR 


forehead  coming  successively  over  the  perineum,  after  which  the  occiput  escapes 
from  behind  the  pubis. 

In  back  posterior  positions  the  mechanism  is  nearly  the  same.  Here  the  an- 
terior buttock  must  rotate  three-fourths  of  the  half-circle  in  order  to  get  under  the 
pubis,  after  which  the  mechanism  is  as  above  described.  It  has  happened  in  such 
cases  that  the  back  rotated  in  front  of  the  sacrum  to  the  opposite  side,  and  before 
delivery  is  completed  has  traversed  three-quarters  of  the  circumference  of  the  pelvis. 
I  have  never  seen  this  occur  except  when  the  posterior  foot  and  leg  had  prolapsed 
and  had  guided  this  abnormal  rotation  {vide  infra). 

Vnusual  J/ec/)07us7ns.— Occasionally,  after  the  breech  is  delivered,  the  back 
rotates  beyond  the  pubis  to  the  other  side  of  the  pelvis,  an  over-rotation,  which 
has  likewise  been  observed  in  the  mechanism  of  the  shoulders  in  head  cases.  The 
remainder  of  the  child  may  come  out  with  the  back  on  the  side  opposite  that  in 
which  it  started.  Even  excessive  internal  anterior  rotation  of  the  breech  has  been 
observed,  the  body  of  the  fetus  issuing  with  the  belly  to  the  pubis.     Subsequently 


Fig.  538. — Delivert  of  After-coming  Head  in  Flexion. 

the  shoulders  enter  in  an  oblique  diameter  and  the  proper  mechanism  is  resumed. 
It  is  not  usually  possible  to  discover  the  cause  of  these  irregular  mechanisms. 

Footling  presentation  has  the  normal  mechanism,  unless  by  chance  the  pos- 
terior foot  has  prolapsed.  In  all  labors  the  tendency  is  for  the  lowest  portion  of  the 
presenting  part  to  slip  under  the  pubic  arch.  The  construction  of  the  front  part 
of  the  pelvis  and  the  arrangement  of  the  sacrosciatic  ligaments  and  the  levator  ani, 
resemble  the  ways  of  a  ferry-boat,  and  any  movable  body  placed  on  these  inclined 
planes,  propelled  from  above,  would  tend  to  go  in  this  direction.  Thus  the  breech, 
when  the  anterior  leg  has  prolapsed,  glides  without  difficulty  along  the  ways.  It  is 
different,  however,  when  the  posterior  leg  has  prolapsed.  Here  the  breech  is  held 
higher,  the  anterior  })uttock  impinges  on  the  horizontal  ramus  of  the  pubis,  and  the 
posterior  leg  is  prevented  from  reaching  the  anterior  inclined  plane.  It  finds  an 
easier  way  on  the  other  side  of  the  pelvis,  and  often,  not  always,  as  some  authors 
claim,  the  back  rotates  in  front  of  the  sacrum,  the  posterior  limb  now  becoming  an- 
terior and  following  out  the  favorite  mechanism,  but  on  the  other  side  of  the  pelvis. 
This  mechanism  might  also  be  explained  on  the  theory  of  Sellheim.     The  anterior 


ANOMALIES    OF   THE    PASSENGERS 


GOO 


limb  fixes  the  lower  trunk  so  that  it  ciuukA  IjcirI  easily  toward  the  fnjnt,  but  d(jes 
so  toward  the  sacrum.  Rotation  then  takes  place  in  the  direction  in  which  the 
fetal  cylinder  can  most  readily  l)end.  After  the  breech  is  on  the  oth(T  side  cjf  the 
promontory,  laterofiexion  of  the  fetal  spine  is  most  favored  in  an  anterior  dire(;tion, 
and,  therefore,  the  fetal  cylinder  rotates  anteri(jrly  to  accommodate  itself  to  the 
birth-canal.  In  several  instances  I  have  observed  the  usual  mechanism,  anterior 
rotation,  even  though  the  posterior  limb  had  been  brought  down. 

•Abnormal  rotation  of  the  back  is  infreciiiently  observed,  unless  the  accoucheur 
is  hasty  and  makes  i)remature  traction  on  the  trunk,  or  ignorantly  interferes  with 
nature's  methotls.  If  the  back  does  not  rotate  to  the  front,  but  to  the  sacrum,  the 
child  descends  with  the  belly  to  the  pubis  of  the  mother.  Usually  the  natural 
powers  are  insufficient  to  deliver  the  infant  in  this  position,  and  art  has  to  aid. 
(Sec  ('ha])ter  LXXI.)  Nature  may  accomplish  the  ])irth,  the  shoulders  being  forced 
out  in  the  transverse,  the  elbows  and  arms  falling  from  behind  the  pubis,  and  anterior 


Fio.  5.30. — Deliveky  of  After-comi.vo  Head  with  OcripuT  Posteriok.     First  Mechanlsm,  Chix  Flexed. 


rotation  of  the  trunk  is  effected  late.  As  a  rule,  the  head  gives  the  most  trouble. 
If  it  turns  with  the  occiput  in  the  hollow  of  the  sacrum,  the  chin  to  the  pubis,  labor 
may  stop,  and  unless  art  aids  the  infant  will  perish.  Nature  sometimes  terminates 
these  cases  in  one  of  three  ways:  (1)  If  the  head  comes  down  well  flexed,  the  chin 
applied  to  the  sternum,  anterior  rotation  of  the  occiput  may  occur  verj'  late.  Usu- 
ally in  these  instances  the  occiput  did  not  lie  directly  behind,  but  more  to  one  side. 
(2)  If  the  head  is  flexed  (Fig.  539),  delivery  with  the  occiput  posterior  occurs,  the 
root  of  the  nose  stems  behind  the  pubis,  the  nape  of  the  neck,  occiput,  and  vertex 
coming  over,  or  through,  the  perineum,  the  face  then  falling  from  liehind  the  pubis. 
This  mode  of  delivery  is  facilitated  by  lifting  the  child  up.  (3)  If  the  head  is  ex- 
tended, the  chin  may  catch  on  one  pubic  ramus  (Fig.  540).  Artificial  aid  is  almost 
always  necessary  here.  By  lifting  the  child  up  the  occiput,  vertex,  and  forehead 
in  order  may  pass  over  the  perineum,  the  neck  forming  the  center  of  rotation. 
Nature,  however,  alone  camiot  do  this;  the  trunk  depends,  and  the  occiput  must 
39 


610 


THE    PATHOLOGY    OF    LABOR 


come  over  the  perineum,  pulling  the  face  after  it,  which  can  seldom  be  accomplished 
quickly  enough  to  save  the  infant. 

Single  breech  presentations  have  a  more  laborious  delivery,  because  the  legs, 
extended  against  the  body,  act  like  a  splint  and  rob  the  fetal  cylinder  of  its  flexibility. 
Descent  and  flexion  are,  therefore,  very  slow  and  difficult.  To  be  considered  also 
are  the  smallness  of  the  advancing  wedge,  which  results  in  imperfect  preparation 
of  the  soft  parts,  and  delay  and  danger  in  the  passage  of  the  shoulders  and  head;  the 
frequency  of  the  early  rupture  of  the  bag  of  waters,  and  the  usually  weak  labor 
pams,  because  no  firm  body  presses  on  the  cervical  ganglia. 

Labor  may  be  complicated  by  the  arms  leaving  the  chest  and  being  stretched 
up  over  the  head,  or  even  crossed  behind  the  occiput  in  the  nape  of  the  neck. 
Nature  cannot  terminate  these  cases  satisfactorily.  Art  must  step  in.  (See 
Chapter  LXXI.) 

Clinical  Course. — During  pregnancy  breech  presentations  sometimes  cause 
symptoms  which  attract  attention.  Pain  and  distress  in  the  epigastrium  may  be 
complained  of,  and  if  the  fetus  changes  its  position,  these  will  be  relieved.    Pendulous 


Fig.  540. — Delivery  of  After-coming  Head  with  OcciPtrT  Posterior.    Second  Mechanism,  Extension. 

abdomen   is   connnon.     Lightening   does   not   occur.     The   fetal   movements   are 
perceived  low  in  the  belly  in  the  iliac  regions. 

Since  so  many  small  and  premature  children  come  by  the  breech,  the  time  of 
labor  is  shorter  than  with  cephalic  presentations,  but,  counting  only  full-sized  in- 
fants, labor  is  actually  longer  in  breech  cases,  and  this  is  especially  true  of  primi- 
parse.  This  increase  of  the  leng"th  of  labor  is  all  in  the  first  stage,  the  second  stage 
progressing  very  rapidly,  seldom  taking  more  than  eight  minutes,  and  usually  less 
than  four.  The  breech  remains  high  and  relatively  immobile  until  the  cervix  is 
completely  dilated;  then,  with  the  rush  of  the  waters,  it  comes  quickly  clown  to  the 
perineum.  The  actual  delivery  is  shorter  and  less  painful  than  head  labors.  Pre- 
mature rupture  of  the  membranes  is  common,  and  this  renders  still  slower  the  dila- 
tation of  the  OS.  In  primipara?  labor  may  be  very  tedious,  and  the  second  stage, 
OAving  to  rigidity  of  the  vagina  and  perineum,  may  be  so  prolonged  that  the  life 
of  the  fetus  is  much  endangered.  In  cases  of  complete  breech  the  large  foregoing 
part  prepares  the  cervix  and  pelvic  floor  for  the  passage  of  the  head.  In  footling 
or  single  breeches  these  parts  are  poorly  dilated,  and  while  the  slender  trunk  slips 
through  easily,  the  head  is  almost  always  arrested,  the  child's  life  being  lost,  or  the 
tissues  being  torn  as  a  result.     Meconium  may  escape  freely  during  breech  de- 


ANOMALIES    OV   THE    PASSENGERS 


611 


liveries,  but  it  has  no  siffnifiranre  unless  it  shows  before  the  breech  has  enga^^ed 
or  other  .si}i;ns  of  intra-uteriue  asphyxia  are  present.     It  has  the  same  cause  as  the 


Fig.  541. — Head  from  Cesare.\n  Section.     Not  Molded. 

formation  of  the  caput  succedaneum;  the  meconium  is  pressed  out  in  the  direction 
of  the  least  resi.^tance,  which  is  the  anal  region  lying  over  the  os. 

In  the  third  stage  of  breech  labors  complications  due  to  anomalous  separation 


Fig.  542. — Head  Fi.attexed  ox  Top.     Bueech  Presext.\tiox  ix   a   Piunupara   (.Ilccker). 


of  the  placenta  occur,  also  a  tendency  to  atony  of  the  so  rapidly  emptied  uterus. 
Postpartum  hemorrhage  is,  therefore,  slightly  more  frequent  than  usual,  and  the 
role  of  lacerations  must  also  be  considered  in  this  connection. 


612 


THE    PATHOLOGY    OF    LABOR 


Plastic  Changes. — The  caput  succedaneum  is  found  on  the  anterior  hip,  but 
may  spread  all  over  the  buttocks.  In  boys  the  penis  and  scrotum  may  be  enor- 
mously edematous  and  black  and  blue  from  extravasated  blood.     In  girls  there  may 

be  a  moderate  vulvitis,  with  leukor- 
rhea,  for  a  few  days.  If  the  leg  has 
been  down  for  any  length  of  time, 
it  swells  and  shows  minute  hemor- 
rhages besides  the  severe  congestion. 
All  this  disappears  within  a  week. 
Ordinarily,  the  child's  head  is  not 
molded,  but  presents  the  round 
shape  it  had  in  utero — this  in  mul- 
tiparse  and  when  the  breech  pres- 
entation was  developed  just  before 
labor  began.  If  the  child  had  lain 
a  long  time  in  this  position,  especi- 
ally if  the  mother  was  primiparous, 
or  if  the  labor  had  lasted  a  long 
time  after  the  rupture  of  the  mem- 
branes, distinct  evidences  of  mold- 
ing will  be  discoverable  on  the  head. 
This  may  take  the  form  of  a  dolicho- 
cephalus,  which  was  especially 
brought  out  by  Fritsch,  the  head 
having  been  pressed  down  by  the 
fundus  uteri  or  one  or  the  other 
side  of  the  head  may  be  flattened. 
If  the  mother  had  a  pendulous  ab- 
domen, the  side  of  the  head  which 
lay  posterior  will  show  the  flattening,  as  in  this  case  the  head  will  be  inclined  toward 
the  anterior  shoulder.  If  the  abdominal  wall  held  the  head  up  firmly,  the  side  of 
the  head  which  lay  anteriorly  will  be  flattened,  the  lateral  inclination  then  being 
onto  the  posterior  shoulder.  The  sterno- 
cleidomastoid and  other  muscles  on  the 
side  opposite  that  showing  the  flattening 
may  be  shortened,  producing  a  wry-neck. 
In  cases  of  oligohydramnion  this  is  the 
rule.  Great  importance  must  be  attached 
to  this  congenital  shortening  of  the  neck 
muscles,  because  if,  during  delivery,  too 
much  traction  is  made  on  them,  they  will 
tear,  hematoma  or  myositis  resulting. 
Permanent  wry-neck,  while  seldom  due 
to  injury  of  a  normal  muscle,  and  sel- 
dom folloAving  a  hematoma  of  the  mus- 
cle, is  often  the  result  of  this  congenital 
shortening,  either  wdth  or  without  in- 
jury. 

Diagnosis. — Unless     labor     is     ad- 
vanced and  the  pains  are  very  strong  and 

frequent,  rendering  the  uterus  rigid,  the  external  examination  will  be  sufficient  for 
diagnosis.  The  ovoid  is  longitudinal,  but  the  upper  portion  of  the  uterus  is  broader 
than  the  lower  and  runs  to  the  side  on  which  the  head  lies,  a  three-cornered  effect 
being  produced.     Over  the  inlet  no  hard,  round  body  is  to  be  found,  but,  instead,  a 


Fig.  543. — Head  Flattened  on  Side.     Breech  Presentation. 


.541.— Touch 


Complete    Breech. 


ANOMALIES    OF   THE    PASSENGERS  613 

soft,  yioldinp;,  iiTop;ular  nuiss  wliich  j>;li(l('s  upward  from  hctworm  tho  hands,  loavinj^ 
the  inlet  empty,  and  the  hands  to  come  uhnost  t(){z;ether.  In  tiie  fundus  the  head 
is  usually  easily  felt,  under  either  the  liver  or  the  spleen.  If  it  is  in  the  middle  line, 
the  examiner  may  surmise  that  the  body  of  the  child  is  straightened  and  that  tho 
cause  of  the  extension  may  ))e  the  legs,  stretched  up  toward  the  face — that  is,  single 
breech  i)resentation.  On  one  side  the  back  is  felt,  and  the  shoulder  is  usually'  easily 
outlined  above  the  navel  and  median.  Between  the  shoulders  and  head  a  deep 
sulcus  is  found.  The  heart-tones  are  loudest  on  the  side  where  the  back  lies,  and 
are  always  al)ove  the  level  of  the  navel,  an  important  diagnostic  point.  Often  the 
head  can  be  grasped  between  the  two  hands,  or  even  measured  with  a  cephalo- 
meter,  but  other  times  it  can  be  felt  only  by  tapping-palpation — and  occasion- 
ally it  is  to  be  recognized  as  a  body  sho"wing  ballottement.  Vaginally,  the  fingers 
have  to  be  deeply  inserted  before  the  presenting  part  can  be  touched,  the  pelvis  being 
empty.  A  convex  hard  tumor  in  the  vaginal  vault  is  not  felt;  instead,  a  roundish, 
soft  mass  of  prominences  and  depressions,  in  which  the  examiner  can  distinguish 
the  buttocks  with  a  crease  between  them,  and  at  one  end  a  pointed  bone — the 
sacrum.  Three  or  four  small  prominences  on  this  will  identify  the  bone  and  show 
the  direction  of  the  pelvis,  but  for  additional  assurance  the  finger  may  follow  the 
genital  crease  to  tho  child's  genitalia,  when  the  scrotum  or  vulva  will  be  distinguish- 
able. The  finger  at  the  anus  may  feel  the  tuberosities,  and,  if  inserted,  ma}'  be 
covered  with  meconium,  of  course,  after  the  membranes  are  broken.  Higher  up  and 
to  one  side  one  or  both  feet  may  be  felt,  though  usually  only  the  heels  are  ^vithin 
reach  of  the  finger.  Suspicion  having  been  aroused  by  the  empty  pelvis,  the  ac- 
coucheur ought  to  have  no  difficulty  in  recognizing  the  breech,  but  mistakes  are  very 
common,  the  breech  being  confused  with  the  shoulder,  the  face,  and  the  bag  of  waters. 
The  closed  axilla  and  the  costal  gridiron  will  identify  the  shoulder,  and  the  saddle  of 
the  nose  and  orbital  ridges,  the  nostrils,  and  the  gums,  will  prove  the  face.  The 
diagnosis  of  the  position  of  the  breech  is  made  from  the  location  of  the  sacrum.  It 
is  advisable  not  to  introduce  the  finger  into  the  anus  or  into  the  vulva  of  the  fetus. 

In  single  breech,  when  the  feet  are  extended  up  to  near  the  face,  they  may  often 
be  felt  there  from  the  outside.  The  uterus  is  longer  and  straighter  compared  with 
the  rounded  outline  when  the  child  is  normally  flexed.  Vaginally,  the  feet  cannot 
be  felt;  the  anus  is  nearer  the  middle  of  the  pelvis,  and  the  straightened  thighs 
disclose  the  direction  of  the  extremities. 

In  footling  the  accoucheur  should  follow  the  prolapsed  extremity  up  to  the 
pelvis  and  make  the  diagnosis  on  general  lines,  the  direction  of  the  big  toe  and  the 
flexure  of  the  knee  giving  added  information.  One  should  not  hastily  conclude 
that  a  breech  presentation  exists  when  the  foot  is  discovered — it  may  have  prolapsed 
with  the  head. 

Prognosis. — Statistics  give  the  maternal  mortality  as  slightly  higher  than  in 
occipital  presentations,  the  reasons  being:  (1)  Labor  is  longer  and  internal  examina- 
tions are  more  frequent,  both  increasing  the  dangers  of  infection;  (2)  effacement 
and  dilatation  of  the  cervix  are  not  so  perfect,  hence  lacerations  are  more  common; 
(3)  since  the  head  comes  rapidly  through  the  unprepared  pelvic  floor,  rupture  of 
the  perineum  is  frequent,  extending  often  through  the  rectum,  and  these  are  not 
always  errors  of  art;  (4)  disturbances  of  the  mechanism  of  labor  are  frequent,  and 
since  they  demand  the  introduction  of  the  hand  or  other  operative  measures,  the 
prognosis  for  the  mother  is  doubtful;  (5)  postpartum  hemorrhage  is  increased. 
Most  of  these  dangers  may  be  eliminated,  and  all  may  be  minimized  by  the  appUca- 
tion  of  the  rules  of  good  obstetrics. 

For  the  child,  breech  presentation  is  certain!}'  dangerous,  the  mortality  tables 
showing  from  6  to  15  per  cent,  of  deaths.  With  proper  treatment,  not  over  5  per 
cent,  of  children  should  die  in  uncomplicated  cases.  Asph^-xia  causes  most  of  the 
deaths,  but  fracture  of  the  skull  and  injuries  to  the  neck  and  spine  also  account  for 


614  THE    PATHOLOGY    OF   LABOR 

many  of  them.  The  asphyxia  is  caused  by  compression  of  the  cord  between  the 
body  and  the  cervix  after  the  breech  is  born,  or  by  its  being  stretched  upward  from 
between  the  child's  legs,  by  premature  detachment  of  the  placenta,  by  compression 
of  the  placenta  by  the  hard  head,  and  by  delay  in  delivery  due  to  rigid  soft  parts. 
In  vertex  presentations  the  soft  breech  lies  against  the  placenta  and  exerts  no  com- 
pression, and  if  the  placenta  loosens  before  the  delivery  of  the  trunk,  the  head  is 
already  out,  or  nearly  out,  so  that  the  child  may  breathe,  whereas  in  breech  presen- 
tation the  first  inspiration  sucks  in  liquor  amnii,  blood,  or  anything  which  lies  near 
the  mouth.  It  is  possible,  too,  that  the  cold  air  striking  the  body,  or  the  manipula- 
tions of  the  attendant,  excite  premature  respirations.  A  child  will  live  five  to  ten 
minutes  after  the  breech  is  delivered,  there  being  very  few  cases  on  record  where  a 
child  was  born  alive  fifteen  minutes  after  the  breech  passed  the  vulva.  It  is  ad- 
visal3le,  therefore,  not  to  allow  the  progress  to  be  too  slow  after  the  breech  has 
passed  the  vulva;  on  the  other  hand,  undue  haste  must  be  avoided  because  of  the 
danger  of  injury  to  the  fetal  person.  Fracture  of  the  femur,  of  the  pelvis,  rupture  of 
the  filled  colon,  of  the  liver,  fracture  of  the  humerus,  of  the  clavicle  (common), 
overstretching  of  the  cervical  spine,  even  fracture  of  the  spine,  pulling  the  nerves 
out  of  the  spinal  cord  (Erb's  paralysis),  rupture  of  the  sternocleidomastoid,  disloca- 
tion of  the  atlas — all  these  and  more  have  been  observed.  In  old  primiparse  or  such 
parturients  as  have  rigid  soft  parts,  these  dangers  are  augmented  and  require  special 
treatment  for  their  prevention. 

Treatment. — If  breech  presentation  is  discovered  during  the  last  few  weeks  of 
pregnancy,  it  is  advisable  to  make  gentle  efforts  to  bring  the  cephalic  pole  over  the 
inlet.  The  patient  is  instructed  to  assume  the  knee-chest  posture  several  times 
daily,  and,  when  reposing,  to  lie  on  that  side  to  which  the  head  points;  for  example, 
in  S.L.A.  on  the  right  side.  The  accoucheur  may  also  try,  by  gentle  external  man- 
ipulation, to  bring  the  head  down,  though  his  efforts  are  not  always  rewarded  by  a 
permanent  change  of  the  presentation. 

Watchful  expectancy  is  the  treatment  during  labor.  Older  writers  usually  ad- 
vised version,  changing  the  breech  to  cephalic  presentation  by  internal  and  external 
manoeuvers,  and  especially  in  old  primiparse.  While  admitting  that  a  head  pres- 
entation is  highly  desirable,  and  particularly  in  aged  primiparse,  unfortunately  the 
operation  in  them  is  more  than  usually  difficult  and  unsuccessful.  Where  the  soft 
parts  appear  very  rigid,  and  when  the  child  is  large,  it  is  wise  to  prepare  the  former 
for  the  rapid  stretching  they  are  about  to  receive.  This  is  done  by  colpeurysis,  a 
Carl  Braun  colpeurynter  being  placed  in  the  vagina  and  filled  with  12  to  16  ounces 
of  weak  antiseptic  solution.  By  the  stretching  it  causes,  and  by  its  presence,  the 
pains  are  strengthened,  the  tissues  softened  and  dilated,  and  if  it  is  expelled  by  the 
powers,  the  pelvic  floor  outlet  is  enlarged  as  by  the  passage  of  the  first  twin.  An- 
other favoraljle  action  of  the  colpeurynter  is  the  preservation  of  the  bag  of  waters, 
which  is  so  highly  desirable  in  breech  cases. 

Otherwise  the  treatment  of  the  first  stage  is  not  at  variance  from  the  usual. 
When  the  second  stage  draws  near,  the  accoucheur  should  have  everything  ready 
for  all  the  emergencies  of  an  operative  delivery.  This  provision  consists  of  a  set 
of  instruments — forceps,  perineorrhaphy  instruments,  etc.,  hot  bath,  towels,  and 
tracheal  catheter  for  treating  the  asphyxiated  child,  a  table  on  which  to  place  the 
parturient  for  delivery,  and  sufficient  assistants.  (To  avoid  repetition,  the  reader 
is  referred  to  the  chapter  introducing  the  subject  of  Operative  Obstetrics.) 

When  the  breech  begins  to  distend  the  vulva,  the  woman  is  placed  on  the  table, 
her  limbs  supported  by  assistants,  and,  in  the  absence  of  trained  help,  by  courageous 
neighbors — not  the  husband,  as  he  is  likely  to  faint.  As  the  breech  emerges  the 
accoucheur  should  restrain  the  desire  to  aid  by  traction,  but  should  encourage  the 
woman  to  bear  down  strongly.  The  foot,  if  it  is  down,  or  the  })reech  is  to  be  wrapped 
in  a  warm  towel  as  it  comes  out.     Nothing  more  is  done,  the  operator  sitting  by 


ANOMALIES    OF   THE    PASSENGERS  615 

Avitli  st('ril(>  hands.  An  tissislaiit  listens  to  tlic  hcarl -tones  ovory  two  minutes,  and 
any  weakening  or  irregularity  is  tlie  signal  for  rapid  delivery.  If  the  foot  is  out, 
tiie  baby's  pulse  may  be  felt  in  the  anterior  tibial  artery.  Anesthesia  is  not  used 
unless  the  pati(>nt  is  very  unruly,  because  her  efforts  are  needed  safely  to  expel  the 
infant.  In  i)riniii)ara'  with  rigid  j)elvic  flo(jr,  or  with  a  big  baby,  it  is  my  own  prac- 
tice to  [jerforni  a  d(>ep  unilateral  episiotoniy  even  before  tlu;  head  is  to  Ije  born.  I 
piclcr  it  to  a  perineal  tear  for  reasons  that  have  Ijeen  mentioned.  It  saves  delay 
in  llu!  delivery  of  the  shoulders  and  the  head,  and  surely  has  saved  many  babies' 
lives,  as  well  as  prevented  conii)lete  lacierations  of  the  perineum. 

When  the  navel  ai)pears,  the  rest  of  the  birth  must  be  rapidly,  but  not  pre- 
cipitately, completed.  The  woman  is  told  to  bear  down  with  all  her  power.  If  she 
is  anesthetized  or  cannot,  the  assistant,  spreading  his  hands  evenly  over  the  fundus, 
exerts  pressure  in  the  axis  of  the  inlet.  This  strengthens  the  uterine  and  abdominal 
action,  and  keeps  the  arms  against  the  chest,  preventing  their  ascent  alongside  the 
head,  which  would  nmch  complicate  the  delivery.  If  both  fail,  manual  aid  is 
rendered.  Manual  aid  means  the  delivery  of  the  shoulders  and  head,  after  nature 
has  accomplished  the  expulsion  to  the  navel.  It  must  be  very  sharply  distinguished 
from  "breech  extraction,"  which  means  bringing  down  the  breech  in  some  way  and 
delivery  of  the  whole  child  from  within  the  birth-canal.  (For  the  details  of  these 
manoeuvers  see  Chapter  LXXI.)  Should  the  natural  powers  avail  for  delivery,  the 
accoucheur  receives  the  child  as  it  emerges,  and  when  the  mouth  is  visible  in  the 
vulva,  he  sponges  the  mucus  from  it  and  restrains  the  head  from  making  a  too  rapid 
exit  through  the  pelvic  floor.  After  delivery  of  the  child  the  accoucheur  should  be 
prepanxl  to  treat  postpartum  hemorrhage  and  all  kinds  of  lacerations. 


TRANSVERSE  PRESENTATIONS 

Another  error  of  polarity  of  the  fetus  is  transverse  presentation.  Here  the 
long  axis  of  the  child  crosses  the  long  axis  of  the  mother.  It  is  rare  that  they  cross 
at  a  right  angle:  almost  always  the  fetal  cylinder  is  oblique  to  the  mother's  spine. 
Usually  the  head  is  tlie  lower  pole,  but  in  some  cases  the  breech  is  nearer  the  inlet. 
Often  early  in  labor  the  head  is  found  deviated  from  the  inlet  and  lying  in  one  iliac 
fossa.  The  breech  may  be  found  similarly  placed.  These  are  called  "oblique  pres- 
entations," or  "deviated  head,"  or  "deviated  breech"  presentations,  and  repre- 
sent a  stage  of  the  transition  from  longitudinal  to  a  transverse  presentation.  By 
external  manipulation  and  proper  posture  of  the  woman  the  abnormal  mechanism 
may  be  corrected. 

Since  the  shoulder  is  the  part  that  usually  enters  the  pel"vis  first,  most  authors 
call  the  cases  under  consideration  "shoulder  presentations,"  but  the  back,  the  side, 
th(^  belly,  or  the  four  extremities  may  present.  True,  all  the  last  four  are  exceed- 
ingly rare. 

Etiology. — Shoulder  presentations  occur  about  once  in  200  cases,  in  multiparae 
oftener  than  in  primiparce,  and  in  premature  labor  oftener  than  at  term. 

In  general,  anything  that  will  prevent  the  engagement  of  the  head  in  the  peh'is, 
also  any  condition  conferring  an  extraordinary  degree  of  mobility  on  the  fetus,  will 
cause  transverse  presentation.  The  causes  may  be  primary,  and  lie  in  some  mal- 
formation of  the  maternal  parts  or  of  the  fetus,  or  secondarj^,  being  produced  by 
some  act  or  accident  during  labor.     The  most  important  are: 

1.  Contracted  pelvis.  Transverse  presentations  occur  t\\ice  as  often  in  con- 
tracted pelvis  as  in  normal  pelves.  So  constant  is  this  that  when  called  to  a  case 
of  transverse  presentation,  the  first  thought  is  of  some  obstruction. 

2.  An^iihing  in  the  pelvis  preventing  the  engagement;  for  example,  ovarian 
tumor,  fibroid,  the  placenta,  full  bladder,  or  rectum.  It  sometimes  happens  that 
after  emptying  a  full  bladder  the  fetus  turns  of  itself  into  a  normal  position. 


616 


THE    PATHOLOGY    OF   LABOR 


3.  Twins  displacing  each  other. 

4.  Multiparity,  hydramnion,  premature  labor.  Here  the  child  is  free  to  move, 
and  the  factors  making  for  a  longitudinal  presentation  are  absent. 

5.  Uterus  bicornis,  uterus  arcuatus,  partly  septate  uterus.  A  cause  of  repeated 
shoulder  presentations. 

6.  Anomalies  of  the  fetus,  for  example,  double  monsters. 

Of  the  secondary  causes,  accident  plays  the  stronger  role.  The  fetus  happens 
to  ])e  in  an  unfavorable  position  when  the  bag  of  waters  ruptures;  the  shoulder 
is  forced  into  the  pelvis,  and  a  transverse  presentation  results.     The  dislocation 


Fig.  545. — Shoulder  Puksentation.     Sc  L.A. 


of  a  second  twin  l)y  the  first  is  also  to  be  reckoned  here,  and  dislocation  of  the  child 
by  an  overfilled  or  badly  placed  colpeurynter  also. 

Often  several  of  these  factors  will  coml)inc  to  cause  the  malprescntation. 
In  some  cases  the  fetus  seems  to  keep  its  embryonal  position  in  utero,  or  the  uterus 
is  not  tense  enough  to  adapt  the;  fetal  ovoid  to  itself. 

Mechanism  and  Clinical  Course. — Although  the  back  or  the  belly  may  lie 
across  the  inlet,  the  shoulder  is  the  part  which  most  often  enters  the  pelvis  first, 
so  that  usually  we  speak  of  shoulder  presentation.  On  the  shoulder  these  landmarks 
arc  to  be  distinguished,  and  th(;y  are  useful  for  diagnosis — the  scapula,  the  acromion 
process,  the  axilla,  and  the  clavicle.  The  scapula  is  selected  as  the  point  of  direc- 
tion. 


ANOMALIES    OF   THE    PASSENGERS 


617 


Four  positions  of  the  child  in  utero  are  observed  (Figs.  545  and  546): 

Scapulohi'X'u  anterior  (Sc.L.A.):    Head  to  left,  l)a(!k  anterior. 
Scapulodextra  anterior  (Sc.D.A.):    Head  to  ngUt,  back  anterior. 

These  are  more  connnon,  are  called  back  anterior  positions,  and  are  easier  to 
deal  with. 

Scapulodextra  posterior  (Sc.D.P.) :    Head  to  right,  })aok  posterior. 
Scai)ulohuva  posterior  (Sc.L.P.):    Head  to  left,  back  posterior. 

These  are  rarer,  are  called  back  posterior  positions,  and  are  much  more  difficult 
to  deal  with.  The  relations  of  the  back  and  of  the  head  to  the  inlet  are  most  im- 
I)ortant  in  the  study  of  the  mcclianism  of  labor. 


Fio.  546. — Shoulder  Presentation.     Sc.D.P. 

Attitude. — Early  in  labor  we  find  the  usual  posture  of  flexion  common  to  O.L.A., 
the  chin  on  the  sternum,  arms  crossed  over  the  chest,  legs  crossed  over  the  belly, 
l)ut  later  many  changes  are  observed.  Commonest  is  the  prolapse  of  the  lower 
arm,  rarely  the  two,  and  still  more  rarely  the  upper  one  alone.  Prolapse  of  the 
cord  is  not  infrequent.  When  the  uterus  has  w'orked  on  the  fetal  ovoid  for  any 
leng-th  of  time,  the  latter  is  compressed  from  side  to  side,  the  head  nears  the  breech, 
and  the  ovoid  is  made  more  glol)ular.  Occasionally  the  fetal  l:)ody  is  twisted  on 
its  long  axis,  so  that,  while  the  shoulder  lies  deep  in  the  pelvis,  the  belly,  instead  of 


618 


THE    PATHOLOGY    OF   LABOR 


looking  to  the  sacrum,  looks  directly  upward,  and  the  legs  also  are  turned  forward. 
The  neck  may  also  be  twisted;  in  one  of  my  cases  the  child's  head  was  deflected, 
resembling  the  attitude  of  face  presentation.  Ahlfeld  noticed  this  in  a  case  of 
breech  presentation. 

Course. — Shoulder  presentations  are  always  pathologic.  True,  they  sometimes 
terminate  spontaneously,  but  with  rare  exceptions  the  children  all  die,  and  often 
the  mother,  too,  so  that  they  are  cases  of  dystocia  and  demand  the  aid  of  art. 
Early  in  pregnane}^  transverse  presentation  is  the  rule.  Even  in  the  last  month, 
in  multiparse,  it  is  occasionally  found,  but  rectifies  itself  before  labor  begins,  the 
process,  of  which  the  accoucheur  usually  has  no  knowledge,  being  called  spontaneous 
rectification.  This  means  that  the  contractions  of  pregnancy  have  changed  the 
polarity  of  the  fetal  ovoid,  and  the  process  may  be  aided  by  proper  position  of  the 
mother.  If  it  does  not  take  place  during  pregnancy,  a  longitudinal  presentation 
may  be  brought  about  spontaneously  during  the  first  stage  of  labor,  or  even  at  the 
beginning  of  the  second  stage  (very  rarely).     This  is  called  "spontaneous  version," 


Fig.  547. — Lauor  in  Conduplicato  Corpoee.     Roederer'.'s  Method  (Zangemeister) . 

is  not  at  all  a  constant  occurrence,  9.nd  in  practice  is  never  relied  on.  Both  of  these 
processes  are  more  likely  where  the  fetus  is  freely  movable,  as  in  polyhydramnion, 
and  where  the  presenting  part  cannot  easily  enter  the  inlet,  as  in  contracted  pelvis. 
As  a  rule,  when  a  change  of  presentation  is  brought  about,  the  head  comes  down, 
but  sometimes  the  breech  may  come  to  lie  over  the  inlet. 

In  order  to  study  the  mechanism  of  transverse  presentation  a  case  will  be 
assumed  where  no  aid  is  rendered.  The  pains  are  hkcly  to  be  slow  and  weak,  since 
no  hard  part  presses  on  the  cervix,  but  the  bag  of  wat(n's  often  ruptures  early,  be- 
cause the  membranes  are  exposed  to  the  full  force  of  the  uterine  contraction.  The 
lower  uterine  segment  is  not  cut  off  from  the  general  cavity  of  the  uterus,  so  after 
the  rupture  of  the  bag  of  waters  all  the  liquor  amnii  escapes,  since  there  is  nothing 
to  hinder.     This  is  a  bad  accident,  especially  if  the  cervix  be  undilated. 

When  the  uterus  has  no  more  liquor  amnii,  the  walls  apply  themselves  to  the 
fetus  very  closely.  Two  conditions  may  now  be  observed :  first,  there  may  be  no 
pains  at  all,  the  uterus  simply  lying  apposed  to  the  fetus  in  a  condition  which  was 


AXOMALIKS    (JK   THE    PASSENGERS 


019 


called  hy  Kiliaii  " passive  contraction."  The  walls  arc  distensible;  the  hanrl  can 
he  easily  introduced,  and  even  version  ])eri"ornied.  This  C(jndition  carries  no  dan- 
ger to  the  fetus  or  the  mother,  may  last  a  few  hours  or  a  few  days,  but  generally 
])asses  over  into  the  other  state,  either  spontaneously  or  as  the  result  of  brusk 
nianii)ulations.  This  first  condition  has  nothing  to  do  with  the  so-called  tetanus 
uteri,  to  b(!  described  presently. 

Sooner  oi'  later,  usually  the  result  of  iiiiprojjer  Ireatiiient,  the  pains  Ix'gin,  and 
very  soon  aciiuire  a  dangerous  violence.     They  force  the  shoulder  iiitfj  the  pelvis, 


Fto.  548. — .SpoNTANKors  Evolt-tiox,     DnrcLAs'   Method.     Ciiiara's  Frozen*  Section'. 


the  fetus  is  folded  together,  the  breech  nears  the  head,  the  ovoid  becoming  more 
globular.  If  the  fetus  is  small  or  macerated  and  th(^  pelvis  large  enough,  the  uterus, 
aided  by  powerful  efforts  of  the  mother,  may  succeed  in  exijelling  it.  This  is  called 
"spontaneous  evolution,"  and  is  the  last,  least  likely,  and  most  dangerous  method 
nature  has  of  overcoming  the  malpresentation.  Spontaneous  evolution  pursues 
tliree  methods,  named  respectively,  after  the  men  who  first  accurately  described 
them,  Roederer's,  Douglas',  and  Denman's.  According  to  the  first,  which  usually 
occurs  without  prolapse  of  the  arm,  the  child  is  folded  like  the  letter  V,  the  shoulder 
and  back  advancing,  the  head  pressed  deep  into  the  chest  and  abdomen  (Fig.  547). 


620 


THE    PATHOLOGY    OF    LABOR 


In  Douglas'  method,  which  oftener  occurs  in  back  anterior  positions  with  prolapse 
of  the  arm,  the  fetal  mass,  under  the  influence  of  strong  pains,  becomes  pointed, 
the  head  is  arrested  above  the  inlet  and  rotates  to  the  pubis,  the  neck  is  applied 
to  the  brim,  and  very  much  leng-thened.  Now  the  chest,  abdomen,  and  breech 
roll  down  alongside  the  shoulder,  the  legs  drop  out,  then  the  other  arm,  and  finally 
the  head  appears  (Fig.  548) .  In  the  rarest  of  all  three  mechanisms,  Denman's, 
which  is  usually  taken  by  back  posterior  positions,  the  head  rotates  behind,  and,  as 
the  breech  descends,  the  shoulder  ascends  in  the  pelvis,  a  sort  of  version  taking 
place  in  the  pelvic  cavity,  the  breech  finally  coming  down  and  out  (Fig.  549).  All 
three  mechanisms  occur  at  the  end  of  the  second  stage;  all  three  require  exception- 
ally favorable  conditions — ^that  is,  large  pelvis,  small,  soft,  molding  fetus,  strong 
pains,  and  great  integrity  of  uterine  muscle,  and  in  none  of  the  three  will  a  full- 


PiG.  540. — Late  Spontaneous  Version  CDenman's  Method). 


term  child  be  delivered  alive.  Zangemeister  reports  the  heaviest  child  delivered 
alive — weight,  2700  gm.  Usually  the  fetuses  are  macerated  or  very  small.  Death 
is  due  to  compression  of  the  vital  organs  in  the  chest  and  head,  interruption  of  the 
placental  circulation  by  the  almost  constant  uterine  contractions  or  by  dislocation 
of  the  placenta  in  the  retracted  fundus  uteri.  Since  the  child  is  almost  invariably 
lost  and  the  mother  exposed  to  risks  of  imminent  death  during  these  processes, 
they  are  never  to  be  relied  on  in  practice. 

Daily  experience  shows  that  nature  is  generally  powerless  safely  to  accomplish 
delivery  in  full-term  cases,  and  labor  is  arrested  with  the  child  forced  together  in 
a  compact  mass,  solidly  blocking  the  pelvis.  If  the  arm  hangs  out,  it  swells  up, 
sometimes  to  the  size  of  a  man's  wrist,  shows  blisters  or  even  peeling  skin,  the 
child  dies,  and  the  vulva  becomes  edematous,  bluish  ])lack,  and  even  gangrenous. 

The  pains  become  irregular  and  tumultuous,  the  distinction  between  pain  and 


ANOMALIES    OF   THE    PASSENGERS 


621 


pauso  is  not  marked,  and  tho  utcirus  is  in  a  state  of  constant  contraction.  The 
l)uti('nt  heconu's  anxious,  and  conii)iains  of  continual  pain  and  ii:,roiit  tenderness 
over  the  h)wer  part  of  the  uterus.  Fulse  and  t<'ni})erat  ure  \H%m  to  rise.  Tiie 
uterus  draws  up  over  the  child;  the  nuisck;  becomes  thick  ahove  the  contraction- 
ring;  the  lower  uterine  segment  is  thinned  out  until  it  is  as  thin  as  a  blotter,  and 
iiere  the  uterus  is  llkchj  to  rupture  (Fig.  550). 

This  condition  is  culled  a  ''yiegledcd  transverse  presentation,"  and  the  uterus 
is  in  a  state  of  threatened  rupture.     Where  the;  fundus,  thick   and  contracting, 


Fig.  .550. — Neglected  SnorLDER  Presentation. 

Uterus  on  point  of  rupturing.      .Vbovc  is  .«liown  the  thick,  retracted  uterine  -nail.      Bolow  the  thinned,  lower  uterine 

segment,  the  white  lines  indicating  the  direction  of  greatest  thinning. 


passes  over  into  the  lower  uterine  segment  and  the  thinned  and  dilated  cervix, 
a  groove  or  depression  can  be  seen  and  felt  on  the  abdomen,  running  from  side  to 
side  about  the  level  of  the  navel.  This  is  the  ominous  retraction-ring,  sometimes 
called  contraction-ring  (Fig.  697).  Above  this  groove  the  parts  can  be  poorly  felt; 
below  this  groove  the  fetus  is  easily  felt.  Unless  aid  is  given,  the  uterus  ruptures 
and  the  mother  dies  of  shock,  hemorrhage,  or  peritonitis.  The  uterus  may  rupture 
during  an  attempt  at  version.  Death  of  the  child  occurs  from  the  interruption  of 
the  placental  circulation  and  from  compression  before  rupture.  If  not,  it  dies 
after  the  rupture,  and  may  be  in  part  or  in  toto  extruded  through  the  rent  into  the 


622  THE    PATHOLOGY    OF   LABOR 

abdominal  cavity.     Or  the  woman  may  die  of  shock  and  exhaustion  before  the 
rupture  takes  place. 

If  the  uterus  should  not  rupture  soon, — and  the  tendency  varies  with  different 
women  (in  primiparce  there  is  not  so  much  tendency  as  in  multiparse), — the  pains 
grow  weaker  and  irregular,  the  cavity  of  the  uterus  becomes  infected — from  the 
vagina,  from  the  air,  from  the  exposed  arm,  or  from  the  examining  fingers;  the 
fetus  and  the  little  liquor  amnii  left  begin  to  decompose;  gas  is  developed  in  the 
uterus  and  distends  it.  The  condition  is  called  tympania  uteri  or  physometra. 
General  infection  is  soon  apparent,  temperature  and  pulse  mounting  rapidly,  the 
features  change,  a  subicteric  hue  develops,  and  the  poor  woman  dies  in  septic 
collapse.  If  successfully  delivered,  the  sepsis  may  continue,  but  recovery  is  un- 
likely when  much  damage  has  been  done  to  the  structure  of  the  parturient  canal. 

Another  condition  that  occurs,  as  well  with  cephahc  as  with  transverse  pres- 
entation, is  called  tetanus  uteri.  It  is  due  to  too  early,  brusk,  and  [unnecessary 
manipulations  on  the  uterus  or  cervix,  and  especially  to  the  administration  of  ergot. 
The  uterus  is  in  one  continual  spasm.  Occasionally  a  pain  will  increase  the  spasm. 
One  finds  the  uterus  hard  all  over,  very  tender,  and  the  woman  in  continual  pain; 
the  cervix  is  red,  dry,  and  hot;  the  vagina  also  is  dry  and  hot.  Labor  is  at  a  stand- 
still, since  in  this  condition  the  cervix  will  not  dilate,  and  it  is  generally  impossible 
to  turn  the  baby  so  as  to  extract  it.  There  is  no  danger  of  spontaneous  rupture, 
but  the  baby  dies,  due  to  the  interruption  of  the  placental  circulation,  and  unless 
something  is  done  the  mother  dies  of  sepsis. 

Fortunately  in  this  country,  and  also  in  Europe,  cases  of  "neglected  transverse 
presentation"  are  becoming  rare.  The  evil  results  of  neglect  must  emphasize  the 
importance  of  early  diagnosis  and  consistent  treatment. 

Diagnosis. — During  pregnancy  abdominal  palpation  gives  the  best  results,  while 
vaginally  nothing  but  the  empty  pelvis  is  felt.  During  labor  the  conditions  are 
reversed  because  the  contracting  uterus  covers  up  the  fetal  parts. 

Ahdominally. — (1)  No  longitudinal  ovoid,  but  one  more  or  less  transverse,  and, 
in  contradistinction  to  uterus  arcuatus,  the  broad  portion  is  just  above  the  inlet, 
not  above  the  navel,  as  with  arcuate  uterus.  (2)  Over  the  inlet,  nothing — the 
space  is  empty  and  the  finger-tips  may  come  together  over  the  pelvis.  (3)  In  the 
fundus  likewise  nothing;  at  most,  some  small  parts  or  a  deep  furrow.  (4)  The 
back  is  in  neither  flank,  and  the  hand  must  search  elsewhere.  Three  of  the  four 
cardinal  principles  of  the  chagnosis  of  presentation  being  negative,  the  diagnosis 
must  rest  on  the  first,  plus  other,  special  findings.  In  scapulolseva  anterior  the 
head  will  be  found  on  the  left  side,  low  in  the  flank,  and  it  is  recognized  by  its  being 
large,  hard,  rounding,  sometimes  with  ballottement.  The  breech  is  high  up  to  the 
right  behind,  the  small  parts  in  the  fundus  to  the  right  of  the  median  line,  the  heart- 
tones  loudest  a  little  to  the  left  and  below  the  navel.  It  is  easy  to  outline  the  dorsal 
plane  in  front.  In  Sc.D.P.  the  head  is  deep  in  the  right  flank,  the  breech  under  the 
spleen,  no  back  can  be  outlined,  but,  instead,  the  region  of  the  navel  seems  filled 
with  small  parts,  and  the  heart-tones  are  to  the  right  of  the  navel,  about  on  a  level 
with  it. 

Vaginally. — An  empty  vaginal  vault  immediately  awakens  suspicion  of  some- 
thing abnormal.  Sometimes  the  bag  of  waters  hangs  down  like  a  stocking,  filling 
the  pelvis,  and  the  attempt  to  feel  something  through  it  may  rupture  the  membranes, 
which  would  be  very  unfortunate.  The  cervix  hangs  down  like  a  cuff,  and  collapses 
in  the  interval  between  pains.  After  labor  has  progressed  a  short  while  the  shoulder 
is  more  accessible,  and,  especially  if  the  membranes  are  ruptured,  all  the  landmarks 
may  be  discovered.  These  are  the  acromion  process,  the  scapula,  the  clavicle,  and 
the  axilla.  The  direction  in  which  the  axilla  is  closed,  that  is,  its  apex,  points  to 
the  fetal  head.  By  noting  whether  the  hard  edge  of  the  scapula  looks  to  the  pubis 
or  to  the  sacrum  we  are  enabled  to  say  that  the  back  lies  to  the  front  or  to  the  rear. 


ANOMALIES    OF   TIIK    PASSENGERS  623 

In  Sc.L.A.  the  apox  of  the  iixilhi  points  to  llic  left,  the  cdfro  of  the  scapula  lies  to  the 
front,  and  tlic  costal  f>;ri(liron  to  the  rear.  Prolapse  of  the  arm  or  elWow  will  aid 
in  diagnosis.  When  th(;  hand  is  down,  the  direction  of  the  thunih  and  llie  hend  of 
the  elbow  will  l)e  toward  the  child's  alxlonien.  Jiy  trying  to  shake  hands  with 
the  child  it  is  possible  to  decide  which  hand  is  prolapsed.  In  Sc.L.A.  the  right  arm — 
the  lower  one — almost  always  falls  down;  therefore  if  you  find  the  head  on  the  left 
side  and  the  right  arm  down,  it  is  safe  to  diagnose  this  positi(jn.  While  much  can 
be  learned  from  the  ])osition  of  the  arm  in  living  fetuses,  preserving  tlu;  tonus  of 
the  nmscles,  it  is  safest  to  follow  up  the  member  to  the  thorax  and  try  to  discover 
the  axilla,  the  ribs,  the  pipe-stem-like  clavicle,  and  the  scapula, — even  the  rosary- 
like  spinal  colunm, — which  gives  absolute  information.  In  scapulodextra  posterior 
the  axilla  points  to  the  right  l)ehin(l  (Fig.  552),  the  costal  gridiron  to  the  front,  the 
clavicle  also  to  the  pubis,  the  edge  of  the  scapula  is  behind,  and  the  arm,  if  down,  is 
the  right  one.  Since  in  very  rare  instances  the  upper  arm  prolapses,  one  must  be 
careful  in  making  diagnoses  on  the  direction  of  the  hand. 

After  labor  has  been  in  progress  for  a  long  time  the  parts  become  so  swollen 
that  diagnosis  is  difficult,  and  if  the  back  or  belly  is  forced  down  into  the  pelvis, 
the  difficulties  encounteretl  may  be  very  great  and  should  warn  to  unusual  care, 


Fig.  5.")1. — Touch  Picture.     Sc.L.A.  Fig.  552. — Touch  Picture.     Sc.D.P. 

Apex  of  axilla  points  to  left.     Note  costal  gridiron.  Apex  of  axilla  points  to  right. 

because  even  very  skilful  accoucheurs  have  made  costly  errors.  In  the  differential 
diagnosis  breech,  face,  and  vertex  presentations,  with  prolapse  of  the  arm,  have  to 
l)c  considered,  and  confusion  will  be  avoided  by  carefullysearching  for  the  landmarks 
peculiar  to  each. 

Of  great  importance  is  the  diagnosis  of  the  state  of  the  uterus  as  regards  the 
imminence  of  rupture  and  the  presence  of  tetanus,  and  no  examination  is  complete 
without  thorough  study  of  the  size  of  the  fetus  and  of  the  cavity  of  the  pelvis. 
In  neglected  shoulder  presentations  the  accoucheur  must  discover  if  nature  intends 
to  terminate  the  case  unassisted,  and  if  so,  which  of  the  three  modes  viill  be  chosen. 
If  these  points  are  properly  evaluated,  the  accoucheur  will  be  alile  to  lay  out  that 
course  of  ]:)ro(^edure  which  will  most  likely  lead  to  a  happy  ending  of  the  case. 

Prognosis. — Transverse  presentation  being  always  dystocic  and  requiring  the 
intervention  of  art,  the  prognosis  depends  on  the  ease  and  safety  with  which  such 
intervention  may  be  made.  If  an  early  diagnosis  is  made,  the  outlook  for  both 
mother  and  babe  is  excellent.  In  neglected  cases  the  existence  of  infection,  trauma- 
tism from  ill-directed  interference,  and  even  of  rupture  of  the  uterus,  indicate  a 
very  grave  situation,  and  to  all  these  must  be  added  the  dangers  of  the  inevitable 
operation.     In  a  recent  article  Schultze  shows  that  in  Germany  alone  fully  400 


624  THE    PATHOLOGY    OF    LABOR 

mothers  and  4000  children  annuall}''  lose  their  lives  in  consequence  of  transverse 
presentation.  For  the  child  the  outlook  is  always  bad  unless  its  precarious  position 
is  recognized  early.  In  neglected  cases  the  infant  almost  always  dies,  from  compres- 
sion of  the  chest,  abruption  of  the  placenta,  or  asphyxia  from  obstructed  placental 
circulation.  Added  to  this  is  the  mortality  attendant  on  the  operations  of  version 
and  extraction  or  even  decapitation  performed  in  the  interests  of  the  mother. 

Treatment. — Version,  not  expectancy,  is  the  treatment  of  transverse  presen- 
tations. The  child  must  be  brought  into  a  longitudinal  presentation — ^it  must  be 
turned.  During  pregnancy  version  by  posture  is  tried,  and  the  woman  should, 
when  abed,  lie  on  the  side  to  which  the  head  points.  Sometimes  the  breech  will 
sag  over  to  this  side,  forcing  the  head  over  the  inlet.  Examination  at  the  end  of 
three  weeks  may  show  a  longitudinal  presentation,  when  a  binder,  with  pads  on 
each  side,  may  be  applied,  though  success  is  not  constant  The  French  recommend 
a  girdle,  or  '^ceinture  eutocique,"  for  this  purpose,  and  the  Japanese  use  daily  massage 
and  kneading  to  keep  the  fetus  straight.  During  pregnancy  cephahc  version  is 
preferred. 

During  early  labor  version  by  posture  may  be  tried,  but  it  is  better  to  aid 
gravity  by  external  manipulation.  By  gently  leading  the  head  over  the  inlet  and 
pulling  the  breech  up  into  the  fundus  much  may  be  accomplished.  Each  manipu- 
lation is  executed  between  pains,  and  when  the  uterus  contracts,  the  hands  hold 
what  has  been  gained.  An  anesthetic  may  be  advantageous  and  advisable.  Many 
cases  will  be  met  where  the  head  or  breech  has  only  slid  off  into  the  iliac  fossa,  and 
for  these,  external  manipulation  almost  always  suffices.  Wiegand's  method  of 
version  consists  in  placing  one  hand  over  the  breech,  the  other  over  the  head,  and, 
with  alternate  pushing  and  stroking  movements,  striving  to  bring  the  head  down 
over  the  inlet. 

Version  during  early  labor  means  cephalic  version,  but  there  are  three  condi- 
tions which  govern  the  operation:  (1)  There  may  exist  no  immediate  nor  prospec- 
tive indication  for  the  rapid  termination  of  labor;  (2)  the  fetus  must  possess  a  high 
degree  of  mobility,  the  pains  being  weak  and  few,  and  the  bag  of  waters  intact; 
(3)  there  may  not  be  too  great  a  degree  of  pelvic  contraction.  Version  by  external 
manipulation,  thus  governed,  should  be  persisted  in  until  the  second  stage  of  labor 
is  on,  when,  if  it  has  failed,  more  definitive  treatment  is  to  be  instituted. 

The  most  unwelcome  accident  in  shoulder  cases  is  the  rupture  of  the  membranes 
before  the  cervix  is  completely  dilated.  As  has  been  shown,  conditions  are  partic- 
ularly favorable  for  it.  The  accoucheur  seeks  to  avoid  or  delay  the  rupture  of 
the  bag  of  waters  by  keeping  the  patient  on  the  side, — that  one  on  which  the  head 
lay, — by  forbidding  her  to  bear  down  with  the  pains,  and,  best  of  all,  by  placing  a 
Braun  soft-rubber  colpeurynter  in  the  vagina  and  filling  it  nearly  full  of  solution. 
This  exerts  counterpressure  on  the  membranes,  and  also  prevents  the  shoulder  from 
wedging  into  the  pelvis.  After  complete  dilatation  of  the  cervix  has  been  achieved 
a  great  deal  has  been  accomplished,  and  the  question  now  arises,  which  shall  be 
done,  cephalic  or  podalic  version?  Without  doubt  the  child's  chances  are  best  in 
head-first  deliveries,  and  the  attendant  will  do  well  to  consider  the  advisability  of 
cephalic  version,  although  few  authors  recommend  it,  and  it  is  very  rarely  per- 
formed in  practice.  Generally,  the  foot  is  brought  down,  with  a  view  to,  with  one 
stroke,  both  correcting  the  malpresentation  and  obtaining  a  good  purchase  on  the 
child,  so  that  its  delivery  can  be  effected  at  will.  In  the  cases  now  cited  Wright's 
method  of  cephalic  version  would  almost  certainly  lead  to  success,  and  it  is  to  be 
recommended  for  trial.  Should  it  fail  or  prove  too  hazardous,  or  should  the  cord 
prolapse,  as  occurred  once  to  me,  the  attempt  is  to  be  given  up,  and  without  with- 
drawing the  hand  a  foot  grasped  and  podalic  version  performed.  Should  the  first 
attempt  succeed,  the  head  is  to  be  led  into  the  pelvis  or  drawn  down  with  long  for- 
ceps, held  in  proper  position  for  a  few  uterine  contractions,  and  the  case  then  left  to 


ANOMALIES    OF   THE    PASSENGERS  G25 

nature,  or  subject  to  a  new  iiuliculiiju  (Icinanding  extruclion.  The  procedure  just 
detailed  would  be  most  desirable  in  priniipara;,  but,  unfortunately,  it  is  this  class  of 
patients  which  present  the  fi;reatest  resistances  to  intra-uterine  manujuvers,  espe- 
cially those  which  would  change  the  location  of  the  fetus. 

Transverse  presentation  cases  seldom  come  for  treatment  under  the  favorable 
conditions  thus  far  considered.  Usually  the  bag  of  waters  has  ruptured,  the  os  is 
imperfectly  dilated,  the  shoulder  wedged  more  or  less  deeply  into  the  pelvis,  and 
the  uterus  retracted  on  the  child.  Truly  neglected  cases,  with  tetanus  uteri,  are 
nowadays,  and  certainly  in  this  city,  exceedingly  rare.  Since  the  rupture  of  the 
membranes  has  deprived  the  uterus  of  its  best  means  of  procuring  sufficient  dilata- 
tion of  the  OS,  nothing  is  more  rational  than  to  try  to  sulistitute  the  bag  of  waters. 
This  is  very  successfully  accomplished  by  the  colpeurynter,  and  this  U'^eful  instru- 
ment should  be  applied  in  all  cases  of  shoulder  presentation  wliere  the  'oag  of  waters 
has  ruptured  and  the  cervix  has  not  opened  sufficiently  for  the  introduction  of  the 
hand.  For  such  cases  Braxton  Hicks'  method  of  bipolar  version  (combined  manip- 
ulation by  two  fingers  inserted  through  the  os,  assisted  l)y  the  outside  hand)  has 
been  reconnnended.  In  the  author's  experience  the  operation  is  very  difficult  and 
often  impossible  when  the  uterus  has  lost  the  liquor  amnii,  while,  besides,  the  cord 
may  prolapse,  the  placenta  may  be  detached,  or  some  other  indication  arise  for 
innnediate  delivery.  This  indication  could  not  be  met  because  the  cervix  is  not 
dilated.  It  is,  therefore,  better  to  apply  a  colpeurynter  inside  the  uterus,  resting 
against  the  cervix.  As  a  rule,  the  pains  now  improve,  becoming  more  regular  and 
effective;  what  liquid  remained  in  the  uterus  is  prevented  from  escaping,  the 
shoulder  cannot  wedge  itself  further  in  the  pelvis,  and  the  cervix  is  dilated  by  a 
fluid  wedge  much  resembling  the  bag  of  waters.  If  10  ounces  of  solution  are 
injected  into  the  metreurynter,  it  will  measure  about  9  cm.  across,  and  in  passing 
through  the  cervix  will  be  compressed  to  about  8  cm.  But  this  sized  opening  is 
sufficiently  large  to  allow  the  hand  to  pass  through,  and  now  version  proper,  with 
the  whole  hand  in  the  uterus,  may  be  performed. 

It  is  dangerous  to  wait  in  these  cases  for  the  pains  to  dilate  the  cervix  for  the 
introduction  of  the  hand,  because  the  labor  will  become  a  "neglected"  one  under 
the  very  eyes  of  the  accoucheur.  If,  on  the  arrival  of  the  attendant,  the  cervix 
will  admit  the  hand,  version  is  immediately  performed,  and,  usually,  by  the  breech. 
Cephalic  version  is  likely  to  be  unsuccessful  in  these  late  cases,  and,  too,  often  an 
indication  for  delivery  coexists  with  that  for  version;  further,  a  slight  degree  of 
pelvic  contraction  may  determine  the  choice  of  method,  and  finally  the  operator 
may  not  have  had  sufficient  experience  with  Wright's  operation.  A  point  of  im- 
mense practical  importance  is  that  after  version  has  been  performed  the  indication 
for  the  operation  has  been  satisfied,  and  the  accoucheur  should  study  the  case 
carefully  to  see  if  anything  in  the  mother  or  the  child  creates  a  new  indication  for 
the  extraction  of  the  child.  In  other  words,  the  operations  of  version  and  extrac- 
tion must  be  separated,  unless,  at  the  same  time,  indications  exist  for  both.  Since 
the  operation  of  version,  by  separating  the  placenta  or  causing  entanglement  of 
the  cord,  may  create  an  indication  for  delivery,  it  is  advisable  to  begin  the  version 
only  after  complete  dilatation  of  the  cervix  has  been  procured. 

Neglected  shoulder  presentations,  especially  those  where  one  of  the  modes  of 
spontaneous  expulsion  is  in  progress,  present  truly  intricate  situations  for  the 
accoucheur  to  solve.  The  tetanically  contracted  uterus  may  foil  every  attempt 
at  version,  even  in  profound  anesthesia,  and  to  force  it  would  inevitably  cause  a 
rupture  of  the  organ.  The  stretched  vagina,  tightly  filled  '^'ith  the  large  bulk  of 
the  presenting  part,  may  not  permit  the  fingers  to  gain  access  to  the  uterine  cavity. 
The  child  may  lie  in  the  dilated  lower  uterine  segment,  which  may  be  so  thinned 
that  the  introduction  of  the  hand  may  rupture  it,  or  the  uterus  will  tear  when  the 
woman's  position  is  changed — and  the  tear  may  even  have  already  begun.  Xo 
40 


626  THE    PATHOLOGY    OF   LABOR 

consideration  need  be  given  to  the  child  in  this  class  of  cases  because  it  almost 
invariabl}^  has  long  succumbed.  Decapitation  and  exenteration  are  the  operations 
of  choice.  If  the  neck  is  within  easy  reach,  decapitation  by  means  of  Carl  Braun's 
hook  may  be  done,  but  the  author  prefers  the  operation  of  exenteration.  Even  the 
most  sldlful  accoucheur,  in  performing  a  decapitation,  will  twist  the  head  against 
the  thimied  lower  uterine  segment  and  precipitate  its  rupture,  while  by  exenterating 
the  fetus  it  can  be  dehvered  Avithout  subjecting  the  uterus  to  any  additional  strain. 
If  the  chest  of  the  child  is  wedged  deeply  into  the  pelvis,  the  accoucheur  will  find 
the  neck  stretched  up  above  the  inlet  on  one  side,  and  the  spinal  column  on  the 
other,  but  almost  parallel  to  the  axis  of  the  pelvis,  and,  of  course,  not  placed  so  that 
a  hook  introduced  from  the  vagina  could  operate  at  a  right  angle  to  them.  Here 
exenteration  is  the  operation  of  necessity.  Should  the  accoucheur  observe  that 
nature  is  terminating  the  case  in  one  of  the  three  modes  described,  he  may,  though 
it  is  contrary  to  most  teachings,  exert  tentative  traction  on  that  part  of  the  fetus 
which  seems  to  advance  most,  or  at  least  seek  to  aid  that  mechanism  which  is 
occurring  under  his  eyes. 

Prolapse  of  the  arm  is  not  a  complication  of  shoulder  presentation.  It  does 
not  interfere  with  any  treatment.  It  is  wise  to  put  a  sling  on  the  wrist,  and  lay 
the  end,  sterile,  over  one  groin.  The  arm  need  not  be  replaced  in  the  uterus,  nor 
should  it  be  amputated  under  any  circumstances.  A  physician  amputated  both 
arms  of  a  presumably  dead  child  and  delivered  it  later  alive! 

What  shall  be  done  in  neglected  transverse  presentations  when  version  is 
impossible  or  too  hazardous  and  the  child  still  alive?  From  the  nature  of  the  case, 
cesarean  section  is  contraindicated,  because  it  jeopardizes  the  mother  too  much, 
and  the  child,  though  living  at  the  time  of  delivery,  in  the  majority  of  cases  dies 
soon  after  from  the  effects  of  the  compression.  In  the  author's  opinion,  embryot- 
omy should  be  done.  While  it  sacrifices  what  little  life  the  child  has  and  is  a  pain- 
ful task  for  the  accoucheur,  it  offers  the  mother  the  greatest  safety. 

Preceding  all  operations  in  shoulder  deliveries  a  painstaking  examination  is 
to  be  made  to  discover  the  existence  of  a  complication  which  might  affect  the 
treatment,  as  contracted  pelvis,  placenta  prsevia,  or  nephritis,  and,  after  delivery, 
the  uterus  and  vagina  must  be  explored  to  determine  the  integrity  of  the  parturient 
canal — advice  which  cannot  be  too  frequently  reiterated. 


PROLAPSE  OF  THE  CORD 

This  error  of  attitude  occurs  once  in  about  400  cases,  and  has  been  observed  as 
early  as  the  fourth  month  of  pregnancy.  During  labor  it  is  most  unwelcome, 
because  the  life  of  the  child  is  so  intimately  concerned.  Three  degrees  of  prolapse 
of  the  cord  may  be  distinguished:  (1)  An  occult  form,  where  the  cord  is  at  or  near 
the  girdle  of  resistance,  but  not  within  reach  of  the  fingers  during  the  ordinarily 
careful  examination.  Here  the  condition  is  not  suspected,  and  the  child  may  die 
from  compression  of  the  cord  in  natural  delivery  or  by  the  blade  of  the  forceps 
(Fig.  5.53).  (2)  The  cord  may  be  forelying,  that  is,  palpable  through  the  os,  but  in 
the  intact  bag  of  waters  (Fig.  554).  (3)  The  cord  may  be  prolapsed  into  the  vagina 
or  even  outside  of  the  vulva,  the  bag  of  waters  being  ruptured  (Fig.  555). 

Etiology. — Anything  which  causes  a  maladaptation  of  the  presenting  part  to 
the  lower  uterine  segment  or  prevents  engagement  of  the  head  will  favor  prolapse 
of  the  cord.  In  normal  presentations  the  lower  uterine  segment  is  so  evenly 
applied  to  the  head  that  there  is  no  room  for  the  cord  to  slip  down.  Mechanical 
causes  are:  (1)  Contracted  pelvis,  the  head  being  arrested  high  and  free  spaces 
being  left  at  the  sides;  indeed,  the  discovery  of  the  cord  must  evoke  the  suspicion 
of  a  contracted  pelvis.  In  Hildel:)rand's  126  cases  of  prolapsed  cord  one-third 
had  contracted  pelvis;    (2)  malpositions  and  malpresentations;    occipitoposterior, 


ANOMALIES    OF   THE    PASSENGERS 


627 


face  and  brow,  breoch  and  sliouldcr  presentations;  (3)  low  attachment  of  the 
placenta,  witii  marginal  insertion  of  the  cord;  (4)  pretca-naturally  long  cord,  though 
a  short  one  may  also  prolapse;  (5)  displacement  of  the  cord  as  an  error  of  art  during 
obstetric  operations;  ((>)  ])rolaiis(!  of  an  arm.  Other  causers  an*  twins,  polyhydram- 
nion,  the  cord  being  rushed  out  with  the  bursting  of  the  meml^rancs,  and  especially 
since  the  head  is  usually  high  in  such  cases;  the  accidental  floating  out  of  the  cord 
when  the  waters  break  before  the  head  is  engaged,  as  occurs  in  multipara;  other- 
wise normal.  It  has  occurred  to  the  author  that  perhaps  the  specific  gravity  of 
the  li(|U(»r  ainnii  may  liave  something  to  do  witii  the  prolapse. 

Course  and  Prognosis. — So  far  as  the  mother  is  concerned,  prolapse  of  the 


Fig.  553. — OccrLT  Prolapse  of  the  Cord. 
In  the  unruptured  membranes  hardly  any  pressure  is  possible. 


cord  does  not  affect  the  course  of  labor,  except  inasmuch  as  the  cause  of  the  prolapse 
might  do  so,  and  she  is  not  endangered  except  by  these  causes,  and  by  the  opera- 
tions which  might  be  undertaken  on  account  of  them,  and  to  save  the  life  of  the 
child. 

For  the  child  there  is  great  danger,  since  the  soft  blood-vessels  easily  suffer 
compression  and  asphyxia  results.  The  cord  is  most  easilj'  compressed  in  head 
presentations  when  it  lies  in  front,  behind  the  pubis.  When  it  has  slipped  do^Mi 
at  the  side,  near  the  sacro-iliac  joints,  it  finds  some  little  protection  behind  the 
jutting  promontory,  though  the  soft  parts  alone  can  exert  fatal  compression. 
Compression  of  the  cord  affects  the  vein  first,  reducing  the  amount  of  blood  going 
to  the  fetal  heart,  and  causing  placental  congestion.     As  the  result  of  the  anemia 


628 


THE    PATHOLOGY    OF   LABOR 


and  the  asphyxia  the  fetal  heart  slows,  sometimes  to  50  or  60,  during  the  contraction 
of  the  uterus,  and,  when  the  compression  is  relieved,  the  heart  bounds  up  to  130 
to  160  a  minute.  But  this  does  not  mean  that  the  circulation  has  recovered,  because 
in  many  instances  minute  hemorrhages  in  the  lungs  and  even  heart-clot  have  been 
produced,  which  render  extra-uterine  existence  impossible.  If  the  cord  hangs  out 
of  the  vulva,  it  may  congeal  from  cold  or  the  mother  may  lie  on  it.  In  breech  and 
shoulder  presentation  the  danger  of  compression  is  not  so  acute,  though  still  serious, 
and  if  an  extremity  has  also  prolapsed,  the  cord  may  find  protection  by  lying 
alongside  and  parallel  ^Adth  it.  An  additional  danger  to  the  child  will  arise  in  the 
operations  undertaken  for  its  rescue — all  of  which  explains  the  40  to  50  per  cent, 
mortality  in  oi3erated  cases  and  the  80  per  cent,  in  those  left  to  nature. 


Fig.  554. — The  Fohelying  Cord. 
This  cord  may  be  compressed. 


Diagnosis. — Occult  prolapse  of  the  cord  should  be  thought  of  when,  in  an  other- 
wise nat  ural  labor,  the  fetal  heart-tones  are  irregular  or  arhythmic,  and  when,  as  in 
the  forceps  operation,  auscultation  reveals  cardiac  tumult  during  the  tractions.  A 
persistent  funic  souffle  with  irregularity  of  the  heart  is  very  significant.  Ausculta- 
tion of  the  fetal  heart  is  an  indispensable  routine  in  the  conduct  of  labor.  By  deep 
insertion  of  the  fingers  behind  the  pubis  it  is  often  possible  to  discover  the  knuckle 
of  cord  as  it  lies — usually  above  one  ear — alongside  the  head.  (See  Forceps.) 
A  forelying  cord  in  the  intact  bag  of  waters  will  escape  only  the  careless  diagnosti- 
cian, and  it  will  also  be  easy  to  differentiate  it  from  velamentous  umbilical  vessels, 
from  pulsating  arteries  in  the  fornices,  and  from  polyps. 

After  rupture  of  the  bag  of  waters  no  difficulty  is  experienced — it  is  often 


ANOMALIES    OF  THE    PASSENGERS 


629 


possi])le  to  see  the  cord.  Palpation  of  the  umbilical  cord  to  determine  if  it  pulsates 
Tuust  be  the  gentlest  possible,  because  it  is  a  sh(;ck  to  tiie  child  to  have  its  placental 
circulation  stopped,  and,  too,  the  vein  is  compressed  first,  shutting  off  the  supply  of 
oxyfi;en.  Pulsation  in  the  cord  may  be  absent,  or  so  slif;ht  that  it  is  impalpable,  and 
yet  the  child  be  living.  Auscultati(jn  of  the  fetal  heart  must  always  be  practised 
before  proiiouiiciiiu;  the  child  dead. 


Fig.  555. — Prolapse  of  Cord.     GRE.\Tfc;sT  Danger  of  Compression. 


In  the  differential  diagnosis  maternal  intestines  fallen  through  a  rent  in  the 
parturient  canal  and  fetal  intestines  in  abdominal  hernia  are  to  be  considered. 

Treatment. — As  has  been  stated  on  similar  occasions  many  times,  all  treatment 
must  be  preceded  by  a  careful  obstetric  examination,  including  pelvic  mensuration, 
to  discover  the  cause  of  the  prolapse,  and  all  adjuvant  factors  which  may  alter 
and  direct  the  course  of  procedure  demanded  by  the  indications.  For  example,  a 
contracted  pelvis  may  inchcate  cesarean  section,  or  a  low-hdng  placenta  Braxton 
Hicks'  version. 

The  Forelying  Cord. — ^^lien  the  cord  is  felt  in  the  intact  bag  of  waters,  the 
accoucheur  should  attempt  its  replacement  by  posture,  the  elevated  Sims'  position 
(Fig.  557),  the  Trendelenburg  (Fig.  556),  even  the  knee-chest,  being  employed.     To 


630 


THE    PATHOLOGY    OF   LABOR 


prevent  the  rupture  of  the  membranes  before  complete  dilatation  has  been  secured 
the  patient  is  forbidden  to  bear  down,  is  kept  abed  in  one — the  most  comfortable — 
of  the  attitudes  mentioned,  and  a  Carl  Braun  soft-rubber  colpeurynter  is  placed  in 
the  vagina.  All  preparations  are  made  for  quick  operative  delivery,  and  the  ac- 
coucheur stays  by  the  bedside.  When  complete  dilatation  of  the  cervix  has  been 
obtained,  nine-tenths  of  the  danger  has  been  obviated. 


Fig.  556. — Trendelenburg  Position  in  Treatment  op  Prolapse  of  Cokd. 
Note  concavity  above  pubis  caused  by  the  head  leaving  the  inlet. 

When  Prolapse  has  Occurred. — First,  if  the  cord  is  outside  the  vulva,  it  must 
be  sterilized  and  replaced  within  the  vagina.  Now  one  of  two  things  must  be  ac- 
complished :  either  the  child  must  be  delivered  or  the  cord  must  be  put  in  a  place 
where  it  will  not  be  compressed.  Naturally,  if  conditions  are  right  for  immediate 
extraction,  this  is  the  most  advisable  procedure,  because  it  instantly  extricates  the 


Fig.  .557. — Patient  in  Elevated  Sims'  Position  in  Treatment  of  Prolapse  of  Cord. 

child  from  its  precarious  position.  For  rapid  extraction  the  cervix  must  be  effaced 
and  completely  dilated,  conditions  which  are  seldom  present.  Everything  depends 
on  the  cervix. 

(a)  If  the  cervix  is  not  open  enough  to  admit  the  hand,  the  accoucheur  must 
relieve  the  cord  from  the  danger  of  compression.  Braxton  Hicks'  version  has  been 
proposed,  but  the  operation  is  difficult;    often  the  cord  does  not  recede  with  the 


ANOMALIES    OF   THE    PASSENGERS  631 

change  of  polarity  of  the  body,  and,  further,  the  chances  of  the  chihl  are  not  much 
improved  hy  tiie  operation,  since  extraction  may  not  he  done  at  once,  and  (hiring  the 
long  wait  for  complete  dilatation  the  child  usually  dies. 

It  is  better  to  replace  the  cord  above  the  head  and  put  a  metreurynter  in  the 
cervix,  to  prevent  its  falling  down  again.  H.  M.  Stowe  advised  to  fill  the  uterus 
with  salt  solution  after  rei)lacing  the  cord,  and  invented  a  metreurynter  for  this 
purpose.  Replacement  of  the  cord  may  be  accomplislied  with  a  catheter  and  stilet, 
as  shown  in  Fig.  559,  g  and  h,  the  catheter  being  left  in  place  until  complete  dila- 
tation has  been  obtained,  or  the  two  fingers  may  be  employed  to  push  the  cord  up. 
All  these  mananivers  are  carried  out  with  the  woman  in  the  knee-chest  posture,  in 
order  to  get  the  benefit  of  gravity,  and,  before  the  hand  is  withdrawn,  a  metreur- 
ynter is  inserted  in  the  lower  uterine  segment  and  filled  with  12  ounces  of  weak 
antiseptic  solution,  or  the  cervix  is  packed  with  gauze — this  precaution  to  hinder 
the  cord  from  falling  out  again  and  to  keep  the  head  away  from  the  inlet.  After 
the  cervix  is  thus  tlioroughly  plugged,  the  woman  may  be  placed  on  her  back  or 
side.  Neither  of  these  methods  is  uniformly  successful.  The  repositor  may  kink 
or  injure  the  cord  or  wound  the  uterus,  and  the  fingers  may  not  be  able  to  push  the 
loops  above  the  globe  of  the  head,  and  in  both  instances  the  cord  is  likely  to  pro- 


^ 


Fig.  55S. — Knee-chest  Position. 

lapse  again  as  soon  as  the  woman  is  laid  on  the  back  or  when  the  colpeu^^^lter  comes 
out.  Then,  too,  the  cord  may  not  be  relieved  of  compression  by  the  operation,  and 
even  the  bag  may  press  on  it.  In  one  case  where  the  cord  could  not  be  replaced  I 
pulled  the  arm  down  alongside  the  head  and  tucked  the  cord  beside  it,  thus  pro- 
tecting it  from  injury.     A  thick  rectal  bougie  might  be  used  for  this  purpose. 

(5)  If  the  cervix  will  admit  the  hand,  there  are  two  methods  to  choose — version 
and  reposition  of  the  cord.  Equally  good  results  are  obtained  from  both  opera- 
tions; the  choice,  therefore,  will  depend  on  individual  skill  and  preference,  plus 
the  conditions  presented  by  each  case.  Version  will  be  selected  when — (1)  Other 
indications  for  version  are  present;  (2)  when  a  contracted  pelvis  of  minor  degree 
coexists;  (3)  in  face,  brow,  or  other  abnormal  presentation;  (4)  when  an  indication 
for  delivery  on  the  part  of  the  mother  or  child  arises  or  is  to  be  anticipated;  (5) 
when  reposition  has  failed  or  the  cord  fallen  do\^^l  again. 

It  is  always  desirable  to  secure  complete  dilatation  before  turning,  because  it 
may  be  necessary  to  follow  the  version  with  the  accessory  operation  of  extraction. 

Reposition  is  practised  as  follows:  If  the  woman  will  permit  the  operation 
without  an  anesthetic,  the  knee-chest  posture  is  employed;  if  not,  the  exaggerated 
Trendelenburg  is  used.     Passins  the  wliole   hand   into   the   vagina,  the   cord   is 


632 


THE    PATHOLOGY    OF   LABOR 


allowed  to  coil  in  the  palm,  which  is  hollowed  out  for  its  reception,  the  fingers  making 
a  sort  of  cage  for  it  (Fig.  560) .  Then,  pushing  the  head  up  and  to  one  side,  going 
in  the  direction  indicated  by  the  cord  itself,  the  loops  are  quickly  carried  to  the 
highest  point  attainable  in  the  uterus,  and,  if  possible,  the  cord  is  hung  over  one  leg. 
While  doing  this  the  other  hand  pushes  the  head  away  from  the  inlet:  After  the 
cord  is  replaced,  the  inside  hand,  acting  with  the  outside  hand,  brings  the  head  over 
the  inlet,  and  a  few  pains  are  awaited  to  force  it  down.  It  may  be  advisable  to  pull 
the  head  into  the  pelvis  with  forceps  and  then  leave  the  case  to  nature.  By  keep- 
ing the  woman  on  the  side  the  cord  is  prevented  from  coming  down  again. 

Reposition  is  not  likely  to  be  successful  nor  advisable  when  the  pelvis  is  con- 


s 


Fig.  5.59. — Various  Cord  Repositors. 
o,  Schoeller's;    6,  Hcyernaux's;    c,  Dueamp's;    d,  Favereau's;    e,  Murphy's;    /,  Poullet's;    o,  Braun's;    h,  Dudan's. 


tracted,  and  it  is  usually  not  practised  in  the  presence  of  an  indication  for  immediate 
extraction.  When  the  child  is  in  bad  condition,  both  reposition  and  version  are 
usually  powerless  to  save  it,  but  in  these  cases  the  author  prefers  reposition  for 
primiparse  and  version  for  multipara?. 

In  all  cases,  after  Braxton  Hicks'  version,  after  version  and  after  replacement, 
the  heart-tones  of  the  fetus  must  he  continuously  observed,  in  order  to  detect  the  first 
signs  of  a  threatening  asphyxia.  Even  after  apparent  successful  replacement  the 
cord  may  be  compressed  at  a  point  not  suspected. 

When  the  head  is  engaged,  reposition  and  version  are  usually  impossible,  and 
the  safety  of  the  child  lies  in  its  quick  delivery.     If  the  cervix  is  fully  opened,  no 


ANOMALIES    OF    THE    PASSENGERS 


033 


(lifTicultics  arc  mot;  if  it  is  not,  nuuiual  (lilatatioii,  Diilirsscn's  incisions,  cvon  vaginal 
cesarean  section,  may  be  employed,  and  tiien  forcej)s  applied.  Which  method 
will  be  selected  depends  on  the  condition  of  the  cervix  as  regards  efTacement  and 
dilatation  and  the  accomplishments  of  the  accoucheur. 

If,  when  called  to  the  case,  the  cord  is  found  i)ulsatinK  feel)ly  or  not  at  all,  the 
accoucheur's  fii'st  duty  is  to  determine,  so  far  as  possible,  the  actual  condition  of 
the  child  anil  its  chances  for  ultimate  recovery  even  if  delivered  alive.  It  is  no  feat 
to  be  proud  of  to  deliver  a  child  at  the  expense  of  extensive  maternal  injuries  when 
it  dies  after  a  few  minutes  or  hours  from  late  asphyxia  or  cereljral  hemorrhage. 
If  a  jjrolapse  of  the  cord  finds  the  accoucheur  unprepared  for  its  proper  treatment, 


Fig.  500. — Repl.\cement  of  PROL.\rsED  Cord  with  Whole  Hand.     Patient  ix  Knee-chest  PosrrRE. 


the  head  may  be  held  l)ack  and  the  cord  protected  In'  the  hand  inside  until  as- 
sistance can  be  procured. 

When  the  infant  is  dead,  the  case  is  to  be  left  to  nature,  but  if  an  indication  for 
delivery  on  the  part  of  the  mother  arises,  craniotomy  is  the  operation  of  choice. 
In  a  primipara  craniotomj^  on  the  dead  child  should  be  recommended  to  save  the 
perineal  floor  from  the  overdistention.  Forcej^ts  and  version  on  a  dead  child  are 
contraindicated.  Of  course,  if  there  is  doubt  of  the  life  of  the  child,  it  should  have 
the  benefit  of  the  doubt.  WTiat  to  do  when  the  cord  is  pulsating  only  feebly  and 
there  is  reason  to  believe  the  death  of  the  child  is  not  far  distant  is  not  easy  to  decide. 
If  the  child  can  be  quickly  brought  to  hght  without  the  danger  of  serious  maternal 


634  THE    PATHOLOGY    OF   LABOR 

injury,  it  ought  to  get  this  chance  for  its  life,  but  if  the  operative  dehvery  promises 
to  be  hard — a  priniipara,  for  example — or  tedious,  it  is  more  than  likely  that  the 
child  will  perish  during  the  attempt  to  save  it,  or  shortly  afterward.  The  almost 
inevitable  cervical  and  perineal  lacerations  will  then  make  the  accoucheur  regret 
his  futile  and  perilous  effort. 

Breech  and  Footling  Presentations. — Prolapse  of  the  cord  complicating  these 
presentations  carries  a  degree  of  danger  slightly  less  than  with  head  presentations. 
]\Iost  authors  say  that  the  cord  is  not  easily  compressed  by  the  soft  breech,  but  this 
is  not  my  experience.  It  is  best  to  replace  the  cord,  hanging  it  over  the  shoulder, 
and  then  put  in  a  metreurynter. 

With  transverse  presentation  prolapse  of  the  cord  requires  no  special  treat- 
ment. During  the  preparations  for  version  the  cord  is  to  be  kept  clean  and  warm 
by  putting  it  into  the  vagina  and  applying  a  vulvar  plug.  If  the  cervix  is  to  be 
dilated  by  a  metreurynter,  the  cord  is  first  pushed  up  into  the  uterus. 

Cesarean  section  has  been  proposed  for  the  treatment  of  prolapsed  cord.  At 
first  breath  it  would  seem  that  such  an  operation  would  never  come  up  for  con- 
sideration, since  it  is  done  almost  entirely  in  the  interests  of  the  child,  but  the  author 
can  think  of  several  conditions  in  which  the  abdominal  delivery  would  command 
serious  attention.  These  are:  (1)  An  aged  primipara,  very  desirous  of  a  child. 
Here,  if  the  parturient  canal  is  unprepared,  the  child  is  almost  invariably  lost; 
(2)  mild  degrees  of  pelvic  contraction,  insufficient  of  themselves  to  indicate  cesarean 
section ;  (3)  where  the  religious  scruples  of  the  family  demand  that  in  all  operations 
the  child  be  given  equal  chances  with  the  mother.  Couvelaire  and  Potocki  report 
successful  cases.  When  cesarean  section  is  considered  in  the  treatment  of  prolapsed 
cord,  two  conditions  must  be  insisted  upon:  the  child  must  be  in  perfect  condition 
and  the  mother  have  not  even  the  suspicion  of  infection. 


PROLAPSE  OF  THE  ARMS  AND  FEET  WITH  THE  HEAD 

In  general,  the  same  causes  which  produce  prolapse  of  the  cord  may  permit  the 
hands  or  feet  to  come  down  alongside  the  head.  Voluntary  motions  of  the  child 
may  also  be  mentioned.  On  several  occasions  the  author  has  felt  the  child  present 
a  hand  at  the  os  and  then  withdraw  it.  If  the  bag  of  waters  should  break  at  this 
moment,  the  extremity  would  be  floated  out.  Contracted  pelvis,  small  or  dead 
fetus  (lack  of  tonicity),  and  sudden  rush  of  liquor  amnii  are  the  usual  causes.  The 
complication  occurs  once  in  about  250  labors.  We  speak  of  the  presenting  or  fore- 
lying  hand  or  foot  when  the  extremity  is  felt  in  the  intact  sac  at  the  os,  and  of 
prolapse  when  the  membranes  are  broken  and  the  part  is  in  the  vagina. 

Prolapse  of  the  arm  may  influence  the  mechanism  of  labor.  In  the  first  place, 
it  may  stiffen  the  fetal  cylinder  and  confer  a  rigidity  which  is  harmful  to  normal 
rotation,  and,  secondly,  by  prolapsing  in  a  portion  of  the  pelvis  which  the  occiput 
should  traverse,  it  may  prevent  anterior  rotation  of  the  same.  For  example,  if  in ' 
O.L.A.  the  posterior  arm  prolapses  alongside  the  forehead,  it  will  aid  anterior  rota- 
tion; if  the  anterior  one  comes  down  behind  the  pubis,  it  will  delay  or  prevent  it. 
An  arm  lying  in  the  anterior  half  of  the  pelvis  will  obstruct  labor  more  than  if  in 
the  hollow  of  the  sacrum,  where  there  is  more  room.  The  anterior  arm  is  the  one 
usually  found,  and  prolapse  occurs  oftener  with  occipitoposterior  positions.  The 
diagnosis  is  simple,  but  the  accoucheur  should  always  remember  that  the  hand  may 
be  that  of  a  shoulder  presentation  or  of  a  second  twin,  and  that  sometimes  the  foot 
may  be  mistaken  for  the  hand. 

Treatment. — Before  rupture  of  the  bag  of  waters,  while  the  head  is  still  above 
the  inlet,  posture  will  usually  suffice.  Place  the  woman  on  the  side  on  which  the 
hand  does  not  lie.  As  labor  advances  the  head  pushes  by  the  arm.  After  the 
membranes  rupture,  as  a  rule,  the  head  enters  the  pelvis,  the  arm  being  held  back, 


ANOMALIES    OF   THE    PASSENGERS 


635 


but  sometimoR  tho  arm  prevents  tlio  engagement  of  the  head.  Here  the  extremity 
nmst  be  replaced,  using  tlie  lialf  or  tiie  wliole  liand,  under  anesthesia,  if  necessary, 
If  this  fails,  or  if  the  arm  falls  down  again,  version  is  performed.  \'ersion  is  also 
done  when,  in  addition  to  the  arm,  tiie  coi'd  is  down  or  the  jjlacenta  is  low  in  the 
uterus,  or  any  other  indication  for  changing  the  jxjlarity  of  the  fetus  exists. 

After  the  head  has  engaged  with  the  arm  nothing  is  done  because  there  is 
evidently  enough  room  in  the  pelvis  for  the  two.  Since  labor  is  longer  and  anom- 
alies of  rotation  commoner,  forceps  are  more  often  needed.  In  api^lying  the  for- 
ceps care  to  sec  tliat  tlic  l)!ad('s  do  not  grasp  the  arm  is  necessary. 

Arms  in  the  Nape  of  the  Neck. — I'ig.  5G1  shows  a  rare  anomaly  of  attitude. 
It  was  described  by  Simp- 
son, and  the  author  has  met 
with  this  one  instance  of  it. 
About  25  cases  have  ])een 
reported,  mostly  English. 
After  the  engagement  of 
the  head  the  arms,  crossed 
al)ove  the  brim,  effectually 
stopped  the  attempted  for- 
ceps delivery,  and  it  was 
only  after  the  half-hand, 
under  deep  narcosis,  was 
passed  up,  the  author  l)eing 
under  the  impression  that 
a  distended  chest  was  the 
cause  of  the  obstruction, 
that  the  real  reason  was 
discovered.  With  consider- 
able difficult}'  the  arms  were 
gotten  into  proper  position 
and  then  the  instrumental 
delivery  was  easily  com- 
pleted. Unless  such  re- 
placement of  the  arms  is 
possible,   the    case  will   be 

formidable.  Version  was  successful  in  Simpson's,  Gray's,  and  Lambert's  cases. 
Craniotomy  may  have  to  be  done;  then,  when  sufficient  room  is  procured  along- 
side the  crushed  head,  the  arms  may  be  reached  and  either  pushed  out  of  the  way 
or  drawn  down. 

Prolapse  of  the  foot  alongside  the  head  is  very  rare,  and  only  four  such  cases 
occurred  in  the  author's  experience.  Version  in  each  instance  was  easy,  though 
most  authors  say  it  is  difficult  under  the  circumstances.  Since  the  fetal  cylinder 
is  made  rigid,  slow  advance  and  delayed  rotation  are  usual,  and,  therefore,  forceps 
oftener  needed.  If  the  foot  prevents  engagement  of  the  head,  it  may  be  pushed 
away  and  the  head  led  into  the  pelvis  by  combined  manipulation;  if  this  does  not 
succeed,  version  is  the  treatment.  If  the  foot  and  head  have  engaged  in  the  pelvis, 
watchful  expectancy  and  forceps,  if  needed,  are  recommended. 


Fig.  561. — Arms  in  Nape  of  Neck. 
Mrs.  L.     Primipara.    Eclampsia.     Heart  disease.     Readjusted  arms.     For- 
ceps. 


Literature 

Couvelnire  and  Polocki:  Annates  de  Gyn.,  February,  1910,  p.  111. — Gray:  Med.  Record,  New  York,  1894,  vol.  xliii, 
p.  5S9. — Schultze:  Monatsschr.  f.  Geb.  u.  Gyn.,  August,  1909,  vol.  xxx,  No.  2,  p.  137. — Simpson:  Obstetric 
Memoirs. 


CHAPTER  LI 

ANOMALIES  OF  THE  PASSENGERS  (Concluded) 

DYSTOCIA  DUE  TO  EXCESSIVELY  LARGE  FETUS 

Older  writers  report  the  birth  of  children  weighing  23  and  24  pounds  (Ortega, 
Rachel,  and  Neumer,  quoted  by  Dubois  in  1897).  Beach  reported  a  giantess'  child 
weighing  10,773  gm.,  about  22}^  pounds,  and  being  76  cm.  long.  It  is  best  to  ac- 
cept the  stories  related  by  patients  as  to  the  immense  size  of  their  previous  children 
vnth.  much  reserve,  because  they  are  usually  exaggerated  or  mere  guesses.  The 
largest  child  delivered  by  the  author  weighed  14  pounds  and  necessitated  cesarean 
section.  It  was  diseased  and  died  with  high  fever  in  sixteen  hours.  Another, 
weighing  12^^  pounds,  Avas  delivered  by  forceps  and  survived.  In  the  service  of 
the  Chicago  Ljdng-in  Hospital  and  Dispensary,  in  over  15,000  cases,  only  3  children 
weighed  more  than  12  pounds,  and  in  2264  hospital  cases  only  2  weighed  over  11 
pounds,  5000  gm.     All  these  children  gave  rise  to  marked  dystocia. 

Given  a  normal  pelvis,  normal  powers,  and  a  normal  presentation,  position, 
and  attitude,  nature  is  usually  capable  of  accomplishing  the  delivery  of  children 
weighing  up  to  9  pounds  without  very  great  difficulty. 

Etiology.^ — (1)  Partus  serotinus,  prolonged  pregnancy,  carrying  overterm,  has 
been  recognized  as  a  cause  of  overdevelopment  of  the  child,  and  was  recently 
statistically  proved  by  von  Winckel.  In  addition,  my  own  studies  show  that  the 
bones  become  harder,  less  malleable,  the  spine  stiffer,  the  fat  and  muscles  firmer,  and 
the  head  actually  larger  and  more  square  in  shape,  with  pointed  parietal  bosses. 
The  fontanels  are  smaller,  the  sutures  almost  closed  and  in  apposition.  Sometimes 
children  carried  overterm  are  lighter  in  weight  compared  to  their  increased  length, 
but  the  difficulties  of  delivery,  rather  than  being  diminished  by  the  long  narrow  fetal 
cylinder,  are  really  augmented,  because  of  the  lack  of  moldability.  (2)  Overeating 
in  pregnancy  is  not  a  common  cause  of  overdevelopment  of  the  fetus,  but  experience 
shows  that  women  of  the  better  situated  classes  and  those  of  indolent  habit  have 
larger  l:)abies  than  those  that  have  to  work  hard  and  are  poorly  fed  in  pregnancy. 
In  France  and  Germany  special  provision  is  made  for  these  women  with  a  view  to 
improving  the  offspring.  (3)  Multiparity — children  of  later  pregnancies  are  usu- 
ally larger  than  that  of  the  first,  but  an  exception  is  to  be  noted  in  old  primiparse 
with  male  children.  These  are  likely  to  be  large  and  a  frequent  cause  of  dystocia. 
(4)  Large  parents  usually  have  large  children,  which  is  fortunate  only  if  the  mother 
exceeds  the  normal  size,  because  then  her  pelvis  will  accommodate  the  child.  A 
large  father  may  procreate  children  which  the  mother  cannot  deliver.  In  one  of 
the  author's  consultations  the  third  wife  of  a  very  large  and  powerful  man  died,  as 
did  the  other  two,  from  obstructed  labor.  (5)  Finally,  no  particular  cause  being 
found,  it  is  supposed  that  some  factor  producing  a  large  ovum  may  be  the  reason 
for  the  overgrowth  of  the  fetus.  Since  the  children  in  placenta  praevia,  placenta 
circumvallata,  and  other  placental  anomalies  are  usually  small,  exceptional  condi- 
tions of  nutrition  may  produce  very  large  children. 

Course. — During  pregnane}',  overdistention  of  the  belly  may  cause  the  same 
disturbancesastwins(whichareusuallysuspected) ;  these  are,  a  feeling  of  greatweight, 
dyspnea,  edema,  albuminuria,  pendulous  belly,  etc.  If  labor  is  postponed,  inter- 
mittent false  pains  may  annoy  the  woman  for  several  weeks.  Labor  is  slow,  and 
usually  characterized  by  weak  pains  (from  overdistention),  with  early  rupture  of 

63G 


ANOMALIES    OF   THE    PASSENGERS  637 

the  mombranos,  borausc^  the  head  ('n^aK<'s  late.  Cephalic  prosfntations  aro  the 
rule.  Occipitopostcrior  positions  are  v('r>'  coininoii.  lu  general,  tlie  course  of 
labor  resembles  that  iu  contracted  pelvis  of  tiie  justominor  type.  If  the  head  is 
not  too  hard,  it  molds  into  the  jK^lvis  and  is  delivered  under  strong  bearing-down 
effort  or  by  the  aid  of  art.  The  broad  shoulders  then  cause  delay,  (lirls  have 
bi'oader  siioulders  than  l)ovs  when  compared  with  tiu;  size  of  tlie  head.  After  the 
head  is  out,  it  snaps  back  against  the  perineum,  jjressing  this  upward  into  the  pelvis, 
due  to  the  ela.sticity  of  the  fetal  neck.  Unless  the  shoulders  can  be  brought  down, 
the  child  c|uickly  dies.  Anomalous  mechanisms  are  very  common,  but  delay  in 
engagement  of  the  shoulder-girdle  is  the  usual  cause  of  the  trouble,  and  this  is  be- 
cause it  is  too  large  or  incompressible.  Rupture  of  the  uterus  may  occur  in  the 
dystocia  due  to  the  delivery  of  voluminous  shoulders.  Even  the  breech  may  be  so 
voluminous  that  its  delivery  is  slow. 

Postpartum  hemorrhage  and  anomalies  of  placental  separation  are  more  fre- 
([uent  than  usual,  because  the  large  uterus  needs  time  to  retract  on  itself  and  may 
not  do  so  perfectly.  Lacerations  must  also  be  expected,  especially  if  any  manipula- 
tions were  required. 

Diagnosis. — A  very  large,  protul)crant  belly  will  excite  the  suspicion  of  an 
overgrown  child,  of  twins,  or  of  hydramnion.  Aljsence  of  fluctuation  will  exclude 
the  latter,  and  the  recognized  methods  will  usually  suffice  to  discover  two  fetuses. 
Cephalometry  {q.  v.)  is  giving  better  results  since  it  is  being  practised  more.  If 
the  accoucheur  will,  in  every  case,  endeavor  to  determine  accurately  the  size  of  the 
child  before  the  birth,  and  control  his  findings  by  later  measurements,  he  will  ac- 
ciuire  a  degree  of  accuracy  in  estimating  the  size  of  the  fetus  which  he  would  not 
have  believed  possible.  The  size  of  the  fetus  is  just  as  important  a  matter  for  the 
obstetrician  to  know  as  the  size  of  the  pelvis.  Of  nearly  equal  moment  is  the  hard- 
ness of  the  fetal  head.  This  is  determinable  by  bimanual  palpation,  from  the  size 
of  the  fontanels,  and  by  noting  how  well  the  bones  of  the  head  overlap  as  the  latter 
enters  the  pelvis  under  the  influence  of  the  pains.  After  delivery  of  the  head  a 
stoppage  of  labor  usually  results  from  the  big  trunk,  but  the  possibility  of  anomalous 
mechanisms  of  the  shoulders  and  of  tumors  of  the  fetal  body,  or  dorsal  displacement 
of  the  arms,  must  be  remembered.  In  a  breech  presentation  the  size  of  the  part 
will  give  a  good  indication,  and  especially  if  the  foot  is  do^\^tl.  A  large  leg  and  foot 
usually  means  a  large  child. 

Prognosis. — For  the  mother,  it  depends  on  the  degree  of  disproportion  between 
the  child  and  the  pelvis,  and  if  this  is  very  great  and  goes  unrecognized,  the  mother 
may  die — of  ruptured  uterus,  sepsis,  exhaustion,  or  inflicted  injuries.  Ordmarily, 
however,  the  mother  may  be  successfully  delivered  if  the  child  weighs  not  over  5000 
gm.  (11  pounds)  and  other  conditions  are  favorable.  The  delivery  of  an  enormous 
child  through  a  normal  pelvis  is  harder  than  the  delivery  of  a  normal  child  tlu-ough 
a  contracted  pelvis,  even  when  the  proportions  are  the  same.  For  the  cliild,  the 
prognosis  is  not  so  good.  jNIany  more  die  in  labor,  from  asphyxia,  compression  of 
the  brain,  and  from  the  injuries  inflicted  in  operative  delivery.  Intracranial  hemor- 
rhage, fissure-fractures  of  the  skull,  cephalhematomata,  spoon-shaped  depressions, 
Erb's  paralysis — all  are  more  frequent.  It  must  be  remembered  that  somctmies 
these  large  children  are  diseased — for  example,  suffering  from  anasarca,  universal 
hydrops,  or  myxedema.  After  delivery  the  large  children  lose  more  in  ^\•eight, 
even  proportionately. 

Treatment. — As  was  already  said,  the  author  considers  it  unAAise  to  allow  women 
to  go  far  overterm,  and  when,  after  careful  consideration  of  all  obtainable  informa- 
tion, subjective  and  objective,  he  decides  that  the  usual  period  of  gestation  has 
been  comjjleted,  he  induces  labor.  (See  Prolonged  Pregnancy.)  This  procedure 
is  still  more  necessary,  and  maj'  be  done  several  weeks  before  term,  when  the  woman 
gives  a  history  of  large  children  and  difl&cult  labors.     Prochownik  instituted  a  special 


638  THE    PATHOLOGY    OF    LABOR 

dietary  for  such  cases,  hoping  thus  to  diminish  the  size  of  the  child,  but  in  my  cases 
it  was  not  successful,  which  failure  other  authors  also  admit  (Ballantyne). 

During  labor  the  important  thing  is  to  discover  early  that  the  infant  is  large, 
because  a  cesarean  section  may  be  the  easiest  and  safest  for  both  patients.  Hebos- 
teotomy  is  not  advisable  as  a  primary  selection,  because  of  the  dangers  to  the  soft 
parts.  If  the  disproportion  is  recognized  only  after  the  favorable  time  for  cesarean 
section  is  past,  a  high  degree  of  expectancy  is  to  be  employed.  Occipitoposterior 
positions  are  to  be  early  corrected,  and  then  labor  allowed  to  proceed  until  the  head 
is  firmly  engaged.  High  forceps  operations  are  bad  in  these  cases,  but  not  so  bad 
as  version,  which  should  be  avoided,  if  at  all  possible,  and  especially  in  primi- 
parse.  If  nature  fails,  and  the  accoucheur  with  his  forceps  cannot  bring  the  large 
and  often  stony-hard  head  into  the  pelvis,  extraperitoneal  cesarean  section,  pu- 
biotomy,  and  craniotomy  are  the  alternatives. 

Difficulty  in  the  delivery  of  the  shoulders  is  overcome  as  follows:  (1)  Have  the 
woman  bear  down  forcibly  and  aid  same  by  Kristeller's  expression.  (2)  Try  to 
rotate  the  shoulders  into  a  favorable  diameter,  which  will  usually  be  an  oblique,  by 
pulling  on  the  shoulder  with  the  inside  finger  and  pushing  from  the  outside,  seeking 
to  tuck  the  shoulder  down  behind  the  pubis.  (See  Fig.  536.)  (3)  Try  to  insert 
the  finger  into  the  posterior  axilla  and  thus  pull  the  shoulder  down;  failing 
the  posterior,  try  the  anterior;  sometimes  it  is  possible  to  bring  this  one  into  the 
pelvis  from  behind  the  pubis.  (4)  Bring  the  posterior  arm  down  and  out,  going 
up  into  the  uterus  with  the  whole  hand;  failing  this,  try  to  bring  the  anterior  arm 
do\\Ti  from  behind  the  pubis.  At  first  be  very  gentle,  but  if  this  does  not  succeed, 
use  force,  well  applied,  of  course,  risking  a  fracture  of  the  extremity.  In  one  case 
I  deliberatelj^  fractured  the  humerus  and  saved  the  child's  life.  After  one  arm  is 
doTVTi  the  extraction  is  usually  possible;  if  not,  get  the  other  arm  also.  Should  the 
child  have  died  during  these  prolonged  manipulations,  all  haste  should  be  at  once 
abandoned;  cleidotomy  and  evisceration  are  now  in  order.  A  deep  episiotomy  is 
almost  always  necessary  in  these  cases,  otherwise  the  perineal  floor,  including  the 
sphincter  and  rectum,  will  be  injured,  often  extensively. 

]\Iorcellation  of  a  giant  child  is  one  of  the  most  formidable  tasks  that  can  con- 
front the  accoucheur,  and  on  several  occasions  the  vaginal  operation  had  to  be 
abandoned  and  cesarean  section  resorted  to  finally.  Amputation  of  the  uterus 
should  be  done  in  such  cases  to  forestall  sepsis. 


RIGOR  MORTIS 

Should  the  child  die  before  delivery,  the  rigor  mortis  may  be  a  cause  of  dystocia. 
Few  such  cases  are  reported  because  it  seldom  happens  that  the  birth  occurs  during 
this  temporary  condition,  and  many  times  it  is  not  recognized;  finally  it  is  not 
constant.  The  child  figured  on  p.  536  gave  rise  to  real  difficulty  in  labor;  the 
forceps  operation  was  very  difficult;  it  was  necessary  to  insert  the  whole  hand  for 
the  purpose  of  pulling  down  the  shoulders,  and  even  the  trunk  came  hard.  Frac- 
tures of  the  extremities  have  occurred  in  such  deliveries. 


ENLARGEMENT  OF  PARTS  OF  THE  CHILD 

Hydrocephalus  may  give  rise  to  severe  dystocia.  Both  external  and  internal 
forms  are  observed,  and  the  skull  may  contain  several  quarts  of  fluid  and  have 
a  circumference  of  80  cm.  (Fig.  562).  Nothing  is  positively  known  of  the  causes, 
Ymt  syphilis  seems  to  have  some  effect,  and  in  general  what  was  said  in  the  chapter 
on  Monsters  applies  here.  The  frequent  association  of  hydrocephalus  with  spina 
bifida,  club-foot,  fetal  rickets,  ascites,  and  all  other  defects  of  growth  is  to  be 
emphasized. 


ANOMALIES    OF   THE    PASSENGERS 


639 


Course. — Prcf^nancv  may  be  interrupted  because  of  a  non-viable  hydroeephalic 
fetus.  Labor  is  usually  a  little  premature,  and  is  often  notable  because  of  weak 
pains,  but,  owing  to  overdistention  and 
thinning  of  the  lower  uterine  segment 
and  the  mechanical  obstruction  to 
labor,  rupture  of  the  uterus  is  a  I're- 
({uent  comi)lication.  For  exami)le,  in 
Schuchard's  74  cases  14  had  uterine 
rupture.  Breech  presentation  is  much 
more  frecjuc^nt  than  usual,  and  the  soft 
head  comes  through  easier  than  when 
it  leads  the  way.  A  small  hydroceph- 
alus may  be  delivered  easily,  or  with 
only  slight  h(4p  from  art ;  a  larger  one 
always  gives  trouble,  but,  curiously,  a 
very  large  head  with  soft  bones  and  not 
strongly  distended  may  mold  its  way 
through  the  pelvis.  A  dead  and  macer- 
ated fetus  may  also  pass  easily,  espe- 
cially if  the  pains  are  good.  Pressure 
necrosis  and  fistulas,  from  prolonged 
labor  and  operative  errors,  are  some- 

,.  1  1         rrii  1  1  •  Fig.     5C2. — Hydrocephalus    (Museum    of    Northwesterc 

times     observed.        ihe     head     remamS  University  Medical  School). 


Fig.  563. — HTOROCEPHALrs,   Molding  its  Way  into  Pelvis. 


640 


THE    PATHOLOGY    OF   LABOR 


high  a  long  time,  and  the  signs  of  thinning  of  the  lower  uterine  segment  are  early 
and  marked.  Sometimes  the  head  bursts  under  the  action  of  strong  pains  or  during 
extraction.  The  fluid  may  escape  outside  or  under  the  skin,  or  a  spina  bifida  bursts 
and  lets  it  out. 

Postpartum  hemorrhage  from  atony  of  the  uterus  and  from  the  frequent  lacera- 
tions is  observed.  The  mother,  therefore,  is  much  endangered  by  hydrocephalus 
mil  ess  it  is  recognized  early,  in  which  event  the  only  mortality  and  morbidity  should 
be  those  of  normal  labor.  Since  the  disease  is  so  fatal  to  the  child,  our  operative 
measures  usually  do  not  consider  it,  but  many  cases  are  recorded  where  the  child 


Fig.  .504. — Puncture  of  Hydrocephalus  with  Trocar.     Note  Spina  Bifida  (author's  case). 


survived  either  spontaneous  or  instrumental  delivery.  Even  in  one  case  where  the 
head  was  perforated  to  facilitate  delivery  the  infant  lived  six  weeks.  Nearly  all 
the  children  rHe  within  a  few  years,  and  hardly  any  are  cured. 

Diagnosis. — From  the  accoucheur's  standpoint,  this  is  the  most  important, 
and  if  only  the  possibility  of  such  a  complication  be  kept  in  mind,  it  is  very  easy. 
Mistakes  are  due  more  to  carelessness  than  to  ignorance.  Abdominally,  the  large 
size  of  the  uterine  tumor,  the  tense  lower  uterine  segment,  the  rigidity  of  the  abdo- 
men, the  broad  head  (over  the  inlet  or  in  the  fundus),  the  lack  of  engagement,  the 
tendency  to  inertia  uteri,  call  attention  to  some  anomaly.  Vaginally,  the  broad 
sutures  and  large  fontanels,  the  large  fiat  elastic  dome  that  seeks  to  enter  the  inlet, 


ANOMALIES    OF   THE    PASSENGERS  641 

but  remains  high,  will  almost  clinch  tiic  diajijnosi.s.  If  the  l)oncs  of  the  cranium  are 
thin,  the  crackling  crauiotal)es  will  Ijc  felt,  and  by  bimanual  palpation,  the  use  of 
which  is  too  much  neglected  in  obstetric  diagnosis,  the  iiiunense  .size  of  the  head  is 
easily  distinguishable.  In  the  differenlial  diagnosis  a  small  hydrocephalus  must 
be  separated  from  a  large  but  normal  head.  A  thin-walled  hydroceplialus  may 
simulate  the  bag  of  waters  or  the  urinary  bladder.  Macerated  and  edematous 
fetal  scalp,  cystic  tumors  on  the  head,  encephaloceles,  and  tough  membranes  have 
been  wrongly  tliagnosed.  A  hydrocephalic  child  presenting  by  the  breech  is  usually 
not  discovered  until  the  head  is  arrested  at  the  inlet.  Occasionally  a  spina  bifida 
or  other  deformity, will  excite  suspicion  of  an  associated  hydrocephalus. 

Treatment. — Since  the  child  almost  invariably  dies  and  is  doomed  to  early 
death  even  if  delivered  alive,  all  effort  is  directed  to  save  the  mother.  Perforation 
of  tlu!  head  with  a  trocar  is  the  operation  recommended  by  almost  all  writers.  A 
long  scissors  will  do  if  a  trocar  is  not  at  hand,  and  the  hole  is  made  in  the  most  ac- 
cessible part  of  the  head.  In  breech  cases  a  spot  beside  the  ear  is  usually  the  best, 
but  the  operation  has  been  performed  through  the  mouth  and  the  spinal  canal. 
Where  the  possibility  exists  that  the  child  may  survive  the  delivery,  the  spot  chosen 
for  the  puncture  should  be  away  from  the  cerebral  sinuses. 

After  the  fluid  is  evacuated  the  collapsed  cranium  offers  little  resistance  to  the 
soft  parts  and  is  usually  quickly  delivered.  Should  an  indication  for  rapid  delivery 
arise  in  a  head  case,  traction  may  be  exerted  on  the  collapsed  sac,  and  if  this  tears, 
as  is  usual,  the  cranioclast  may  be  applied  to  the  base  of  the  skull  and  the  cervical 
spinal  column.  Version  may  also  be  done,  but  a  skilful  operator  will  seldom  need 
to  expose  the  uterus  to  the  additional  risk  of  rupture  thus  involved. 


DISTENTION  OF  THE  ABDOMEN 

This  may  result  from  ascites,  enlarged  liver,  neoplasms  and  cysts  of  the  hver, 
congenital  cystic  kidneys,  dilated  bladder  or  ureters,  and  a  few  other  isolated  con- 
ditions. Ascites  accompanies  most  of  those  mentioned.  Syphilis  plays  an  im- 
portant role  in  the  causation  of  ascites,  fetal  peritonitis,  and  liver  diseases.  The 
diagnosis  of  excessive  abdominal  distention  of  the  fetus  is  seldom  made  until  delay 
in  the  exit  of  the  child  is  manifest.  Great  abdominal  distention  of  the  mother  or 
polyhydramnion  will  only  direct  attention  to  the  possibility  of  a  fetal  anomaly. 
In  head  cases,  after  the  shoulders  are  ready  to  escape  from  the  vulva,  progress  is 
arrested,  and  in  spite  of  strong  traction  delivery  may  not  be  effected.  Examina- 
tion with  the  whole  hand  will  clear  the  diagnosis.  Fig.  565  shows  a  case  of  labor 
arrested  by  congenital  cystic  kidneys.  Since  the  breech  did  not  advance,  the  hand 
was  inserted  and  the  large  belly  easily  circumscribed  with  the  fingers. 

Treatment. — In  head  presentation,  after  the  head  is  born  and  the  distended 
trunk  will  not  come,  several  ribs  and  the  sternum  are  to  be  exsected  with  Siebold's 
scissors,  the  lungs  and  heart  removed,  the  diaphragm  punctured,  and  the  abdominal 
contents  thus  evacuated.  When  the  breech  presents,  simple  puncture  of  the  belly 
suffices  in  ascites,  but  if  there  is  a  solid  tumor  also,  it  is  removed  by  morcellation. 


TOUGH  MEMBRANES 

The  meral)ranes  are  sometimes  a  source  of  obstruction  to  labor,  and  a  slightly 
increased  resistance  here  may  be  the  cause  of  great  delay.  They  may  be  either 
adherent  over  the  internal  os  and  lower  uterine  segment,  thus  preventing  the  dila- 
tation of  same,  or  they  may  be  so  tough  that  they  do  not  rupture  when  the  cervix 
is  dilated.  In  either  case  labor  is  retarded :  in  the  one  at  the  beginning,  in  the  other 
at  the  end,  of  the  first  stage.  The  second  is  easily  recognized — delay  after  complete 
dilatation. 
41 


642 


THE    PATHOLOGY    OF   LABOR 


Lack  of  progress  in  the  first  stage  of  labor,  due  to  adherent  membranes,  may  be 
suspected  when  the  os  dilates  very  slowly  in  spite  of  good  contractions,  the  head 
being  well  do^vn  in  the  pelvis,  the  completely  effaced  cervix  fitting  it  closely  like 
a  cap,  and  the  membranes  stretched  tightly  over  the  scalp,  with  no,  or  hardly  any, 
fore  waters.  The  adherences  may  be  felt.  Labor  may  be  delayed  one  or  two  days 
by  such  a  condition. 

Treatment. — In  the  first  stage  it  is  advisable  to  push  up  the  head  a  little, 
loosen  the  membranes  all  around  the  margin  of  the  internal  os  to  the  extent  of  one 
inch,  and  allow  a  little  liquor  amnii  to  come  down,  to  make  a  good  hydrostatic 
dilator.     After  several  hours,  if  delay  is  still  manifest,  it  is  justifiable  to  rupture 


Fig.  565. — Congenital  Cystic  Kidneys  with  Ascites  Obstructing  Labor  (author's  case). 
After  the  ascites  was  let  off  the  large  kidneys  still  gave  difficulty.     Patient's  sister  had  a  similar  anomaly,  but  not  so 

marked. 


the  membranes.  Indispensable  conditions  for  this  little  operation  are:  Occipital 
presentation  and  engagement  of  the  head,  effacemcnt  of  the  cervix,  normal  pelvis,  and 
soft  parts. 

When  tough  membranes  do  not  rupture  after  complete  dilatation  of  the  cervix, 
but  delay  is  manifest  for  one  or  two  hours,  it  is  justifiable  to  rupture  them  Con- 
ditions are:  th(^  pelvis  may  not  be  contracted;  the  child  not  too  large;  the  head 
mu.st  be  well  fixed  on  th(!  inlet;  the  presentation  and  position  must  be  normal. 
Special  additional  indications  are  required  in  those  cases  where  these  conditions 
are  not  fulfilled. 

After  fixing  the;  head  in  the  inlet  from  without  so  as  to  prevent  the  prolapse 
of  the  cord  and  extremities,  the  membranes  arc  pierced  with  a  pointed  instrument, — 


ANOMALIES    OF   THE    PASSENGERS  643 

scisKors,  for  exaniplo, — and  tho  finger  iinnicdiutcly  placed  against  the  opening. 
This  is  to  permit  only  tlie  slow  escai)(!  of  the  licjuor  anmii,  whicli  guarantees  tlic 
safety  of  the  cord.  As  the  I'Kiuid  slowly  trickles  away,  the  assistant  from  the  out- 
side forces  the  head  into  the  pelvis.  Should  the  waters  start  to  come  with  a  rush, 
the  operator  holds  the  labia  together,  thus  closing  the  vulva.  Some  accoucheurs 
perform  the  operation  with  the  patient  on  the  side.  When  performed  fc^r  the  proper 
indication  and  under  fiUetl  conditions,  labor  usually  terminates  very  cjuickly. 


CHAPTER  LII 

ANOMALIES  OF  THE  PASSAGES 

Dystocia  due  to  anomalies  of  the  soft  parts  is  more  frequent  than  that  due 
to  the  bony  pelvis.  Both  give  the  accoucheur  many  intricate  problems,  especially 
since  he  is  required  to  manage  labors  after  the  numerous  operations  performed  for 
the  relief  of  gNTiecologic  complaints.  In  order  will  be  considered:  (1)  Dystocia 
due  to  anomalies  of  the  parturient  canal;  (2)  that  clue  to  diseases  of  the  bladder — (3) 
of  the  rectum. 

ANOMALIES  OF  THE  PARTURIENT  CANAL 

Most  of  these  have  already  been  studied  under  the  Pathology  of  Pregnancy. 
Reference  has  been  made  to  the  relation  of  tumors  to  pregnancy  and  labor,  to 
hematoma  of  the  pelvic  cellular  tissue,  to  varicosities,  hemorrhoids,  etc.,  and  the 
congenital  deformities  of  the  genitalia  have  also  been  described  under  the  heading 
of  Local  Diseases  Accidental  to  Pregnancy. 

Rigidity  of  the  Cervix. — Older  writers  distinguished  two  kinds:  the  spasmodic 
and  the  anatomic,  in  the  latter  there  being  an  organic  change  in  the  cervical  tissue. 
Spasmodic  rigidity  has  already  been  described  under  Anomalies  of  the  Uterine 
Action.  Rigidity  of  the  cervix  due  to  disease  is  rather  rare,  which  is  remarkable 
when  one  thinks  of  the  number  of  diseased  uteri  which  make  up  the  clientele  of  the 
gynecologist.  During  pregnancy  the  extreme  softening  of  the  tissues  provides 
for  the  great  dilatation  required  in  labor.  Causes  of  such  rigidity  are:  chronic 
cervicitis,  scars  from  cautery,  nitrate  of  silver  treatments,  Emmet's  operations,  or 
amputations;  scars  from  old  ulcerative  processes,  especially  those  following  infections 
postpartum — carcinoma,  etc.;  sj^philis,  senility  of  the  tissues  (old  primiparse);  ad- 
hesion of  the  membranes  around  the  internal  os,  conglutination  of  the  external  os. 

Conglutinatio  Orificii  Externi  (Fig.  566)  is  a  condition  where  the  few  circular 
fibers  around  the  external  os  refuse  to  dilate;  as  a  result,  the  cervix  is  not  opened, 
but  thinned  by  the  head,  and  may  be  delivered  externally,  still  covering  the  head. 
The  condition  is  not  a  true  conglutination,  and  a  better  name  should  be  selected 
for  it.  The  os  cannot  always  be  found  by  the  finger,  but  the  opening  can  be  seen 
in  the  speculum  as  a  tiny  hole  with  a  little  mucus,  and  surrounded  by  a  very  red 
ring.  By  pressure  with  the  finger  the  resistance  of  the  external  os  is  overcome,  and 
then  the  dilatation  usually  goes  on  rapidly. 

Old  primiparse  often  have  hard  cervices.  Dilatation  is  very  slow  and  sometimes 
incomplete.  The  cervix  contains  muscular  and  elastic  fibers,  the  muscular  strands 
drawing  the  cervical  walls  actively  apart.  If  the  fibrous  tissue  predominates,  there 
is  no  autogenous  dilatation  of  the  cervix,  and  the  hydrostatic  effect  of  the  bag  of 
waters  is  not  enough.  Since  the  membranes  in  old  i)rimiparae  often  rupture  early, 
the  mechanism  of  the  first  stage  is  deprived  also  of  this  help.  Further,  the  uterine 
pains  in  old  primiparae  often  leave  much  to  be  desired.  The  pelvic  joints  are  rigid 
and  do  not  allow  the  nutation  of  the  sacrum  which  facilitates  delivery,  but  this 
causes  delay  in  the  second  stage  and  mention  of  it  does  not  belong  here. 

Adhesion  of  the  membranes  around  the  internal  os  is  a  not  infrequent  cause 
of  delayed  dilatation,  since  it  prevents  the  action  of  the  dilating  fibers.  Mild 
forms  of  rigidity  or  apparent  rigidity  are  due  to  inefficient  pains.  Owing  to  the 
delayed  labor  and  occasionally  to  circulatory  disturbance,  the  cervix  gets  thicker, 

644 


ANOMALIES   OF  THE   PASSAGES 


645 


harder,  inelastic,  and  sometimes  edematous.  No  progn^ss  may  be  notcfl  for  hours, 
and,  unless  relieved,  the  case  passes  into  th(!  danj^erous  class  of  obstructed  lal)or. 

Syphilis  (;auses  a  very  serious  lorin  of  cervical  ri{;idity,  and  is,  fortunately,  rare; 
th(!  wholes  cervix  is  chanfi;ed  into  a  tou^h,  fibrous,  undilatable  tube,  (.'esarean 
section  and  craniotomy  have  be(>n  found  n(!cessary.  Scars  from  ul(;eration  may 
close  up  the  cervix  so  that  th(^  finest  probe  may  not  discover  the  passage,  and  if, 
as  som(>tinies  happens,  the  cervix  has  slouf2;hed  off,  the  vault  of  the  vagina  may  be 
one  arclu^l,  smooth  scar,  in  which  the  opening  into  the  uterus  cannot  be  found. 
( )ne  of  my  Porro  cesareans  was  for  this  condition,  complicated  by  a  rectovaginal 
hstula — all  the  result  of  a  previous  puerperal  sceptic  process. 

Labor,  in  cases  of  cervical  disease,  shows  delay  in  the  first  stage,  and  a  great 


Fig.  566. — Conglutinatio  Orificii  Exterxi. 

deal  depends  on  the  site  and  extent  of  the  stricture.  If  it  is  in  the  supravaginal 
portion  of  the  cervix,  the  worst  forms  of  dystocia  arise;  if  in  the  vaginal  portion, 
the  case  is  easily  handled,  and  there  are  intermediate  forms.  Under  the  action  of 
the  pains  the  cervix  dilates  up  to  the  point  of  obstruction.  If  the  pains  are  strong, 
the  uterus  healthy,  and  the  stricture  not  too  rigid,  nature  finally  succeeds  in  pro- 
curing a  passage  for  the  child.  If  not,  labor  stops,  the  child  dies,  the  cervix  may 
tear,  the  child  being  born  through  the  rent,  or  the  uterus  may  rupture  and  the  child 
escape  into  the  abdominal  cavity,  or  (rarest)  the  cervix  may  tear  off  circularly  in 
part  or  in  toto.  At  the  Chicago  Lying-in  Hospital  a  colpeur^mter,  put  in  the 
uterus  to  facilitate  delivery  through  a  scarred,  indurated  cervix,  was  expelled, 
bringing  the  cervix  torn  off  circularly  with  it.  Usually  the  posterior  cervix  is 
torn,  the  child  escaping  through  the  rent,  the  ring-like  piece  hanging  alongside  it. 


646  THE    PATHOLOGY    OF   LABOR 

Severe  dystocia  due  to  pathologic  cervices  is  rare.  Slight  induration,  which 
lengthens  labor  but  allows  spontaneous  termination,  is  fairly  common.  A  large 
number  of  children  are  lost  through  delay  caused  by  rigidity  of  the  cervix  (Seitz) . 

Diagnosis. — Not  ever}'  hard  cervix  is  caused  by  anatomic  disease.  As  was  said, 
abnormal  uterine  action  can  produce  secondary  cervical  rigidity.  The  diagnosis 
must  comprise  the  cause,  the  nature,  the  location,  and  the  extent  of  the  stricture, 
also  the  relation  of  surrounding  organs;  for  example,  as  in  one  case  where  the  cervix 
in  toto  was  missing,  the  bladder  lay  close  to  the  rectum,  and  a  rectovaginal  fistula 
coexisted.  ''Relative  rigidity"  of  the  cervix  exists  when  an  indication  for  delivery 
arises,  but  the  cervix  is  closed,  though  normal. 

Treatment. — Cesarean  section  as  a  primary  operation  is  to  be  performed  where 
a  careful  examination  has  proved  that  obstruction  exists,  unamenable  to  the 
ordinarj'  methods.  If  the  stenosis  of  the  cervix  is  very  marked,  the  Porro  operation 
should  be  done,  because  the  passage  will  be  too  small  to  permit  the  escape  of  the 
lochia.  In  cases  where  the  stricture  does  not  appear  to  offer  an  insuperable  obstacle 
to  labor,  the  action  of  strong  pains  is  to  be  awaited.  When  it  is  evident  that 
nature  has  accomplished  as  much  as  she  is  able,  art  steps  in  to  aid  in  overcoming 
the  rigidity.  Five  methods  of  dilatation  of  the  cervix  are  practised:  (1)  By  means 
of  the  Lands,  advocated  since  the  time  of  Celsus,  and  perfected  by  Bonnaire  and 
Harris;  (2)  the  use  of  rubber  balloons;  (3)  instrumental  dilators  of  the  glove- 
stretcher  design,  of  which  Bossi's  is  the  best  known;  (4)  the  incisions  of  Dtihrssen — 
hysterostomotomy;    (5)  the  vaginal  cesarean  section  of  Dtihrssen. 

In  mild  cases,  where  the  cervix  is  effaced  and  the  os  more  or  less  dilated,  the 
fingers  usually  are  able  to  stretch  the  opening  sufficiently  to  permit  delivery. 
Almost  invariably  the  cervix  tears  more  or  less.  If  the  ring  is  too  tough  to  be 
stretched,  clean  incisions  radiating  to  the  fornices  may  be  made.  When  the 
cervix  is  not  effaced,  these  methods  are  dangerous  and  inefficient.  If  an  indication 
for  rapid  delivery  on  the  part  of  the  mother  or  child  does  not  exist,  a  metreurynter 
is  to  be  put  into  the  uterus  and  the  effect  of  the  hydrostatic  dilatation  tried.  Often 
the  cervix  will  soften  sufficiently.  If  it  does  not,  or  if  delivery  is  required,  the 
vaginal  cesarean  section  is  the  operation  of  choice.  Bossi's  dilator  is  not  to  be 
recommended.  (See  Chapter  LXIX.)  In  cases  of  annular  rupture  of  the  cervix 
nothing  can  be  done  if  the  amputation  is  complete  except  to  whip  the  vaginal  edge 
over  the  raw  surface  as  much  as  possible.  If  incomplete,  the  detached  portion 
may  be  sutured  in  place  if  the  accoucheur  considers  its  nutrition  not  too  much 
compromised;  otherwise  it  should  be  removed,  always  cutting  off  as  little  as  pos- 
sible, to  avoid  stricture  of  the  cervix,  and  covering  the  raw  surface  with  the  vagina 
if  it  can  be  gotten  into  place. 

Stenosis  of  the  vagina  is  an  occasional  cause  of  dystocia. 

Etiology. — Congenital  deformities,  duplicity  (already  considered),  atresia 
(usually  causes  sterility),  vaginal  bridges  or  septa  (the  relics  of  congenital  duplicity), 
tumors  in  and  near  the  vagina,  hematoma  of  the  neighboring  cellular  tissue,  cica- 
trices from  previous  ulcerative  processes,  puerperal  sepsis  or  injury  following  labor, 
scarlet  fever,  diphtheria,  measles,  variola,  syphilis,  and  gonorrhea.  In  one  of  the 
author's  consultations  the  cervix  and  vagina  sloughed  out  in  toto  after  a  hard,  high, 
forceps  delivery,  leaving  a  narrow,  tortuous  passage,  hardly  sufficient  for  the  men- 
strual discharges.  In  another,  after  measles,  a  portion  of  the  vagina  became  saccu- 
lated and  contained  pus,  and  the  cavity  burst  during  delivery.  (See  also  Brindeau.) 
Sometimes,  in  small  women,  the  vagina  is  too  narrow  for  safe  delivery.  In  women 
who  have  been  married  a  long  time  without  children,  and  in  prostitutes,  the  vagina 
msiy  be  constricted  and  tough,  so  that  it  will  not  dilate,  but  when  forced,  tears. 
Old  primiparse  also  are  likely  to  have  rigid  vaginas,  and  in  cases  of  frigiditas  sexu- 
alis  the  author  has  often  found  a  short,  dry,  indistensible  passage.  Finally,  the 
vagina  may  be  relatively  too  small ;  that  is,  it  may  be  normal,  but  in  the  presence 
of  some  indication  for  immediate  delivery  it  is  unprepared  for  rapid  dilatation. 


ANOMALIES    OF   THE    PASSAGES  647 

Lal)or  in  cases  of  vaginal  atresia  is  n(jt  delayed  until  the  head  reaehes  the 
point  of  ohstruetion.  Congenital  sejjta  or  bridges  an;  usually  pushed  aside  or 
torn  through  by  the  i)resenting  part;  rarely  is  discission  recjuired.  Tumors  may 
be  flattened  or  even  extruded  Ix'fore  tin;  head,  as  occurred  in  one  cas(;  of  large 
vaginal  cyst  in  the  author's  practice.  Vaginal  rigidity  is  usually  overcome  by  the 
powers  of  nature,  the  vagina  softening  or  dilating,  tiiough  sometimes  splitting  longi- 
tudinally— the  last  oftener  during  operative  interference.  Even  a  scar  may  some- 
times soften  and  dilate  under  the  infhience  of  the  pains,  but  scars  often  give  rise 
to  obstinate  dystocia. 

Diagnosis. — This  is  easy,  the  finger  meeting  a  hard  ring  or  narrow  passage 
beyond  which  the  cervix  is  felt,  but  care  is  required  to  determine  how  nmeh  the 
contiguous  organs  are  involved.  Sometimes  the  vagina  folds  up  Ijefore  the  on- 
coming head  and  a  stricture  is  simulated  (Fig.  118).  Such  a  fold  is  soft  and  easily 
pushed  open.  Th(>  full  rectum  may  encroach  on  the  vagina  (Fig.  568)  and  simulate 
a  i^elvic  tumor. 

Treatment. — Cesarean  section  is  performed  when  the  first  examination  shows 
an  insuperable  obstacle  to  delivery,  and  if  the  passage  is  apparently  too  small  to 
allow  the  escape  of  the  lochia,  the  uterus  must  be  amputated.  A  cicatricial  septum 
may  be  split  by  three  or  four  radial  incisions,  care  being  exercised  to  avoid  opening 
the  rectum  or  bladder.  Occasionally  a  stricture  may  be  dilated  with  a  colpeurj-nter. 
A  rigid  or  small  vagina  may  be  better  prepared  for  the  dilatation  it  has  to 
undergo  by  means  of  the  colpeurynter.  During  operative  delivery  a  narrow,  tight 
vagina  must  not  be  allowed  to  burst :  it  is  better  to  incise  it.  Since  the  tears  almost 
always  occur  in  the  lower  half,  a  deep  vaginoperineal  incision  will  usually  suffice 
{vide  infra).  A  vaginal  tumor  may  be  enucleated,  or  at  least  enough  of  it  removed 
to  permit  extraction  of  the  fetus.  A  cyst  may  be  enucleated  or,  if  need  be, 
punctured.  A  hematoma  may  be  punctured,  the  clot  evacuated,  and,  after  de- 
livery, the  cavity  packed  with  gauze. 

Rigid  Pelvic  Floor. — Two  forms  of  rigidity  of  the  pelvic  floor  may  be  distin- 
guished, anatomic  and  spasmodic.  Disease  of  the  muscles  or  connective  tissue  may 
compromise  the  dilatation  of  the  parts — for  example,  syphilis,  scars  from  injury 
or  from  previous  labors,  the  cicatrices  following  repair  operations,  hematoma,  and 
hypertrophy  of  the  muscle.  Bicycle-riding  hardens  the  perineum,  and  old  primi- 
para?  will  often  present  such  a  complication  in  addition  to  rigid  vagina.  Spasmodic 
rigidity  may  be  fomid  in  those  women  subject  to  vaginismus;  it  is  a  spasm  of  the 
levator  ani  muscle,  and  in  one  of  Pinard's  cases  necessitated  the  use  of  forceps. 
Sometimes  a  nervous,  apprehensive  parturient  will  contract  the  outlet  of  the  pelvis 
and  stop  labor.     Here  a  narcotic,  by  relieving  the  pain,  aids  delivery. 

Laljor  progresses  until  the  presenting  part  is  on  the  perineum,  and  then  delay 
is  manifest.  If  the  parturient  has  a  good  reserve  store  of  strength,  she  will  be  able 
to  overcome  the  added  resistance.  If  not, — if  it  has  been  wasted  by  premature 
iDcaring-down  efforts  or  if  the  woman  has  an  oversensitized  nervous  system, — arrest 
of  the  head  now  occurs  and  exhaustion  begins,  the  life  of  the  fetus  also  coming 
into  jeopardy. 

Seitz  {loc.  cit.)  shows  the  importance  of  rigid  pelvic  floor  in  his  statistics  from 
the  Munich  Maternity,  by  proving  that  one-third  of  the  fetal  deaths  in  head  pres- 
entation arc  due  to  delay  in  lalwr  at  this  point.  Our  own  experience  confirms  this 
and  emphasizes  the  strong  necessity  to  listen  to  the  fetal  heart-tones  everj'  few 
minutes  toward  the  end  of  the  second  stage.  B}-  following  this  practice  a  very 
large  number  of  children  will  be  saved. 

Diagnosis. — Delay  at  the  end  of  the  second  stage  demands  careful  examination. 
One  will  diagnose  a  rigid  pelvic  diaphragm  only  when  it  is  manifest  that  the  head 
presses  firmly  on  the  pelvic  floor  but  does  not  advance.  To  lie  eliminated  as  causes 
of  delay  are  contracted  bony  outlet  (funnel  or  masculine  pelvis),  overgrowth  of  the 
child,  faulty   rotation    (deep  transverse  arrest — occipitoposterior),  enlargement  of 


648  THE    PATHOLOGY   OF   LABOR 

the  trunk  of  the  fetus,  and  primarily  weak  pains.  The  diagnosis  of  an  asphyxia 
threatening  the  child  forms  part  of  the  accoucheur's  duties  at  the  same  time. 

Treatment. — When  the  parturient  has  shown  her  inability  to  overcome  the 
resistant  pelvic  floor,  or  when  the  child  begins  to  show  signs  of  asphyxia,  delivery 
must  be  accomplished.  One  should  not  wait  until  the  mother  is  exhausted  or 
until  her  nervous  system  is  tried  to  the  limit;  rather  one  should  determine  how 
much  nature  can  accomplish,  not  how  much  she  can  endure.  Resistance  at  the 
outlet  may  often  l^e  overcome  by  a  deep  episiotomy,  and  this  little  operation  will 
obviate  many  applications  of  the  forceps.  If  the  birth  does  not  now  occur,  forceps 
are  applied  and  nothing  has  been  lost,  because  in  all  probability  episiotomy  would 
have  been  done  in  any  case  to  avoid  deep  rupture  of  the  perineum.  Tetanic  spasm 
of  the  levator  ani  is  treated  by  anesthesia,  failing  which  the  forceps  are  used. 

Stenosis  of  the  Vulva. — Congenital  closure  of  the  vulva  is  usually  complete,  and, 
when  an  opening  exists,  it  leads  to  a  deformed  uterus  and  tubes,  so  that  conception 
is  almost  mikno"\va.  As  a  miicum  may  be  mentioned  the  case  of  von  Meer,  of 
pregnancy  in  the  uterus  connected  with  the  bladder,  coitus,  and  abortion  per 
urethram.  Acquired  closure  of  the  vulva  may  result  from  injury — burning  with 
fire  or  acids  (author's  case),  inflammation  ^vith  ulceration  in  childhood.  A  pin- 
hole hymen  may  offer  a  distinct  resistance  to  the  exit  of  the  head.  In  one  of  the 
author's  cases,  when  cut,  the  hymen  was  one-fourth  inch  thick.  Hymenal  septa 
may  offer  a  slight  barrier  to  progress,  but  they  usually  break,  or  can  be  easily 
snipped  in  two.  Edema  of  the  vulva  resulting  from  prolonged  and  obstructed 
labor  may  sometimes  be  very  great,  and  the  labia  may  even  slough  off.  This  is 
usually  due  to  concomitant  infection.  Sometimes  the  edema  seems  to  aid  the 
dilatation  of  the  vulva;  again  it  seems  to  predispose  to  lacerations  of  the  tissues. 
Varicosities  do  not  delay  labor,  but  they  comport  the  dangers  of  hemorrhage  and 
hematoma. 

Treatment. — When  it  is  plain  that  the  vulvar  outlet  is  holding  the  presenting 
part  back,  the  resisting  ring  is  either  to  be  stretched  with  the  fingers  or  incised 
(episiotomy).  A  closed  hymen  is  incised  radially.  In  the  author's  case  of  sten- 
osis of  the  vulva  due  to  carbolic  acid  burn  the  child  was  delivered  outside  the  bony 
pelvis  under  a  tough,  glistening  scar,  which,  with  the  skin,  dissected  itself  off  the 
perineum  and  thighs  to  the  extent  of  6  inches.  After  a  long  median  incision  had 
released  the  dead  fetus  the  flaps  were  readjusted  and  sewn  in  place  so  as  to  form  a 
new  vulva  and  a  shallow  vagina. 

Infantile  Genitalia.— Infantilism  of  the  genitalia  is  not  very  rare,  and  often 
leads  to  absolute  or  "one-child"  sterility.  Dysmenorrhea,  dyspareunia,  frigid- 
itas  sexualis,  nervous  weakness,  and  a  syndrome  which  resembles  Basedow's  dis- 
ease are  the  usual  symptoms,  and  a  tendency  to  firm  obesity  is  noticeable.  The 
vulva  is  small,  \\\i\\  little  hair;,  the  vagina  narrow,  short,  and  hard,  with  little 
secretion;  the  fornices  flat,  the  uterus  being  either  normal  in  size,  but  infantile  in 
shape  (large  cervix  with  small  fundus) ,  or  very  small  and  undeveloped.  Not  seldom 
it  is  found  bent  or  curled  on  itself  in  sharp,  retroposed  anteflexion.  Bossi  called  the 
cervix  "tapir  nosed."  The  pelvis  is  either  generally  contracted,  of  infantile  type, 
or  it  is  large,  with  masculine  lines  and  a  funnel  outlet.  It  seems  to  me  that  perhaps 
the  thyroid  gland  is  concerned  in  this  hypoplasia.  Marasmus  of  enteric  origin  in 
early  life  and  prematurity  are  also  causative.  Should  pregnancy  ensue,  abortion 
in  the  early  months  is  frequent,  and  this  often  ends  the  reproductive  effort  of  the  in- 
dividual. Labor  is  characterized  l;)y  weak  pains  and  delay  in  the  second  stage. 
This  comes  from  Vjoth  the  rigid  vagina  and  perineum  and  the  bony  outlet.  In- 
strumental delivery  is  often  recjuired,  and  it  is  usually  attended  by  extensive  lac- 
erations. It  is  highly  important  to  preserve  the  fetus  in  these  cases,  because  the 
first  is  so  often  the  onlj^  pregnancy.  Later  effects,  as  pointed  out  by  Pfannenstiel, 
are  retroflexio  uteri  from  overstretching  of  the  isthmus,  and  prolapsus  from  in- 
jurj^  and  overdistention  of  the  levator  ani  with  subsequent  atrophy. 


ANOMALIES    OF   THE    PASSAGES 


649 


DYSTOCIA  DUE  TO  OBSTRUCTION  OFFERED  BY  OTHER  PELVIC  ORGANS 

Bladder,- — A  full  bladder  (Fig.  5G7)  provonts  the  onRagonicnt  of  the  hoad,  and 
labor  may  not  proceed  until  it  is  emptied.  It  may  cause  tleflexion  attitudes  and 
l)re(lisi)ose  to  prolajjse  of  the  cord.  In  one  case  it  appeared  to  me  to  favor  an 
O('cii)itopost('rior  position,  Ix'cause  the  ])a('k  at  once  came  to  the  front  after  the 
viscus  was  emptied  by  catlieter.  It  causes  Aveak  pains  and  interferes  with  bearing- 
down  efforts,  and  thus  increases  the  number  of  forceps  operations.  A  cystocele 
may  delay  the  head,  and  itself  run  the  danger  of  severe  contusion  or  bursting. 
After  tiie  birth  of  th(^  child  tiie  full  bladder  may  obstruct  the  delivery  of  the  i)lacenta 
or  weaken  the  uterine  contractions,  in  cither  case  causing  postpartum  hemorrhage 
or  rc^tention  of  the  i)lacenta. 

The  diagnosis  is  easily  made,  there  being  a  soft,  fluctuating,  rounded  tumor 


Bladder 


Fig.  5G7. — Full  Bladder  Cacsinq  Dystocia. 


stretching  from  the  pul^is  toward  or  to  the  navel.  It  resemliles  the  thinned-out 
low(^r  uterine  segment,  but  catheterization  will  settle  the  diagnosis  if  the  presence 
of  distinct  fluctuation  has  not  already  done  so.  The  treatment  is  catheterization 
with  a  soft-rubber  catheter,  pushing  up  the  head  if  necessary. 

Tumors  of  the  bladder  have  seldom  been  known  seriously  to  complicate 
delivery — two  cases  of  fibroma  are  on  record.  Vesical  calculi  may  cause  serious 
troul^le;  the  traumatism  of  lal:)or  may  crush  them  or  crush  the  bladder-wall, 
resulting  in  fistula.  It  is  best  to  remove  the  stone  per  vaginam  late  in  pregnancy. 
If  labor  has  started,  it  may  be  possible  to  push  the  stone  and  the  bladder  out  of  the 
pelvis  and  lead  the  head  into  it,  but  it  may  be  necessary  to  perform  lithotomj'  during 
labor.  The  diagnosis  is  easy  if  all  the  possibilities  are  considered.  A  stone  was 
once  mistaken  for  a  pelvic  exostosis. 

The  Rectum. — A  full  rectum  may  act  very  much  like  the  full  bladder  in  pre- 


650 


THE    PATHOLOGY   OF   LABOR 


venting  engagement  and  modifying  uterine  action.  One  danger  of  the  full  rectum 
which  is  not  sufficiently  emphasized  is  infection  from  feces  expelled  during  the 
birth  of  the  child.  In  spite  of  extraordinary  precautions  on  the  part  of  the  accou- 
cheur, particles  of  feces  may  be  carried  into  the  genitals  and  give  rise  to  fatal 
puerperal  infection.  When  the  head  is  held  above  the  pelvis  by  the  full  viscus, 
faulty  presentations,  positions,  and  attitudes  may  result.  Ofttimes  a  colonic 
flushing  Anil,  by  emptjdng  the  pelvis,  permit  engagement,  which  is  followed  by 
rapid  delivery  (Fig.  568). 

Tumors  of  the  rectum  may  cause  sufficient  dystocia  to  require  cesarean  section. 


Fig.  508. — Full  Rectum  as  Obstruction. 

In  one  of  my  cases  a  large  gonorrheal  stricture  of  the  rectum,  with  its  surrounding 
cellular  tissue  infiltration,  caused  obstruction  and  prolonged  delay  in  delivery, 
during  which  the  child  })ccame  asphyxiated.  Forceps  were  employed  to  overcome 
the  obstacle,  but  the  child  succuml^ed  in  eighteen  hours. 

Fissures  of  the  anus  are  a  common  sequence  of  the  great  stretching  of  the 
anus  during  labor.  They  cause  painful  defecation  and  bloody  and  purulent  dis- 
charges in  the  late  puerperium.  A  few  applications  of  10  per  cent,  nitrate  of  silver, 
with  perhaps  a  little  stretching  of  the  muscle,  usually  suffice  to  cure  them. 


Literature 

Brindeau:  L'Obstetrique,  1901,  vol.  xl,  p.  00. — Dohrn:  Cent.  f.  Gyn.,  1908,  p.  530. — Mayer:  "Infantilism,"  Beitrage 
f.  Geb.  u.  Gyn.,  1911,  vol.  xv,  H.  .3.  Literature. — "Labor  in  Youns  and  Old  Primiparae,"  Jour.  Obstet.  and 
Gyn.,  Brit.  Empire,  December,  1909,  p.  408. — Pfannenalid:  Munch,  ined.  Woch.,  May,  1909. — Seitz:  Arch.  f. 
Gyn.,  1910,  vol.  xc,  H.  1. — Theilhaber:  Monatsschr.  f.  Geb.  u.  Gyn.,  vol.  ix,  p.  400.  Literature  on  Cystic 
Kidneys. 


CHAPTER  LIII 


ANOMALIES  OF  THE  BONY  PELVIS 


As  mucli  variation  is  found  among  female  pelves  as  in  female  features.  A 
perfectly  synnnetric  pelvis  is  the  greatest  rarity.  Tramond,  of  Paris,  who  prepared 
many  thousands  of  them,  found  hardly  one  in  5000  that  was  nearly  perfect.  The 
variations  are  individual,  racial,  pathologic.  Large  women  usually  have  large 
jielves,  women  of  masculine  habitus  have  masculine  pelves,  small  women  usually 
have  small  i^elves,  women  of  delicate,  effeminate  constitution  have  slender  bones, 
while  the  muscular  individual  develops  a  strong,  rigid  pelvis.  Racial  differences 
also  exist,  but  have  not  been 
sufficiently  studied.  In  general 
there  are  four  forms,  judging 
from  the  shape  of  the  inlet: 
The  transverse  ellipse,  the 
heart  shape,  the  round,  and 
the  anteroposterior  ellipse. 
European  women  have  the 
large  transverse  elliptic,  with 
a  tendency  to  heart-shaped 
inlet.  The  Bush  women  of 
Australia,  the  African  negress, 
and  the  Indian  women  have 
a  round  pelvis,  but  also  with 
a  tendency  to  lengthening  of 
the  anteroposterior  diameters. 
English,  Irish,  and  German 
women  have  large  cordate 
pelves,  the  French  a  large  pel- 
vic canal  with  tendency  to 
small  bones.  Jewnsh  women 
have  small  pelves. 

The  study  of  the  adult  pel- 
vis is  much  facilitated  by  fol- 
lowing its  development  from 
the  fetal  stage,  and  the  study 
of  the  effects  of  disease  in  early 
childhood  upon  the  configura- 
tion of  the  bones  would  throw 
much  light  on  this  complicated 
subject.     Here  exists  a  fertile 

field  for  investigation.  The  pelvis  of  the  new-born  child  (Fig.  569)  is  long, 
narrow  from  side  to  side,  and  converges,  funnel  shaped,  toward  the  outlet. 
The  sacrum  is  long  and  straight;  the  bodies  of  the  vertebrae  do  not  project 
from  between  the  wings,  which  are  small.  The  promontory  is  high  and  not 
]:)rominent;  the  pelvic  inclination  is  marked.  Fehling  was  able  to  distinguish 
differences  between  the  male  and  female  pelvis  even  in  fetal  life,  but  the  greatest 
changes  occur  during  the  years  of  most  active  skeletal  development.  Since  the 
time  of  Denman  the  factors  in  the  development  of  the  shape  of  the  adult  pehis 
have  been  under  discussion,  and  the  names  of  Litzmami,  H.  von  ^Nleyer,  Schroder, 

651 


Fig.  5G9. — Sagittal  Section  of  Pelvis  of  New-born-  Girl  (Xorth- 
western  University  Medical  School). 


652 


THE    PATHOLOGY   OF   LABOR 


Fehling,  Bayer,  Balandin,  Freund,  Breus,  and  Kolisko  might  be  mentioned  as  a 
few  of  the  many  who  took  part  in  it.  We  cannot  go  into  the  details  of  the  dis- 
cussion, but  briefly  may  give  the  results,  which  are  now  quite  well  established. 
In  general  there  are  two  factors  which  form  the  adult  pelvis,  the  first  and  most 
important  being  the  inherent  property  of  growth  of  the  bones;  the  second,  the 
mechanical  influences  exerted  on  the  growing  child.  That  the  inherent  growth- 
tendencies  of  the  bones  are  the  determining  factors  is  proved  by — (a)  The  pelvis 
of  the  new-born  girl  already  differs  slightly  from  that  of  the  boy;  and  (6)  though 
subjected  to  the  same  mechanical  influences,  assumes,  in  its  maturation,  a  much 
different  shape;  (c)  even  when  distorted  by  disease,  after  the  cause  is  removed, 
nature  tries  to  correct  the  deformity,  for  example,  in  rachitis;  (d)  when  other 
anomalies  of  gro^A^h  are  present  abnormality  of  the  pelvis  often  coexists,  for  example, 
aplasia  of  the  genitals  with  infantile  pelvis. 

Mechanical  influences  after  birth  are  auxiliary  in  the  production  of  the  devel- 
oped pelvis.     Litzmann  (1861)  and  H.  von  Meyer  emphasized  the  action  of  the 
pressure  of  the  trunk,  and  considered  also  the  resistance  of  the  pelvic  bones  and  car- 
tilages and  the  dragging  force 
of  the  muscles  and  ligaments  of 
the  pelvis. 

The  three  bones  of  the  pel- 
vis are  put  together  so  that  the 
sacrum  does  not  act  like  a  key- 
stone or  wedge.  The  sacrum  is 
movable,  being  held  in  place  by 
the  ligaments,  aided  by  the  inter- 
locking of  the  roughnesses  of  the 
apposed  articular  surfaces  of  the 
ilia. 

In  the  growing  child  the 
line  of  direction  falls  through  a 
point  somewhat  anterior  to  the 
sacrum.  This  causes  pressure  to 
be  exerted  on  the  first  sacral  ver- 
tebra when  the  child  is  erect  or 
sitting.  The  lower  end  of  the 
sacrum  is  prevented  from  going 
backward  by  the  strong  sacro- 
sciatic  ligaments.  A  bending  of 
the  sacrum,  therefore,  occurs  in 
the  sagittal  diameter,  which  is  most  marked  at  the  third  sacral  vertebra. 

A  tendency  of  the  sacrum  to  become  concave  from  side  to  side,  which  might 
result  from  the  same  factors,  is  counteracted  by  the  weight  of  the  body,  transmitted 
through  the  spinal  column  to  the  sacrum  (the  "body  or  trunk  pressure  "),  forcing  the 
bodies  of  the  sacral  vertebrae  downward.  In  pelves  softened  by  disease  this  forcing 
down  and  forward  of  the  vertebral  l)odies  is  very  pronounced.  Another  effect  of  this 
trunk  pressure  is  the  flattening  of  the  posterior  portions  of  the  bocUes  of  the  vertebrae. 
The  body  pressure  also  forces  the  whole  sacrum,  and,  of  course,  the  promontory, 
more  into  the  pelvis;  when  the  sacrum  goes  down,  it  puts  the  iliosacral  ligaments 
on  the  stretch,  and  this  gives  the  posterior  iliac  spines  the  tendency  to  approach 
each  other.  This  would  be  attended  with  a  separation  of  the  symphysis  were 
this  joint  loose  (Fig.  571).  Let  us  call  this  tendency  of  the  innominate  bones  to 
separate  at  the  pubis,  because  of  the  iliosacral  ligaments  tugging  at  the  posterior 
spines,  "transverse  tension."  A  marked  tension  posteriorly  with  soft  bones,  but 
fast  symphysis,  would  result  in  the  approach  of  the  symphysis  to  the  promontory. 
But  this  is  counteracted  by  the  pressure  of  the  heads  of  the  femora  in  the  acetabula, 


Fig.  570. — Pelvis  of  NEw-noRN  Girl  (Northwestern  University 
Medical  School). 


ANOMALIES    OF   THE    BONY    PELVIS 


G53 


which  forces  the  honos  upward  aii<l  iiiwai'd.      Let   us   call   this   pressure  "lateral 
lircssiur"  (Figs.  571  and  572). 

Tran-sverse  tension  would  he  increased  by  the  active  growth  of  the  sacrum  in 
the    l)i-eadth.     T.ateral    pressure   would    l)e    increased   hy   the  carrying  of  heavy 


Fig.  571. — Diagr.wi  to  Illustrate  Transverse  Tension  and  Lateral  Pressure. 
a,  o,  a,  Trunk  pressure;    b,  h,  drawing  together  of  posterior  superior  spines;    c,  c,  c,  tendeney  of  ilia  to  part;  d,  d, 
transverse  tension  or  thrust,  the  result  of  c,  c,  c,  c;  e,  e,  e,  resultant  flattening  of  pelvis;  /, /,  lateral  pressure  exerted  by 
the  femora,  wliich  tends  to  counteract  d,  d. 


Fig.  572. — Diagram  to  Illu.strate  -Vction  of  Trunk  Pressure  in  Caus.\tion  of  Flat  Pelvis.     (Lettering  same 

as  Fig.  571.) 
The  weight  of  the  trunk  falls  on  the  sacrum,  as  is  indicated  by  the  arrows  a,  a,  a.  .\s  a  result,  the  sacrum,  which 
has  no  wedge  action,  tends  to  fall  downward  and  inward  into  the  plane  of  the  inlet.  This  tendency  is  resisted  by  the 
stout  sacro-iliac  ligaments,  h,  b,  and  the  posterior  superior  spines  of  the  ilia,  to  which  they  are  attached,  tend  to  come 
together.  If  the  pubic  joint  were  open,  as  in  Fig.  572,  the  rami  pubis  would  tend  to  separate  more  and  more,  a  condi- 
tion which  is  actually  observed  in  the  rare  cases  of  split  pelvis.  Since  the  symphysis  prevents  the  divulsion  of  the  ends 
of  the  pubes,  the  resultant  of  all  the  forces  is  to  cause  the  symphysis  to  approach  the  promontorj'.  To  a  certain  extent 
the  lateral  inward  pressure  exerted  by  the  femora,  /,  /,  counteracts  this  flattening  action  of  the  trunk  pressure. 


654  THE    PATHOLOGY    OF    LABOR 

weights  during  the  formative  period.  All  these  mechanical  results  would  be  exag- 
gerated if  the  resistance  of  the  bones  and  cartilages  were  reduced,  as  in  rachitis 
and  osteomalacia,  or  removed,  as  in  split  pelvis. 

jMuscular  action  has  a  decided  influence  on  the  formation  of  the  pelvis;  for 
example,  the  outward  rolling  of  the  lower  edges  of  the  descending  rami  pubis  is 
probably  due  to  traction  by  the  adductores  femoris. 

A  harmonious  operation  of  all  the  above  factors  is  necessary  for  the  production 
of  the  normal  pelvis,  and,  in  the  study  of  the  pathologic,  we  shall  see  how  abnormal 
tendencies  of  gro^vth,  abnormal  application  of  the  body  pressure,  reduced  resis- 
tances, disease  of  the  bones  and  joints,  etc.,  produce  distorted  pelves. 

Classification. — Scientifically,  the  best  way  to  classify  abnormal  pelves  would 
be  accorcUng  to  their  etiology  or  pathology.  Kolisko  presents  12  different  systems, 
proposed  by  various  German,  English,  and  French  authors  since  1840,  but  admits 
that  all,  including  his  own,  are  unsatisfactory.  This  is  because  the  genesis  and 
pathology  of  most  of  the  pelves  is  either  unknown  or  not  universally  agreed  upon, 
so  that  they  can  be  given  a  settled  place  in  any  classification,  and,  further,  a  system 
that  would  suit  the  anatomist  would  not  aid  the  obstetrician  in  his  daily  practice. 
The  latter  would  prefer  a  system  based  upon  the  dimensional  and  morphologic 
characters  of  pelves,  because  these  are  what  he  has  to  consider  at  the  bedside. 
Litzmann,  in  1861,  proposed  such  a  classification,  and  nearly  all  obstetric  writers 
since  have  adopted  it,  at  least  as  a  basis  for  their  presentment  of  the  subject. 

Litzmann's  System 

I.  Pelves  with  normal  shape,  but  either  too  large  or  too  small: 

Pelves  sequabiliter  justomajor  and  justominor. 

II.  Pelves  with  abnormal  shape: 

(a)  Flat  pelvis. 

1.  Simple. 

2.  Rachitic. 

3.  Generally  contracted,  flat  pelvis. 

(b)  The  transversely  contracted  pelvis. 

(c)  Irregularly  contracted  pelvis. 

1.  The  scoliotic. 

2.  The  coxalgic. 

3.  Amputation. 

4.  Dislocation  of  femur. 

5.  Asymmetric  sacrum,  as  the  Naegele  pelvis,  tubercular  hip  disease,  etc. 

(d)  Crushed  together  pelves,  the  osteomalacic  and  pseudo-osteomalacic  pelves. 

Schauta's  System 
I.  The  re.sults  of  developmental  anomalies. 

1.  Generally  contracted,  not  rachitic,  pelvis. 

(a)  Infantile  pelvis. 
(6)   Masculine  pelvis, 
(c)  Dwarf  pelvis. 

2.  Simple  flat,  not  rachitic,  pelvis. 

3.  Generally  contracted  flat,  not  rachitic,  pelvis. 

4.  Funnel-shaped  pelvis,  fetal  type. 

5.  Insufficient  development  of  one  wing  of  the  sacrum  (Naegele). 

6.  Insufficient  development  of  two  wings  of  the  sacrum  (Robert). 

7.  The  generally  too  large  pelvis  (justomajor). 

8.  The  split  pelvis.    Absence  of  closure  of  the  symphysis  pubis. 

II.  Anomalies  the  result  of  diseases  of  the  pelvic  bones. 

1.  Rachitis. 

2.  Osteomalacia. 

3.  Neoplasms. 

4.  Fracture. 

5.  Atrophy,  caries,  and  necrosis. 

III.  Anomalies  of  the  pelvic  joints, 
(a)  Synostosis  of  one  or  more. 
(6)  Softening  of  one  or  more. 

IV.  Anomalies  cau.sed  by  diseases  of  the  trunk. 

1.  Spondylolisthesis. 

2.  Kyphosis. 

3.  Scoliosis. 

4.  Kyphoscoliosis. 

5.  Assimilation. 


Fig.  578.— Obliquely  contracted  pelvia. 


Fig.  579. — Crowded  together  pelvis. 


Figs.  573-579. — Di.\c.r.vms  to  Show  the  V.\rieties  of  Deformed  Pelves,  all  Dr.\wn  from  Specimens  of  the 
Northwestern  University  Medical  School. 

655 


656  THE    PATHOLOGY    OF   LABOR 

V.  Anomalies  the  result  of  diseases  of  the  supports  of  the  pelvis. 

1.  Coxitis. 

2.  Dislocation  of  one  or  both  femora. 

3.  Club-foot. 

4.  Absence  or  inefficiency  of  one  or  both  legs. 

TaRNIER. — BUDIN. — BONNAIRE. 

I.  Deformities  due  to  excess  of  malleability  of  the  bony  tissue, 
(o)  Rachitic  pelvis. 

(b)  Flat,  non-rachitic  pelvis. 

(c)  Osteomalacic  pelvis. 

II.  Anomalies  in  the  application  of  the  spinal  pressure. 

(a)  Lordotic  pelvis. 

(b)  Scoliotic  pelvis. 

(c)  Kyphotic  pelvis. 

III.  Anomahes  from  displacement  of  the  spinal  column,  spondyloUsthetic  and  spondy- 

lolizematic  pelves. 

IV.  Anomalies  due  to  misapplication  of  femoral  counterpressure. 
(a)  Unilateral  lameness. 

(6)  Bilateral  lameness. 
V.  Anomahes  of  the  initial  development  of  the  bones  of  the  pelvis, 
(a)  General  large  and  small  pelves. 
(6)  Local  and  asymmetric,  oblique  oval  pelves. 

(c)  Local  and  symmetric,  double  oblique  oval,  split  pelvis,  arrest  of  development  of 
sacrum,  etc. 
VI.  Atypical  deformities,  as  tumors,  fractures. 

It  must  be  remembered  that  several  causes  can  combine  to  produce  a  pelvis 
which  may  be  fitted  into  no  classification — for  example,  a  child  born  with  a  dis- 
location of  one  hip  becomes  rachitic,  or  a  rachitic  child  develops  a  tubercular  hip, 
etc.  If  the  deforming  disease  appears  late  in  fife,  the  pelvis  is  altered  in  a  way 
differing  from  that  resulting  from  early  changes;  variations  in  degree  of  deformity, 
also  of  location,  occur,  and  these,  with  many  other  factors,  sometimes  produce 
pelves  of  most  bizarre  shapes  and  irregular  sizes. 

Too  Large  Pelves. — Dystocia  may  arise  from  the  pelvis  being  too  large,  and 
usually  this  is  found  in  large  women,  but  as  these,  as  a  rule,  have  big  babies,  the 
proper  proportion  is  reestablished.  Often  enough  a  large,  apparently  well-built 
woman  will  have  a  difficult  delivery,  even  resulting  in  the  death  of  the  child,  and 
on  investigation  the  accoucheur  is  surprised  to  find  a  large  inlet,  but  with  a  small 
pelvic  outlet,  that  is,  a  large  funnel-shaped  pelvis.  If  the  pelvis  is  too  large,  all 
the  diameters  exceeding  the  normal  by  2  cm.  or  more,  the  mechanism  of  labor  may 
be  influenced.  During  pregnancy  the  head  sinks  low  down  and  causes  pressure 
symptoms  in  the  bladder  and  rectum.  In  labor  the  soft  parts  are  exposed  to  the 
full  force  of  the  powers,  and  often  tear  or  stretch  too  much,  permitting  the  rapid 
exit  of  the  fetus.  Subsequent  relaxation  of  the  pelvic  floor  and  prolapse  of  the 
uterus  may  result.  Flexion  and  rotation  of  the  head  are  not  so  marked,  and  occi- 
pitoposterior  positions  are  common — all  of  which  rnay  cause  serious  dystocia  if  not 
promptly  recognized.  It  has  seemed  to  the  author  that  such  women  have  a  tendency 
to  postpartum  liciiKjrrhago. 

Anomalies  of  pelvic  inclination  may  cause  dystocia  by  influencing  the  direction 
of  the  uterine  axis.  Engagement  of  the  head  may  be  delayed  by  too  great  incli- 
nation, and  the  pelvic  floor  is  endangered  by  the  direct  pressure  of  the  head 
when  the  outlet  lies  in  a  way  to  receive  the  full  force  of  the  uterine  action.  On  the 
living  it  is  very  difficult  to  measure  the  pelvic  inclination,  except- with  Neuman  and 
Ehrenfest's  complicated  cliseometer,  but  the  skilful  accoucheur  can  usually  discover 
the  abnormality  if  it  is  causing  dystocia,  and,  by  raising  or  lowering  the  parturient's 
trunk,  bring  the  axis  of  the  uterus  into  parallelism  with  that  of  the  pelvic  canal. 

Literature 

Breus  und  Kolisko:   Die  pathologische  Bcckenformcn.     Five  volumes,  1900-1912. 


CHAPTER  LIV 
CONTRACTED  PELVIS 

Definition  and  Frequency. — Authors  generally  state  that  a  pelvis  which  shows 
a  diniiimtion  of  13  2  to  2  cm.  in  an  important  diameter  should  be  called  contracted, 
but  cHnically  every  pelvis  should  be  so  designated  when  it  is  certain  that  the  anomaly 
has  produced  a  disturbing  influence  on  the  parturient  function.  It  is  also  a  general 
practice,  since  contraction  at  this  point  is  the  most  common,  to  use  the  conjugata 
vera  as  the  determining  diameter,  and  to  say  that  a  pelvis  is  contracted  when  the 
conjugata  vera  is  shortened,  and,  too,  the  degree  of  the  contraction  is  measured  by 
the  amount  of  the  shortening  of  the  conjugata  vera.  Thus  Michaelis,  who  really 
founded  the  scientific  obstetric  study  of  pelves,  placed  the  beginning  of  contracted  pel- 
vis at  a  10  cm.C.  V.in  the  justominor  types,  and  at  9.5  cm.  in  those  of  the  flat  variety. 

Litzmann,  who  published  jMichaelis'  posthumous  Ijook,  proposed  four  grades, 
according  to  the  length  of  the  conjugata  vera,  thus:  If  the  conjugata  vera  was  less 
than  5.5  cm.,  absolute  contraction;  a  second  degree,  from  5.5  to  7.3  cm.,  a  third 
degree,  from  7.4  to  8.3  cm.,  and  a  fourth,  8.4  cm.  to  normal.  Schroder  proposed 
a  simjiler  division.  As  the  shortest  conjugata  vera  which  would  permit  the 
delivery  of  a  normal-sized  child  through  the  natural  passages  6.5  cm.  was  set,  and 
pelves  smaller  than  these  were  called  absolutely  contracted.  If  the  conjugata  vera 
was  from  6.5  to  9  cm.  long,  the  pelvis  was  called  relatively  contracted,  because  a 
living  child  could  be  gotten  through  in  a  large  proportion  of  cases,  and  a  mutilated 
fetus  always.  A  third  grade  took  in  those  with  a  conjugata  vera  from  9  cm. 
to  the  normal,  and  labor  in  these  cases  was  complicated  more  often  l^y  errors 
of  mechanism  than  by  spacial  disproportion  between  head  and  pelvis.  These 
measurements  applied  to  flat  pelves.  In  generally"  contracted  pelves,  since  there  is 
diminution  of  all  the  diameters  and  the  area  of  all  the  planes  is  smaller,  0.5  cm.  is 
to  l)e  added  to  the  upper  limit  of  each  division. 

A  moment's  thought  will  show  how  artificial  and  futile  such,  or  any,  division 
of  pelves  is,  but  for  purposes  of  description  and  discussion  some  standard  must 
ho  used,  and  this  one  is  the  best  of  all  yet  proposed.  The  size  of  the  child,  the 
hardness  and  moldability  of  its  head,  the  presentation,  position,  and  attitude,  all 
make  the  pelvis  smaller  or  larger  as  far  as  the  question  of  spacial  relations  is  con- 
cerned. Add  to  this  the  difficulty  of  measuring  the  pelvis  and  the  inaccuracies 
always  present,  and  it  becomes  apparent  why  authors  vary  so  'much  in  their  esti- 
mate of  the  frequency  of  contracted  pelves  and  in  the  division  into  degrees  or  grades 
of  obstruction. 

In  Germany,  considering  a  pelvis  rontracted  when  tlie  main  diameter  is  IJ^  to  2  cm.  short- 
ened, it  is  estimated  that  from  14  to  20  per  cent,  are  tlius  to  be  designated,  and,  considering 
contraction  to  exist  only  when  serious  dystocia  results,  3  to  5  per  cent.  One  element  of 
irregularity  is  the  lack  of  standardization  of  contracted  pelves. 

One  author  n^ports  all  j^clves  contracted  with  a  conjugata  vera  less  than  10  cm.,  another 
with  less  than  91  2  cm.,  another  uses  the  conjugata  diagonalis  and  calls  all  pelves  contracted  with 
a  conjugata  diagonalis  less  than  11}2  cm.  Another  author  relies  on  the  external  measurements, 
and  we  already  have  shown  how  uncertain  these  are.  Statistics  collected  by  Dohrn  in  1S96  show 
a  total  frequency  varying  from  .5  to  27  per  cent.  In  Austria  a  variation  of  from  2.15  to  16  per  cent. 
exists;  in  Smtzerland,  7.0  to  20.07  per  cent.;  in  Holland.  3.51  to  33  per  cent.;  in  the  United 
States,  11.45  to  25  per  cent.  (Dobbin,  \\iUiams,  Flint,  Davis). 

These  figures  carry  the  stamp  of  unreliability  on  their  faces     INIost  of  them 
were  collected  in  clinics,  to  which  a  large  proportion  of  obstructed  labors  is  brought, 
42  057 


658  THE    PATHOLOGY    OF   LABOR 

which,  of  course,  increases  the  percentage,  and  the  others  are  from  out-maternities, 
in  which  only  those  cases  exhibiting  delay  in  labor  are  accurately  measured,  or, 
practising  among  the  poor,  disclose  a  higher  proportion  of  deformities  than  the  whole 
community  would  show.  In  America  it  is  impossible  to  obtain  accurate  information 
of  the  frequency  of  pelvic  contraction.  In  American-born  women  it  is  undoubtedly 
rare,  many  practitioners  in  such  communities  meeting  hardly  one  or  two  in  a  hfe- 
time's  practice.  JNIilder  degrees,  insufficient  to  provoke  serious  dystocia,  are  per- 
haps unobserved,  the  delay  in  labor  being  ascribed  to  malpositions,  etc.  Among 
our  foreign-born  and  colored  population  high  grades  of  contraction  are  not  infre- 
quently observed,  but  here  again  statistics  furnished  by  the  obstetric  specialist 
and  the  clinic  or  the  hospital  are  useless,  because  the  difficult  labors  are  referred  to 
these  institutions  and  swell  the  percentages. 

Still  greater  uncertainty  exists  regarding  the  frequency  of  the  various  forms 
of  contracted  pelves.  It  seems  to  the  author  that  the  abnormal  pelvis  most  com- 
monly met  with  in  general  practice  is  a  mild  degree  of  the  funnel,  infantile,  or 
masculine  type.  In  consultations  on  obstructed  labor  the  generally  contracted 
has  been  more  frequently  encountered  than  the  flat  type.  Williams  noted  the 
latter  in  one-third  of  the  cases  in  white,  and  two-thirds  in  colored,  women.  In 
Germany  the  simple  flat  and  rachitic  flat  pelves  predominate,  but  even  there  the 
authors  are  not  agreed.     Osteomalacia  is  exceedingly  rare  in  America. 

THE  GENERALLY  CONTRACTED  PELVIS 

Other  names  for  this  type  of  anomaly  are:  Pelvis  sequabiliter  justominor 
(Stein);  pelvis  nimis  parva  (Deventer,  who  first  described  it).  Several  varieties 
are  to  be  considered:  The  simple,  equally  contracted  pelvis,  the  infantile,  the 
masculine,  knd  the  dwarf.  Fig.  580  shows  an  equally  contracted  pelvis.  It  has 
beautiful  lines,  and  is  a  normal  pelvis  in  miniature.  This  pelvis  is  found  in  women 
of  small  stature  and  gracile,  never  in  large  women,  and  is  in  proportion  to  the  rest 
of  the  skeleton.  All  its  diameters  are  shortened,  though  rarely  is  the  relation  of  the 
conjugata  vera  to  the  others  absolutely  correct — usually  a  slight  flattening  exists. 
This  seems  to  indicate  that  perhaps  rickets  had  something  to  do  with  the  produc- 
tion of  the  general  hypoplasia.  Fig.  582  shows  a  justominor  pelvis  of  the  infantile 
or  juvenile  type.  The  inlet  presents  an  anteroposterior  oval;  the  sacrum  is  high 
and  long;  the  pelvic  inclination  marked.  Compare  it  with  Fig.  570,  a  child's 
pelvis.  This  pelvis  is  deep,  and  the  tuberosities  are  close  together,  giving  the 
excavation  a  funnel  shape.  A  woman  bearing  this  pelvis  will  have  narrow  hips, 
the  female  escutcheon  (the  hairy  portion  of  the  mons  veneris)  will  be  long,  narrow, 
and  sparsely  covered,  the  posterior  superior  spines  of  the  ilia  close  together,  the 
rhomboid  of  Michaelis  short  and  narrow,  the  labia  majora  small  and  undeveloped, 
the  same  being  true  of  the  breasts,  and  altogether  the  person  will  show  a  child's 
habitus.  Frigiditas  sexualis,  sterility  or  pregnancy  late  in  marriage,  and  other 
general  evidences  indicate  that  the  individual  was  not  completely  developed. 

If  the  bones  are  very  heavy  and  thick,  the  cavity  of  the  pelvis  may  be  en- 
croached upon  and  the  pelvis  may  partake  of  the  characters  of  the  male.  The 
sacrum  is  long  and  narrow,  the  arch  of  the  pubis  high,  the  sides  of  the  pelvis  close 
together,  and  the  inlet  even  an  anteroposterior  oval.  This  masculine  type  of  con- 
tracted pelvis  will  be  again  mentioned  under  funnel  pelves. 

Minor  degrees  of  general  pelvic  contraction  are  very  common — those  with  a 
conjugata  vera  between  9  and  10  cm.  are  moderately  rare,  while  those  Ijelow  9  cm. 
are  almost  always  combined  with  rachitis,  the  dwarf  pelves  alone  showing  a  true 
conjugate  of  7  cm.  or  less. 

Dwarf  pelves  am  vpry  ram  in  this  country.  Breus  and  Kolisko  distinguish  five  varieties 
of  dvvarf;^ : 

1.  The  chondrodystrophic  dwarf,  the  result  of  achondroplasia  fcetalis,  which  formerly  was 


CONTUACTKI)    PELVIS 


659 


The  flattening  is  due  to  iiisutriciciil  (Icvclopiiicnt   of 
(Fig.  584). 

2.  In  the  "true"  dwarl"  pc|\is  tirowlli  ceased  at  an  early  [)eriod  of  life  and  the  pelvis  shows 
it,  the  ossification  of  all  the  pelvic  synostoses  heinn  absent,  and  the  pelvis  itself  retainin^i  infantile 
shape  and  characteristics.     Of  the  two  such  female  dwarfs  known,  Boeckh's  is  llie  one  usually 


Fig.  5S0. — Pelvis  Justominor  (author's  collection). 


Fig.  oSl. — Pelvi.s  .JusTOMixon.     Measurements  of  Fig.  oSO. 


described.     Her  age  was  thirty-one  years,  height,  lOS  cm.,  conjugata  vera,  S.6;  transverse  diam- 
eter, 9.5. 

3.  Cretins  often  have  dwarf  pelves.  They  are  characterized  by  general  lack  of  develop- 
ment of  the  bones  and  delay  or  absence  of  ossification  of  many  of  the  epiphyses,  the  latter  point 
difTercntiating  them  from  true  dwarfs,  where  all  the  epiphyses  fail  to  fuse,  even  very  late  in  life. 
A  cretin's  pelvis  is  often  flat,  with  thin  l)ones,  but  thickened  junctions  of  the  ossification  areas; 
the  foramina  are  large,  and  the  sacrum  is  short  and  well  curved.  Other  evidences  of  insufl5cient 
thyroid  secretion  are  always  present. 

4.  Rachitic  dwarfs  are  of  two  kinds — first,  those  showing  general  hj-poplasia  due  to  disease; 
second,  those  reducing  the  size  of  the  individual  by  the  excessive  bending  and  shortening  of  the 
long  bones.  Only  the  first  kind  should  really  be  called  dwarfs,  because  here  the  bones  are  actually 
shorter  and,  in  addition,  bent  in  a  moderate  degree.  The  pelves  of  such  indi\'iduals  come  under 
the  classification  of  generally  contracted  flat  pehis  (q.  v.  Fig.  oSo). 


660 


THE    PATHOLOGY    OF   LABOR 


5.  Hypoplastic  dwarfs  are  persons  whose  whole  skeletal  system  shows  a  quantitative  restric- 
tion in  gi'owth.  This  may  be  combined  with  rickets.  The  author  has  observed  it  in  the  later 
development  of  very  premature  infants. 

Causation  of  Justominor  Pelves. — Little  is  positively  known  about  the  causes 


Fig.  582. — Generally  Contracted  Pelvis.     Infantile  Type  (.Chicago  Lying-in  Hospital  Museum). 


Fig.  58.3. — Measure.ment.s  of  Fig.  582. 


and  their  manner  of  action,  Ijut  those  may  be  mentioned  as  having  some  influ- 
ence: heredity  (small  parents);  prematurity  at  birth;  bottle-feeding;  marasmus; 
improper  hygiene  at  the  time  of  puberty  (overcrowding  the  growing  girl  with 


CONTRACTED    PELVIS 


661 


studies,  social  clcinands,  etc.);  improper  dress.  Four  sisters  in  the  author's  prac- 
tice have  generally  contracted  pelves,  and  symphysiotomy,  induced  labor,  crani- 
otomy, and  forceps  have  been  rendered  necessary  in  their  labors.  Since  the  ovary 
and  thyroid  are  known  to  have  an  influence  on  the  osteogenetic  processes,  we  may 
look  to  tlicir  patlioiotiy  for  the  explanation  (jf  some  of  the  cases. 

Diagnosis  of  Justominor  Pelves.—  All  the  external  pelvic  measurements,  in- 
cluding tlu'  circumference,  are  smaller  than  normal,  but  it  is  not  safe  to  diagnose 
pelvic  contraction  on  these  figures,  l)ecaus(!  the  canal  may,  nevertheless,  be  very 
roomy.     The  stature  of  the  ])ati('nt  is  usually  small,  but  a  large  woman  may  have 


Fig.  5S4. — Pelvis  of  Chondkodtstrophic  Dwarf. 
The  femur  is  nine  inches  long. 


Fig.  5S5. — PsEUDOOSTEOiiAL- 
ACic  (Rachitic)  Dwarf 
(Xorthwcstern  University 
^ledical  School). 


a  heavy  pelvis  of  the  masculine  type,  with  a  much  reduced  lumen.  The  rhom- 
boid of  Michaelis  is  small  and  short.  "Women  with  infantile  pelves  show  other 
evidences  of  hypoplasia — small  face,  small  breasts,  long  thorax,  visceroptosis, 
straight  spine,  small  vulva,  narrow  hips,  and  generally  one  gets  the  impression 
as  of  a  grown-up  child.  Dysmenorrhea,  sterility,  and  neurasthenia  are  frequent 
symptoms. 

On  the  internal  examination  the  general  reduction  of  all  the  diameters  will 
make  the  diagnosis,  and  only  on  these  may  reliance  be  placed.  The  sides  of  the 
pelvis  are  very  easily  reached  with  two  fingers,  and  one  can  often  palpate  the  linea 
terminalis  throughout  its  entire  length.  The  spines  of  the  ischia  are  close  together; 
the  tuberosities  usually  still  closer,  and  the  arch  of  the  pubis  narrow^ 


662 


THE    PATHOLOGY    OF    LABOR 


The  Flat  Pelvis  (Pelvis  Plana)  (Fig.  586). — This  is  a  pelvis  contracted  in  the 
anteroposterior  diameters,  and  many  authors  distinguish  two  kinds — the  simple  flat 
and  the  rachitic  flat.  The  writer  is  inclined  to  the  opinion  expressed  by  Ahlfeld  and 
Sellheim,  Breus  and  Kolisko,  that  the  so-called  ''simple  flat"  pelvis  is  really  rachitic 
in  origin.  The  absence  of  the  characteristic  rachitic  landmarks  on  the  pelvis  induced 
Betschler,  who  first  described  it,  and  Michaelis  to  separate  it  from  those  of  known 
rickety  origin.  It  was  believed  that  the  carrying  of  heavy  weights  in  early  childhood 
or  putting  the  child  too  early  on  its  feet  caused  the  simple  flattening  of  the  pelvis, 
but  in  all  probability  the  cause,  if  not  due  to  rickets,  will  be  found  in  the  abnormal 


Fig.  5S6. — Simple  Flat  Pelvis   (author's  collection). 


Fio.  5S7. — Simple  Flat  Pelvis. 


tendency  of  growth  of  the  bones.  In  all  respects  save  two  the  simple  flat  pelvis 
looks  like  a  normal  one — the  sacrum  has  sunk  downward  and  forward,  giving  the 
inlet  a  broad,  kidney-shaped  outline,  and  the  pelvic  cavity  also  is  slightly  flattened. 
Schroder  says  this  pelvis  never  is  highly  contracted,  and  that  it  is  very  frequent 
in  Germany.  There  is  no  widening  of  the  outlet,  and  the  distance  between  the  an- 
terosuperior  spines  bears  the  usual  relation  to  that  between  the  crests.  Among 
the  large  number  of  flat  pelves  of  the  Northwestern  University  Medical  School, 
not  one  could  be  found  that  did  not  at  the  same  time  show  positive  evidences  of 
rachitis.     Flat  rachitic  pelves  are  not  rare  in  any  obstetric  museum  (Fig.  588). 


CONTRACTED    PELVIS 


663 


Piorro  Dionis  (1724)  first  called  attention  t<;  the  association  of  rachitis  in  child- 
hood with  tiie  flat  pelvis. 

Rachitic  flat  pelves  are  usually  smaller  than  normal  ones  because  the  bones 


Fig.  oSS. — Rachitic  Fl.\t  Pelvis  (Northwestern  University  Medical       Fig.  589. — S.vgittal  Skction  of  Fl.\t  R.\ch- 
School  Museum;.  itic  Pelvis. 


Fig.  590. — Rachitic  Fl.\t  Pelvis,  Viewed  from  Below. 
Shows  large,  flaring  outlet. 


664 


THE   PATHOLOGY   OF   LABOR 


are  smaller  and  thinner.  Rarely  the  bones  are  heavier.  The  ilia  flare  outward 
and  are  flattened  so  that  the  distance  between  the  anterosuperior  spines  is  equal 
to,  or  greater  than,  the  distance  between  the  crests.  The  pelvic  inclination  is 
increased,  the  pubic  arch  broad,  the  angle  which  the  pubis  makes  with  the  inlet 
obtuse,  the  tuberosities  widely  separated,  and  the  acetabula  look  more  anteriorly 
than  is  normal.  This  peculiar  insertion  of  the  femora  gives  the  patient  a  remarkable 
gait,  the  feet  being  thrown  outward.  The  most  characteristic  changes  are  shown 
by  the  sacrum.  This  bone  is  forced  downward  into  the  pelvic  cavity;  the  con- 
cavity of  its  anterior  face  is  changed  in  both  directions,  so  that  it  becomes  flat, 


Fig.  .501. — Pf;i,vis  nr  Xi;\v-nonx  Girl,  Showin'g  Rachitis 
(Northwestern  University  Medical  Scliool  Museum). 


Fig.  592. — Pelvis  of  Rachitic  Gikl  Aged  Three. 

Had  the  child  lived,  her  pelvis  would  probably  be 

like  Fig.  593. 


and  in  advanced  cases  convex  from  side  to  side,  and  straight  from  above  downward, 
the  bodies  of  the  sacrum  protruding  from  between  the  wings,  and  the  sacrum  being 
bent  on  itself.  A  second,  or  false,  promontory  is  sometimes  found  below  the  true 
one  (Fig.  589).  Important  alterations  result  in  the  shape  and  size  of  the  pelvic 
canal,  most  prominent  of  which  is  the  flattening  of  the  inlet  from  before  backward. 
The  inlet  may  have  the  shape  of  a  kidney,  and  the  highest  degree  of  contraction 
may  exist  in  the  conjugata  vera.  The  transverse  and  oblique  diameters  may  be 
normal  or  even  larger.  The  true  pelvis  is  shallow,  the  outlet  usually  much  enlarged 
(Fig,  590),  and  this  gives  labor  a  character  different  from  that  in  generally  con- 
tracted pelves.     In  the  latter,  because  the  pelvis  is  usually  uniformly  contracted 


CONTRACTED   PELVIS 


665 


throughout  the  length  of  the  canal,  the  head  has  to  overcome  resistance  all  the  way 
down,  while  \vitii  the  flat  pelvis,  after  the  inlet  has  once  })een  passed,  the  rest  of 
the  distance  is  (luickly  and  easily  traversed.  Rachitic  pelves  often  show  exostoses 
on  the  posterior  surface  of  the  symphysis  pubis.  One  of  my  cases  had  such  a  bony 
crest  8  nun.  high. 

Mechanical  factors  have  bcon  invoked  to  explain  the  formation  of  the  rachitic  pelvis,  but 
one  must  not  forget  that  tlie  inherent  tendencies  of  growth,  perverted  by  the  disease  of  the  bone, 
may  have  much  to  do  with  it.  When  th(;  rachitic  child  sits  or  stands,  the  trunk  pressure  forces 
the  sacrum  downward  into  the  pelvis,  tilting  the  promontory  forwarrl,  increasing  the  transver.se 
tension,  and  drawing  tlie  pui)ic  symj)liysis  backward,  as  is  shown  in  tlie  diagram  (^Fig.  .571). 
The  lower  end  of  the  sacrum  may  not  reced(>  backward  because  of  the  strong  sacrosciatic  ligaments; 
the  sacrum,  therefore,  is  bent  in  its  lower  portion,  and  the  bony  edge  of  tlie  sciatic  notch  and  the 
spine  of  the  ischium  are  much  developed.  The  lateral  pressure  of  the  heads  of  the  femora,  acting 
on  the  softened  bone,  tend  to  force  the  acetabula  inward,  as  is  clearly  shown  in  Fig.  .571.  In 
exaggerated  cases  the  pelvis  is  pressed  together  from  all  sides,  as  in  Fig.  .593,  presenting  the  shape 


Fig.  .593. — Pseudo-osteomal,\cic  Pelvis  (Northwestern  University  Medical  School  Mu.scum). 

of  an  osteomalacic  pelvis,  and  is  called  "  pseudo-osteomalacic  pelvis."  That  these  changes  in 
shape  are  not  due  to  the  trunk  pressure  alone  is  proved  by  the  occurrence  of  similar  pelves  in  new- 
born children  (Figs.  591  and  592).  In  rickets  the  osteoid  substance  near  the  epiphyses  remains 
soft  and  unossified  for  a  long  time,  and,  therefore,  the  bone  at  these  points  bends  under  the  influ- 
ence of  the  trunk  pressure  and  muscle  action.  Then,  too,  the  apposition-relations  of  the  various 
ossification  centers  are  disturbed,  and,  as  a  result,  when  the  rachitic  disease  later  abates,  nature 
is  unable  to  restore  the  proper  l)alance  in  the  various  lines  of  ossification.  The  adult  rachitic 
pelvis,  therefore,  is  the  result  of  the  disturbance  of  bony  growth  and  of  the  deformation  of  the 
pelvis  by  misdirected  or  relatively  too  powerful  mechanical  forces. 

Diagnosis. — In  the  routine  history  the  fact  of  delayed  walking  and  dentition- 
illness  when  a  child,  bottle-feeding,  etc.,  may  be  noted.  An  inspection  of  the  whole 
person  ^\ill  not  fail  to  reveal  stigmata  of  rachitis — the  square  head,  distorted 
clavicles,  rachitic  rosary,  bowed  tibiiie  and  femora,  "bow-legs,"  short  and  broad 
hands  and  feet,  etc.  The  spine  is  usually  scoliotic,  ]\Iichaelis'  rhomboid  low  and 
broad — indeed,  it  may  be  a  triangle  instead,  i^ith  the  base  upward.  The  vulva 
is  usually  retroposed  because  of  the  exaggerated  pelvic  inclination.  There  is 
often  so  much  compensatory  lordosis  that  the  hand  can  be  run  under  the  spine 
when  the  woman  lies  on  her  back.  The  area  between  the  thighs  is  broad,  the 
escutcheon  squarer. 


666 


THE    PATHOLOGY    OF    LABOR 


The  characteristic  of  rachitis  is  the  flattening  of  the  pelvis,  and  the  experienced 
accoucheur  may  feel  this  at  once  by  grasping  the  hips  in  both  hands.  The  distance 
between  the  spines  of  the  ilia  is  usually  equal  to,  or  even  more  than,  that  between 
the  crests,  a  fact  which  also  can  be  determined  by  palpation;  the  iliac  bones  flare 
out  and  appear  smaller  than  usual.  Baudelocque's  diameter  is  short,  running 
from  19  do-^Ti  to  153^  cm.,  and  when  scoliosis  exists  too,  the  external  oblique  diam- 
eters are  very  unequal,  but  seldom  is  there  a  difference  of  more  than  3  cm. 

On  internal  examination  will  be  noted  the  shallowness  of  the  pelvic  cavity; 
the  startling  prominence  of  the  sacral  promontory;   the  projection  of  the  ischiatic 


w 


Fig.  594. — Mrs.  S.     ,V-ray  of  Obuquely  Contracted  II.vchitic  Pelvis. 


spines,  with  the  tense  sacrosciatic  ligaments;  the  possibility  of  palpating  the  linea 
terminalis  all  the  way,  and,  near  the  sacrum,  its  sharp  bend  forward ;  the  presence 
of  an  exostosis  on  the  posterior  wall  of  the  pubis;  the  low  and  broad  pubic  arch, 
with  distant  tuberosities  of  the  ischia;  the  flat  or  even  convex  sacrum  when  pal- 
pated from  side  to  side  and  from  above  downward  (but  here  one  may  note  that  the 
lower  third  of  the  bone  is  sharply  incurved) ;  and  the  reduced  conjugata  diagonalis. 
It  is  the  rule  to  deduct  2  cm.  from  the  length  of  the  diagonal  conjugate  to  obtain 
the  true  conjugate,  but  this  is  not  always  reliable.  If  the  angle  which  the  symphysis 
makes  with  the  inlet  is  very  obtuse;    if  the  pubis  is  very  high;    if  there  is  a  high 


CONTRACTED    PELVIS  667 

exostosis  or  bony  ridge  on  Ihc  posterior  surface  of  the  pubic  joint — it  may  be 
necessary  to  deduct  3  cm.  Fig.  504  sliows  an  x-ray  picture  of  a  rachitic  pelvis. 
It  is  of  more  scientific  interest  than  practical  use.  The  information  it  gives  was 
more  easily  obtainal)le  by  palpation. 

Finally,  the  course  of  the  labor  will  often  disclose  the  nature  of  the  pelvic  con- 
traction, but  this  will  again  be  discussed. 


THE  GENERALLY  CONTRACTED  FLAT  PELVIS 

When  rachitis  is  very  severe  and  prolonged,  the  bony  growth  is  so  stunted  that 
the  pelvis  does  not  attain  to  normal  size.  Added  to  this  insufficient  development 
are  the  deformations  of  the  pelvic  bones,  the  sinking  down  of  the  sacrum,  etc., 
all  of  which  combine  to  produce  the  generally  contracted  and  flat  pelvis.     We  find 


Fig.  595. — Generally  Contracted  and  Flat  Pelvis. 
Conjugata  vera,  5.3  cm.  (Northwestern  University  Medical  School  Museum). 

the  smallest  pelves  in  this  class,  and  the  inlet  may  be  so  narrowed  that  it  will  hardly 
let  a  six  months'  fetus  pass  through  (Fig.  595) .  Rachitic  dwarfs  have  such  pelves, 
and  in  the  chondrodystrophic  dwarf  pelvis  of  the  author's  collection  much  flattening 
exists. 

OBLIQUELY  CONTRACTED  PELVES 

A  perfectly  symmetric  pelvis  is  a  great  rarity — as  rare  as  a  perfect  face  or 
head.  One  oblique  diameter  is  always  a  little  larger  than  the  other.  When  this 
difference  in  size  of  the  two  halves  of  the  inlet  is  marked,  we  speak  of  an  obliquely 
distorted  pelvis.  Several  varieties  are  to  be  described,  but  the  general  efTects  of 
such  pelves  on  pregnane}^  and  labor  are  about  the  same. 

The  most  common  of  the  obliquely  contracted  pelves  is  the  result  of  scoliosis 
of  the  vertebral  column,  and,  of  the  various  forms  of  scoliosis,  the  rachitic  causes 
the  most  marked  alterations  in  the  pelvis.  JNIuch  depends  on  the  location  of  the 
curvature,  because  if  it  is  high  up,  compensation  takes  place  below%  and  the  effect 
on  the  pelvis  is  hardly  noticeable.  The  rotation  of  the  spinal  column  and  the 
torsion  of  the  vertebra?  are  distinguishable  in  the  sacrum  when  the  deformity  is 
located  low  down.  Another  point  is  that  the  pelvic  asjmimetry  may  cause  the 
scoliosis.      Fig.  596  shows  a  pelvis  with  simple  scoliosis,  probably  due  to  muscular 


668 


THE    PATHOLOGY    OF   LABOR 


weakness.     Only  the  slight  flattening  indicates  the  possible  rachitic  origin.     Mild 
cases  of  such  scoliosis  are  not  uncommon,  but  very  rarely  do  they  give  rise  to 


Fig.  596. — Asymmetric  Pelvis  Due  to  Scoliosis  from  Mtjsculak  Weakness  (Northwestern  University  Medical 

School  Museum). 


Fig.  597. — Asymmetric  Pelvis  prom  Infantile  Paralysis. 
Al.so  .shows  high  assimilation  (Northwestern  University  .Medical  Scliool  Museum).    Note  difference  in  size  of  femora. 


CONTRACTED    PELVIS 


669 


dystocia.  Fig.  597  shows  a  pelvis  with  a  larf^c  lumen,  hiil  distorted  as  the  result 
of  a  scoliosis  due  to  infantile  rij!;ht  spinal  pai'alysis.  It  is  easy  to  sec  that  the  bones 
of  that  side  are  smaller  than  the  healthy  side. 

Fig.  598  shows  a  pronouncedly  rachitic  ])elvis,  the  flattening  of  the  inlet,  the 
sinking  and  frontal  rotation  of  the  sacrum,  the  development  of  the  spines,  the 
flaring  of  the  ilia,  all  being  well  in  evidence.  Common  to  all  these  pelves  are  these 
points:  (1)  The  inlet  is  smaller  on  that  side  to  which  the  convexity  of  the  lumbar 
scoliosis  points,  this  l)eing  tlue  to  the  fact  that  the  sacrum  is  pushed  over  onto  that 
side,  and,  the  trunk  pressure  being  greater  here,  the  sacrum  sinks  lower;  (2)  since 
the  trunk  pressure  comes  to  bear  on  one  wing  of  the  sacrum  more  than  on  the  other. 


Fig.  598. — Obliquely  Contracted  Flat  Rachitic  Pelvis. 


the  part  of  the  bone  which  suffers  the  pressure  is  less  well  developed,  the  foramina 
are  smaller  and  closer  together,  even  the  iliac  portion  of  the  sacro-iliac  joint  some- 
times taking  part  in  this  atrophy;  (3)  the  pelvis  is  tilted  so  that  the  more  contracted 
side  is  higher  than  the  larger  side;  this  is  due  to  the  fact  that  the  line  of  direction 
of  the  body  falls,  not  through  the  middle  line  of  the  sacrum,  but  to  the  side,  away 
from  the  greatest  convexity  of  the  scoliosis;  this  throws  the  weight  of  the  trunk 
almost  entirely  on  one  leg,  and,  therefore,  this  femur  is  forced  upward,  inward, 
and  Imckward;  (4)  the  sciatic  notch  is  narrowed;  (5)  the  arcus  pubis  points  to  the 
contracted  side;  (6)  the  conjugata  vera  runs  obliquely  backward;  (7)  the  obstetric 
transverse  diameter  is  always  shortened;  (8)  the  oblique  diameters  are  very  un- 
equal; (9)  one  ischial  tuberosity  is  higher  than  the  other. 


670  THE    PATHOLOGY    OF   LABOR 

The  Coxalgic  Pelvis. — Disease  of  tlie  hip-joint  in  infancy  almost  always  leaves 
marked  pelvic  deformity,  but  rarely  does  sufficient  encroachment  on  the  lumen 
result  to  cause  serious  dystocia.  Fig.  600  shows  a  coxalgic  pelvis.  Since  the 
diseased  side  of  the  pelvis  is  painful,  the  patient  throws  all  her  weight  on  the  well 
side,  and,  as  a  result,  the  head  of  the  femur  flattens  this  half  of  the  pelvis  and  the 
whole  pelvic  girdle  is  distorted.  The  bones  of  the  diseased  side  are  smaller  because 
of  atrophy  from  disuse  of  the  muscles,  and,  owing  to  irregular  muscular  and  liga- 
ment traction,  the  diseased  half  of  the  pelvis  is  enlarged  and  pulled  outward.  Since 
the  patient  tries  to  spare  herself  pain  by  keeping  that  leg  off  the  ground,  she  pulls 
up  the  diseased  side  of  the  pelvis,  which,  therefore,  is  higher  than  the  well  side — 
an  action  which  is  aided  by  the  crutch  worn  under  the  corresponding  axilla.  The 
asymmetry  of  the  pelvis  obtains  throughout  the  whole  pelvic  canal,  the  tuberosity 
of  the  ischium  of  the  affected  side  being  usually  drawn  upward  and  outward. 

Similar  pelvic  changes,  but  less  pronounced,  occur  with  tuberculosis  of  the 
knee,  amputation  of  the  thigh,  or  other  disturbance  of  function  of  one  limb. 

Naegele  Pelves. — One  of  the  most  typical  of  this  class  of  pelves — the  obliquely 


Fig.  599. — Measurements  of  Fig.  598. 

contracted — is  that  due  to  disease  of  the  sacro-iliac  joint  and  the  neighboring  por- 
tions of  the  ilium  and  the  sacrum.  F.  C.  Naegele,  in  1839,  first  described  it,  having 
collected  37  cases,  but  it  was  mentioned  by  various  obstetric  writers  long  before 
this,  and  Naegele  found  one  in  an  Egyptian  mummy. 

All  the  findings  of  oblique  contraction,  and  those  due  to  exaggerated  pressure 
of  one  thigh,  are  present  in  this  pelvis,  and  since  one  wing  of  the  sacrum  is  often 
atrophic,  aplastic,  or  even  missing,  in  addition  to  the  distortion  actual  reduction  in 
the  size  of  half  of  the  pelvis  is  present,  and,  what  is  important  from  a  clinical  point 
of  view,  the  narrowing  of  the  pelvic  lumen  extends  down  to  the  very  outlet.  The 
innominate  bone  of  the  affected  side  is  dislocated  upward  and  backward,  while  the 
pubic  joint  is  pushed  to  the  healthy  side.  The  linea  terminalis  of  the  healthy  side  is 
given  an  exaggerated  curve,  being  straightened  on  the  diseased  side.  In  nearly 
all  cases  a  firm  synostosis  is  found  in  the  affected  sacro-iliac  joint,  and  a  sharp 
polemic  was  waged  among  the  students  of  this  pelvis  as  to  whether  this  was  primary 
or  secondary.  Naegele  believed  that,  most  likely,  a  primary  congenital  deformity 
of  the  joint  existed,  and  he  did  not  deny  that  the  entire  change  could  be  due  to 


CONTRACTED    PELVIS 


671 


Fig.  601. — Outlet  of  Coxalgic  Pelvis.     Ankylosis  of  Left  Hip. 

Delivery  is  best  accomplished  by  placing  woman  on  left  side  and  bringing  occiput  up 

over  right  ramus  pubis. 


672 


THE    PATHOLOGY    OF    LABOR 


Fig.  602. — N.\egele  Pelvis.     Osteo-ahthkitic  Type  (Northwestern  University  Medical  School  Museum). 


tio.  HUH. — Left  Coxitis. 
Sketch  at  side  is  from  a  pelvis  almost  identical  with  that  of  the  living  patient. 


CONTRACTKI)    I'KLVIS 


673 


acquired  disoaso.  TTohl  proved  that  the  wins  of  tlie  sacrum  could  be  congenitally 
al)sent,  hut  other  speciineus  were  exliibited  which  siiowed  that  characteristically 
defor-ined  pelves  could  he  jjioduced  by  acquired  disease  of  the  sicro-iliac  joint. 
FiS-  <><)2  shows  a  pelvis  I'roni  the  authoi-'s  collection,  and  it  presents  positive  evi- 
dences of  disease  of  the  sacro-iliac  joint.  Disease  of  the  ri<i;ht  hip-joint  coexists, 
a  point  which  Lit/inann  emphasizes  and  draws  into  the  causation  of  the  Xaegele 
pelvis.  Hreus  and  Kolisko  find  traces  of  ostitis  in  all  so-called  Nae^ele  pelves, 
and  insist  that  the  deformity  is  always  due  to  arthritis,  caries,  or  trauma  of  the 
sacro-iliac  synchondrosis  or  other  portions  of  the  i)elvis.     Pelves  with  congenital 


%nji»^ 


Fig.  004. — Coxalgic  Pelvis. 

Tiltint;    of    the   pelvis   is   shown   by  the  rhomboid   of 

Michaelis. 


Fig.  605. — Simple  Scoliotic  Pelvis. 

Compensation  not  complete,  and  pelvis,  therefore,  tilted 

as  shown  by  rhomboid.     Normal  labor. 


defects  of  the  wings  of  the  sacrum  exist,  but  they  do  not  produce  such  great  de- 
formity of  the  inlet  nor  do  they  show  contraction  of  the  whole  length  of  the  pelvic 
canal,  as  do  these  pelves  with  disease  of  the  sacro-iliac  joints.  Here  the  sacral 
and  iliac  portions  are  wasted,  absorbed,  and  ankylotic.  If  the  disease  occurs  in 
early  life,  the  developmental  portions — the  ossification  centers — are  destroyed, 
and  groT\i:h  of  the  bone,  of  course,  is  rendered  impossible.  Xow  come  the  mechani- 
cal factors,  the  pressure  of  the  trunk,  the  lateral  pressure  of  the  femora,  and  the 
cliaracteristic  changes  are  brought  about. 

Diagnosis. — It  is  usually  easy  to  discover  an  obliquely  distorted  peh-is,  but 
43 


674 


THE    PATHOLOGY    OF   LABOR 


not  SO  easy  to  decide  on  the  actual  pathology  of  it,  nor  on  the  degree  of  spacial 
contraction.  Attention  may  be  called  to  the  deformity  by  an  uneven,  limping 
gait,  a  scoliosis,  or  by  the  unequal  length  of  the  legs.  Scars  from  old  sinuses  point 
to  disease  of  the  hip  or  sacro-iliac  joints,  and  the  history  will  usually  show  some 
infantile  disease  or  injury.  Spinal  paralysis,  rachitis,  habit  scoliosis,  coxitis, 
gonitis,  amputation  of  the  leg,  and  spina  bifida,  have  been  the  causes  of  the  asym- 
metry in  the  cases  which  came  under  my  observation,  and  it  was  possible  to  decide  in 
all  of  them  how  the  deformity  was  produced.  Fig.  603  is  a  photograph  from  a 
marked  case  of  coxitis,  and  Fig.  605,  one  of  a  simple  scoliotic  pelvis.     A  rachitic 


^' 


Fig.  G06. — Ktphoscoliotic  Asymmetric  Rachitic  Pelvis.     Cesarean  Section  (x-ray  by  O'Donnell). 


kyphoscoliotic  dwarf  pelvis  is  shown  in  Fig.  006  by  an  a;-ray  picture.  In  addition 
to  the  scoliosis  and  the  apparent  shortening  of  the  leg,  one  will  notice  the  hip  of  one 
side  higher  and  retroposod,  the  pubic  region  displaced  to  one  side,  and  the  hair-line 
oblique.  The  rhomboid  of  Michaelis  is  asymmetric  or  tilted,  and  the  gluteal  fold 
lower  on  one  side.  Palpation  of  the  bones  confirms  the  above  findings,  and,  in 
addition,  discovers  that  the  ischial  tuberosity  of  one  side  is  higher  and  the  ramus  of 
the  pubis  has  a  different  direction  on  that  side.  Examining  first  with  one  hand  and 
then  with  the  other,  it  is  usually  possible  to  distinguish  the  flat  linea  terminalis 
of  one  side  and  the  bowed  arc  on  the  other,  and  the  fact  that  one-half  of  the  pelvis 


CONTRACTED    PELVIS 


675 


is  less  roomy.  External  nieasureinents  Iroin  eorn'spondinp;  points  may  show  a 
discrepancy  between  the  two  sides,  but  it  is  almost  imp(jssible  to  diagnose  the  kind 
of  a  pelvis  from  them.  By  excluding  all  the  other  varieties  we  may  make  a  diag- 
nosis of  a  Naegc'le  pelvis,  and  this  may  be  confirmed  by  finding  the  corresponding 
half  of  the  rhomboid  of  Michai'lis  reduced  in  size,  the  spine  of  tiie  last  hnubar  verte- 
l)ra  lying  close  to  the  posterosujierior  spine  of  the  ilium.  On  internal  examination 
the  corresponding  half  of  the  pelvis  is  very  small  and  the  encroachment  of  the 
ischium  on  the  lumen  persists  even  to  the  outlet.     Ankylosis  of  the  sacro-iliac  joints 


Fig.  607. — A'-ray  of  Left  Coxitis.     Cr.vxioto.my,  First  Labor.     Subsequently  Spontaneous  Delivery. 
Note  general  sniallness  of  outlet,  al.so  reduction  of  space  of  left  side.     Reproduction  has  reversed  the  x-ray  picture. 

may  be  palpated  by  the  fingers  per  vaginam  or  rectum  if  exostoses  and  pericapsular 

thickening  exist. 

After  the  fact  of  pelvic  distortion  has  been  discovered,  the  degree  of  pelvic  con- 
traction must  be  determined. 

A  few  cases  of  dislocation  of  the  ilium  upon  the  sacrum  are  on  record.  It  is 
easily  diagnosed  if  its  existence  is  suspected.  It  causes  persistent  backache, 
difficulty  in  locomotion,  and,  if  it  occurs  in  labor,  occasional  dystocia. 


TRANSVERSELY  CONTRACTED  PELVES 

It  has  been  generally  taught  that  contraction  of  the  superior  strait  is  the  most 
common  of  the  pelvic  deformities,  and  of  these,  anteroposterior  shortening  is  the 
most  important.  From  the  pathologist's  standpoint  this  ma}'  be  true,  but  clin- 
ically the  justominor  and  transversely  contracted  pelves  are  more  commonly  found 
as  the  cause  of  dystocia.  Pelves  much  contracted  transversely'  at  the  inlet  are 
very  rare. 


676 


THE    PATHOLOGY    OF   LABOR 


:\Iild  degrees  of  contraction  are  found  in  the  kyphotic,  the  infantile,  and  some 
varieties  of  high  assimilation  pelves.  Contraction  of  the  pelvic  outlet  is  found  in 
the  funnel  pelvis  and  those  of  the  masculine  type. 


Fig.  608. — Robert's  Pelvis   (after  Robert's  Dubois'  pelvis  in  Paris). 


Fig.    609. — Kyphotic    TRAXsvEnsELv    Contracted    Pelvis 
(N'orthwestcrn  University  Modicul  School  Museum). 


Fig.   CIO. — Left  View  op  Same. 


The  Robert  Pelvis. — Only  10  or  more  of  these,  the  classic  transversely  con- 
tracted pelvis  named  after  Robert,  who  in  1842  first  described  it,  are  in  existence. 
This  deformity  is  due  to  the  same  cause  which  produces  the  Naegele  pelvis,  that 


CONTRACTED    PELVIS 


677 


is,  tin  ostco-aiihritis,  l)ut  a(iin<2;  on  both  sacro-iliac  joints.  Both  sides  of  tlie  pelvic 
cavity  are  coni])n)niis('(l,  and  tiic  inlet  assumes  the  form  of  a  narrow  wedge  CFig. 
608).  The  narrowing  of  the  pelvis  usually  extends  to  the  very  outlet,  and  in  one 
case  described  li\-  Hrcus  and  Kolisko  the  (hstance  between  the  spines  of  the  ischium 
was  only  2  cm. 

The  Kyphotic  Pelvis. — Fig.  609  shows  a  pelvis  contracted  in  the  transverse 
diameter,  and  [jossessing  also  some  of  the  characteristics  of  the  funnel  type.  It  is 
from  a  young  girl,  ossihcal  ion  still  being  incomplete.  If  the  kyphosisissituatedinthe 
upper  part  of  the  spinal  column,  a  compensatory  lordosis  lower  down  restores  the 
line  of  direction  of  gravity  to  its  normal  position  in  the  statics  of  the  person,  and, 
therefore,  the  pelvis  suffers  little,  if  any,  change.  If,  as  in  Fig.  010,  the  knuckle 
or  "giblnis"  is  in  the  luml)ar 
spine,  marked  alteration  of  the 
pelvis  occurs.  The  sacrum  is, 
as  it  were,  drawn  upward  and 
out  of  the  pelvis;  at  the  same 
time  it  rotates  on  a  transverse 
axis  so  as  to  throw  the  promon- 
tory iij)  and  back,  the  coccyx 
forward  and  inward.  As  a  re- 
sult of  the  rotation  of  the  sac- 
rum the  innominate  bones  are 
rolled  around  the  sacral  articu- 
lar surfaces,  so  as  to  bring  the 
ischia  together  and  exaggerate 
the  forward  dip  of  the  crests, 
that  is,  increasing  pelvic  in- 
clination. This  action  is  pro- 
duced by  the  patient  throwing 
her  head  and  shoulders  back  to 
counteract  the  tendency  of  the 
body  to  fall  forward  when  the 
bodies  of  the  vertebrae  soften 
and  break  down  under  the 
tubercular  caries  (Fig.  612). 

The  extreme  pelvic  in- 
clination of  these  pelves  is 
easily  understood.  The  pa- 
tient throws  the  lower  abdo- 


men  forward   and  holds   the      fig.  cii.— normal  statobe, 

1        ,     1  •    1  1,1  1         11  Black;     Kyphosis,    Red. 

chest  high  and  the  shoulders  body  Falls  forward  and 

backward.     Pendulous  belly  is  pixiEXT  ^  tiikows '''hiL^d 

AND  Shoulders  Back. 


Fig.  612. — Shows  Rotation 
OF  Trunk  on  Hip-joints, 
WITH  Backward  Propul- 
sion of  Promontory  and 
Forward  Movement  of 
Lower  Sacrum. 


more  marked  in  these  women 
than  in  all  others. 

If  the  caries  of  the  vertebrae  is  in  the  lowest  lumbar  or  in  the  first  sacral  verte- 
bra, the  upper  arm  of  the  knuckle  comes  to  lie  over  the  inlet,  roofing  it  over — spon- 
dylolizema,  as  Herrgott  called  it,  or  pelvis  obtecta,  a  better  term,  offered  by  Fehling. 
While  the  inlet  may  be  large,  the  spinal  column  roofs  it  over  so  that  the  head  cannot 
gain  entrance  to  the  pelvic  canal. 

The  Funnel  Pelvis. — When  the  lumen  of  the  pelvis  grows  smaller  from  the 
inlet  to  the  outlet,  we  speak  of  fuimel  pelvis.  ^lost  pelves  of  the  generally  con- 
tracted type  belong  in  this  class,  as  do  also  several  of  the  other  varieties  already- 
considered — the  kyphotic,  the  Naegele,  the  Robert's,  and  some  of  the  rachitic. 
The  causes  of  the  convergence  of  the  pelvic  bones  toward  the  outlet  cannot  always 


678 


THE    PATHOLOGY    OF   LABOR 


be  determined.  Fig.  613  shows  a  pelvis  normal  in  every  other  particular,  but  the 
sacrum  and  the  ischial  portions  of  the  innominates  converge  toward  the  outlet. 
Women  of  masculine  habitus,  who  have  large,  leonine  features,  hirsuties,  a  tendency 
to  firm  obesity,  and  who  are  often  sterile,  frequently  have  heavy  bony  funnel  pelves. 
Infantilism  of  the  genitalia  sometimes  is  associated  with  funnel  pelvis.  Williams 
emphasizes  the  frequency  of  high  assimilation  as  a  cause  of  funnel  pelvis,  and  my 
own  observation  tends  to  confirm  this  view. 

High  degrees  of  funnel  pelvis  are  exceedingly  rare,  but  moderate  contraction 
of  the  outlet  is,  in  the  author's  experience,  a  pelvic  deformity  very  commonly  met. 
True  this  is  not  usually  recognized,  the  dystocia  being  ascribed  to  some  anomaly 
of  the  soft  parts  or  of  the  presentation  and  position,  the  size  of  the  fetus,  or  weak- 
ness of  the  powers  of  labor.  Without  doubt  many  of  the  forceps  operations  per- 
formed for  delay  in  the  second  stage  are  necessitated  by  contraction  of  the  bony 
pelvic  outlet. 

Diagnosis. — Funnel  pelvis  of  the  kyphotic  type  is  easily  recognized — the  gibbus 
low  do"UTi  in  the  back  will  point  to  it.     Not  so  easy  is  the  recognition  of  the  mascu- 


FiG.  G13. — Funnel  Pelvis  (author's  collection). 


line  pelvis,  and  the  attendant  is  usually  only  apprised  of  the  latter's  existence  when 
a  stop  in  the  labor  occurs  with  the  head  low  down  in  the  pelvic  canal.  If  in  the 
routine  pregnancy  examination  the  accoucheur  will  take  care  to  palpate  the  descend- 
ing rami  of  the  pubis  as  in  Fig.  275,  p.  245,  and  measure  the  distance  between  the 
tuberosities,  as  in  Fig.  273,  such  surprises  will  come  to  him  very  seldom.  During 
labor,  if  the  palpation  of  the  side  walls  of  the  parturient  canal  does  not  indicate 
narrowing,  the  pelvimeter  used  as  in  Fig.  269  will  give  positive  information.  A 
masculine  pelvis  may  be  looked  for  if  the  patient  is  large,  with  a  tendency  to  firm 
adiposity,  with  large  leonine  features,  and  hirsuties  of  the  face.  Often  such  women 
are  married  late,  are  sterile  for  many  years,  have  frigiditas  sexualis,  early  meno- 
pause, and  often  develop  fibroids.  If  they  do  become  pregnant,  it  is  often  the  only 
reproductive  effort  (single  child  sterility),  for  which  reason  special  care  should  be 
exerted  to  preserve  the  child. 

Schauta  found  funnel  pelves  in  about  6  per  cent.,  Stocker  in  about  26  per  cent., 
and  Klien  in  24  per  cent.,  of  the  cases  examined. 


CONTRACTED    PELVIS 


679 


Assimilation  Pelves. — In  the  (•iiil)r\'()  t  lie  iliac  hones  (Icvclo])  in  the  rogion  of  the 
twcnty-fiftii  to  the  twenty-ninth  sijiniU  vci'tchnc,  which  five  vcrtchric  later  are  fused 
together  to  form  the  sacrum.  The  sacro-iliac  joint  is  usually  made  with  the  twenty- 
sixth  spinal  vertebra  at  first,  but  soon  the  twenty-fifth  and  twenty-seventh  are  in- 
volved. If  the  iliac  bones  are  united  with  vertebrae  higher  up  in  the  s))inal  column, 
for  example,  the  twenty-fourth,  twenty-fifth,  and  twenty-sixth,  we  will  find  the  sa- 
crum long  and  narrow,  and  the  first  sacral  vertebra  presenting  the  characteristics  of 
the  last  lumbar.  The  last  luml)ar  vertebra,  therefore,  seems  to  be  "assimilated" 
with  the  sacrum,  and  such  a  pelvis  is  called  "upper  assimilation  pelvis" — upper, 
Ijccause  the  union  of  the  ilia  with  the  spinal  column  is  higher  up  than  normal. 

If  the  union  of  the  ilia  with  the  sjiinal  colunm  occurs  with  the  twenty-sixth, 
twenty-seventh,  and  twenty-eighth  vertebrae,  we  find  a  short,  usually  Inroad  sacrum, 
and  the  last  lum))ar  vertebra  having  many  of  the  characteristics  of  the  first  sacral. 


Fig.  G14. — High  Assimilatiox  Pelvis.     Round  In'let. 
Drawn  from  a  specimen  Professor  Kolisko  gave  to  the  author. 


The  last  lumbar,  the  twenty-fourth,  seems  to  be  assimilated  with  the  sacrum,  and 
such  a  pelvis  is  called  a  "lower  assimilation  pelvis" — lower,  because  the  union  of 
the  ilia  with  the  spinal  column  is  lower  than  normal. 

In  many  instances  the  insertion  of  the  ilium  is  normal  on  one  side  and  higher  or 
lower  on  the  other,  asymmetric  assimilation  pelvis  resulting.  Only  half  of  the  last 
luml)ar  vertelira  then  goes  to  help  make  up  the  sacro-iliac  joint.  Scoliosis  is  a 
frequent  result  of  this  dcformit}'.  Unless  one  has  the  whole  spinal  column  for 
study,  it  may  be  difficult  to  determine  where  the  assimilation  occurred.  Indeed, 
in  many  cases  it  is  not  easy  to  recognize  the  deformity. 

Sometimes  the  coccyx  is  assimilated  with  the  last  sacral  vertebrce.  This  is 
of  little  practical  importance.  Perhaps  fracture  of  the  cocc^-x  is  more  common, 
and,  too,  since  assimilation  sometimes  causes  fminel  and  transversely  contracted 
pelvis,  the  delay  in  labor  at  the  outlet  may  be  prolonged  by  the  abnormal  bony 
formation,  which  latter,  too,  predisposes  to  fracture. 


680 


THE    PATHOLOGY    OF   LABOR 


Breus  and  Kolisko,  of  Vienna,  to  whom  we  are  indebted  for  the  most  thorough 
study  of  these  pelves,  distinguish  five  kinds:  (1)  The  high  assimilation  pelvis;  (2) 
the  transversely  contracted;  (3)  the  midplane  contracted;  (4)  the  low;  (5)  the 
asymmetric.     The  terms  high  and  low  have  nothing  to  do  with  the  site  of  the  union 


Fig.  615. — Transversely  Contracted  Assimilation  Pelvis  (Breus  and  Kolisko). 


Fig.  G16. — Midplane  Contracted  Assimilation  Pelvis  (Breus  and  Kolisko). 

of  the  pelvic  girdle  with  the  spinal  column,  that  is,  upper  or  lower  assimilation,  but 
refer  to  the  height  of  the  pelvic  canal. 

Fig.  614  shows  a  high  assimilation  pelvis,  which,  with  those  of  Figs.  615  and 
616,  they  kindly  presented  to  me.     Its  characteristics  are:  a  very  high  promontory, 


CONTRACTED    PELVIS 


681 


lon<i;  suciuni,  coiiiposcd  almost  al\v;i\'s  of  six  vciichra' and  with  five  sacral  loraininu, 
tiic  first  of  which  may  lie  above  the  plane  (jf  the  inlet;  almost  ])er])eii(licular  winj^s 
of  the  sacrum,  which  are  thin;  i)elvic  canal  deep,  conjugata  vera  lengthened,  con- 
jugata  transversa  sometimes  shortened. 


Fig.  017. — Low  Assimilatiox  Pelvis  (Breus  and  Kolisko). 


Fig.  (US. — A'-RAY  of  Probable  Partial  U.\"ii„vteral  Assi.mil.\.tiox   (case  of    Dr.   F.  Johnson,  at    Michael  Reese 

Hospital). 


Fig.  615  shows  a  transversely'  contracted  assimilation  pelvis  from  the  same 
source.  The  promontory  is  very  high,  and  another,  or  double,  exists.  The  sacrum 
is  long  and  narrow,  the  wings  being  poorl}'  developed,  and  the  transverse  contrac- 


682 


THE    PATHOLOGY    OF   LABOR 


tion  may  continue  downward  to  the  outlet,  giving  this  pelvis  a  funnel  shape  or 
masculine  type. 

Fig.  616  is  one  of  Breus  and  Kolisko's  midplane  contracted  assimilation  pelves. 
The  forward  prominence  of  the  sacrum  is  evident,  and  this  causes  a  shortening  of 
all  the  sagittal  diameters,  especially  that  of  the  second  parallel  of  Hodge.  This 
pelvis  has  two  promontories,  and  the  uppermost  sacral  vertebra,  carrying  the  sacral 
foramina  with  it,  seems  to  be  bent  backward,  to  get  into  alinement  with  the  lumbar 
spine.     All  these  pelves  have  extreme  inclination  to  the  horizontal. 


Fig.  019. — Chiaki'.s  Spondylolisthetic  Pelvis  (Breus  and  Kolisko). 


Fig.  617  shows  a  low  or  shallow  assimilation  pelvis;  its  promontory  is  very  low 
and  prtjjccts  forward,  the  pelvis  being  shallow,  but  roomy. 

Fig.  597  (p.  668)  shows  an  asymmetric  assimilation  pelvis  from  the  author's 
collection.  It  was  combined  with  scohosis.  Since  the  pelvic  lumen  is  not  seriously 
encroached  upon  in  the  assimilation  pelves,  much  practical  importance  is  usually 
not  attributed  to  this  deformity  by  most  authors.  I  am  convinced,  however,  that 
many  of  the  lesser  irregularities  of  labor,  such  as  occipitoposterior,  occipitosacral 
positions,  arrest  of  rotation  in  the  midplane;,  deep  transverse  arrest,  extensive 
pelvic  floor  lacerations,  etc.,  are  due  to  the  irregular  shape  of  the  pelvic  canal  pro- 
duced by  these  peculiarities.     Transverse  contraction  can  be  so  pronounced  as  to 


CONTRACTED    PELVIS 


G83 


cause  rcul  dystocia,  aiitl  if  I  he  child  is  l:irjj;;c,  it  may  die  in  delivery  or  even  craniotomy 
may  be  re(iuired. 

Diagnosis. — It  ma}'  Ije  possible  to  feel  six  sacral  vertebra;  in  exceptionally 
favorable  cases,  but  usually  the  diagnosis  of  assimilation  pelvis  on  the  living  is 
only  a  surmise.  When  distinct  narrowing  of  the  outlet  exists  and  signs  of  infan- 
tilism are  absent,  one  may  suspect  that  such  deformit}^  exists.  A  very  high  or 
double  promontory  with  normal  measurements  is  suggestive,  and  a  scoliosis  which 
has  no  other  apparent  cause  may  also  lead  one  to  think  of  assimilation.  The 
.T-ray  might  discover  it  (Fig.  618). 

Spondylolisthetic  Pelvis. — Kilian,  in  1854,  first  named  this  pelvis,  the  term 
being  dei-i\-e(l  from  the  ( li-eek,  which  means  a  sliding  of  the  vertebra.  F.  L.  Neuge- 
bauer  is  entitled  to  the  greatest  credit  for  his  thorough  investigations,  and  many 
monographs  have  placed  the  subject  in  a  very  clear  light. 

The  essential  feature  of  this  pelvis  is  a  sliding  of  the  body  of  the  last  luml)ar 
vertebra  over  the  first  sacral  and   into  the  pelvis,  carrying,  of  course,  the  spinal 


Fracture   lino 


Upper  articu- 
lar process 


Loft  arch 


Body  of  vertebra 


Lower   left  ar- 
ticular process 

Middle  portion  of  the  left 
interarticular  proccbs 


Fig.  620. — Detail  of  Spondylousthetic  Sacrum  (Breus  and  Kolisko). 
From  the  "large  Vienna  pelvis." 


column  with  it.  The  articular  processes  of  the  vertebra  and  sacrum  are  not  dis- 
located, the  slipping  of  the  l^ody  of  the  former  being  permitted  ]:)y  a  stretching  or 
fracture  of  the  interarticular  processes.  The  interarticular  portion,  instead  of 
running  vertically  and  being  one-fourth  inch  long,  runs  horizontally  and  may  be  an 
inch  or  more  long.  The  last  lumbar  vertebra  thus  comes  to  be  much  elongated  from 
before  backward,  and  may  even  be  bent  over  the  sacrum  like  a  clamp. 

The  apposed  portions  of  the  two  bones  are  compressed  and  often  synostotic, 
with  the  formation  of  an  exostosis.  Severe  injury  is  probably  seldom  the  cause 
of  this  peculiar  deformity — more  likely  Neugebauer's  exj^lanation  applies.  There 
is  a  congenital  lack  of  fusion  of  the  ossification  areas  of  the  anterior  and  posterior 
ossification  centers  of  the  lateral  portions  of  the  vertel^ra,  a  spondylolysis  inter- 
articularis,  which  finding  is  not  rare  in  skeletons.  This  weak  spot  is  made  up  of 
cartilage,  is  a  pseudarthrosis,  or  is  held  together  l:)y  fibrous  bands,  and,  under 
exterior  agencies,  injury,  or  carrying  heavy  loads,  gradually  yields  to  the  pressure 
of  the  trunk,  allowing  the  anterior  portion  of  the  vertebra,  especially  the  body, 


684 


THE    PATHOLOGY    OF    LABOR 


to  warp  over  the  sacrum  into  the  pelvis.  The  deformity  has  been  observed  in 
coal-heavers,  but  probably  here,  too,  some  congenital  deformity  of  the  bone  pre- 
existed or  it  should  be  more  common. 

On  the  pelvis,  spondylolisthesis  has  a  very  deforming  action:  (1)  The  in- 
clination of  the  pelvis  is  obliterated,  in  marked  cases  the  inlet  being  almost  hori- 
zontal; this  is  due  to  the  attempt  of  the  woman  to  keep  her  balance  by  throwing 
the  trunk  back,  and  thus  overcome  the  tendency  to  fall  forward;  (2)  the  lower 
lumbar  spine  projects  over  and  into  the  inlet, — pelvis  obtecta, — in  a  way  similar 
to  that  of  Imnbosacral  kyphosis,  and  the  promoritory  becomes  the  fourth,  third, 


/ 


\ 


Fig.  621. — Spo-ndylolisthetic  Pelvis. 
Shows  the  hump  of  last  lumbar  spine. 


Fig.  G22. — Spondylolisthetic  Pelvis. 
Shows  pubis  rotated  upward. 


or  even  the  second  lumbar  vertebra;  (3)  the  available  true  conjugate  of  the  inlet 
may  be  reduced  to  even  5  cm. ;  (4)  the  sacrum  is  rotated  on  a  transverse  axis  in  a 
manner  similar  to  that  of  the  kyphotic  pelvis,  and  the  lower  tip  tends  to  approach 
the  pubis,  forming  a  funnel-shaped  canal;  (5)  the  innominate  bones,  responding 
to  the  rotation  of  the  sacrum  and  the  tug  of  the  muscles  and  iliofemoral  ligaments, 
converge  toward  the  outlet,  exaggerating  the  outlet  contraction;  (6)  the  distance 
between  the  posterosuperior  iliac  spines  is  increased;  (7)  the  arcus  pubis  is  nar- 
rowed;   (8)  the  pelvic  joints  are  sometimes  loose. 

Diagnosis. — To  the  123  cases  collected  by  Williams  I  can  add  one  (Figs.  621 


CONTRACTED    PELVIS 


685 


to  624).     Breus  and  Kolisko  could  find  oiil}'  20  aiiatouiically  pioved  specimens  of 
tlie  deformity. 

A  study  of  the  acc()nii)anyin<;-  ])lH)tographs  will  disclose  llie  main  points  on 
which  a  (lia<i,n<)sis  may  be  based,  an<l  internal  examination  will  almost  always  render 
the  same  positive.  This  patient  gave  a  history  of  a  severe  fall  in  childhood,  fol- 
lowed by  a  long  confinement  to  bed.  The  following  features  are  to  be  noted:  (1) 
Short  sc|uat  stature,  but  the  arms,  legs,  and  chest  are  of  normal  size;  (2)  the  pelvis 
seems  rotated  upwai'd  (indicated  by  the  course  of  the  lines  which  have  been  painted 
over  the  iliac  crests),  and  the  ribs  nearly  rest  on  the  iliac  bones;    (3)  the  vulva  is 


Fig.  023. — Spondylousthetic  Pelvis  (Side  Vie-w). 

Shows  spine   of   last   lumbar  and    horizontal   crest   of 

ilium. 


Fig.  624. — Spondylolisthetic  Pelvis. 

Ribs  almost  rest  on  crests  of  ilia.     Upward   curve  of 

crests  is  shown  by  lines  drawn  on  the  skin. 


turned  upward  and  looks  forward;  (4)  the  posterosuperior  spines  are  far  apart, 
the  rhomboid  of  Michaelis  is  broad,  runs  vertically,  and  the  spines  are  prominent, 
particularly  the  last  Imnbar,  which  stands  out  sharply,  as  is  seen  in  Fig.  623.  The 
extreme  compensatory  lordosis  is  well  shown,  and  the  head  too  is  thrown  back. 
This  patient  was  allowed  to  walk  on  a  long  strip  of  paper,  her  feet  ha\dng  been 
painted  with  rubber-stamp  ink,  and  Fig.  625  reproduces  her  footprints.  They 
show  clearly  the  short  steps  and  the  narrow  tread  (tight-rope  walker's  gait),  cor- 
responding ■\^'ith  Xeugebaucr's  ichnographic  tracings  very  closely. 

On  the  internal  examination  the  overhanging  lumbar  spine  could  be  easily 


686 


THE    PATHOLOGY    OF   LABOR 


outlined,  but  it  was  not  so  marked  as  in  most  of  the  specimens  published.     The 
sacrum,  with  its  lateral  wings,  could  be  easily  distinguished  from  the  last  lumbar 


#'.. 


^ 


Fig.  626. — Osteomalacic  Pelvis.     Mild  Degree  (Chicago  Lying-in  Hospital  specimen). 


% 


Fia.  62.5. — Tread  of  Spon- 
dylolisthetic        Pa- 
tient.    "Tight-rope 
Walker's  Tread." 
Patient's      feet      were 
painted  with    red   ink   and 
Hhe    walked    on  a  strip  of 
wall-paper,  which  was  then 
photographed. 


Fig.  627. — Measurements  of  Fig.  626.     Osteomalacic  Pelvic  Inlet. 


CONTRACTED    PELVIS 


687 


vertebra,  the  sharp  angle  could  easily  be  felt,  and  there  was  nothing  at  either  side 
of  the  body  of  this  vertebra — the  bifurcation  of  the  common  iliac  artery  was  dis- 
tinctly palpable  on  the  left  side,  but  not  on  the  right.  Von  Winckel  proved  that 
this  last  fmding  was  unreliable,  being  found  also  in  kyphotic  pelves. 

The  Osteomalacic  Pelvis. — Part  of  the  general  affection,  osteomalacia,  which 
has  already  been  considered,  is  the  deformity  of  the  pelvis,  and,  from  the  ob- 
stetrician's point  of  view,  the  most  important.  As  the  result  of  the  action  of  the 
trunk  pressure,  the  pressure  of  the  heads  of  the  femora,  the  traction  of  the  muscles 
and  ligaments  on  the  softened  bones,  the  pelvis  is  crowded  together  in  an  astonish- 
ing manner.  Figs.  02G  and  027  show  these  deformations,  and  d(;scription  is  unnec- 
essary. The  sinking  downward  and  forward  of  the  sacrum,  the  beak-like  distortion 
of  the  horizontal  pubic  rami  (due  to  the  inward  pressure  of  the  femora),  the  ap- 
proach of  the  tuberosities  of  the  ischia,  the  rolling  inward  of  the  iliac  crests,  must 
l)e  emphasized.  On  the  pelvic  lumen  this  invasion  from  three  sides  and  above  pro- 
duces very  decided  effects — indeed,  the  cavity  may  be  almost  obliterated. 


Fig.  62S. — Osteomalacic  Pelvis.     Highest  Degree. 


Fig.  629. — Left  View  of  Fig.  628. 


Labor  is  rendered  impossible  if  the  process  is  at  all  advanced,  but  if  it  occurs 
when  the  osteomalacia  is  in  the  florid  stage,  the  soft  bones  may  give  way  to  the  head 
advancing  under  the  influence  of  strong  pains,  and  dilate  enough  to  allow  the  child 
to  pass  through.  This  dilatation  of  the  pelvic  canal  has  been  found  in  17  to  30 
per  cent,  of  the  cases,  but  in  practice  it  is  best  not  to  depend  on  it. 

Diagnosis. — From  the  history  of  the  patient  one  will  learn  that  the  body  has 
gradually  grown  shorter,  with  complaint  of  rheumatoid  pains  in  the  back  and  the 
pelvis,  difficult  and  painful  locomotion  (duck-gait),  contraction  of  the  adductor 
thigh  muscles,  muscular  trembling,  paresis,  asthenia,  and  progressive  invalidism. 
Previous  labors  have  grown  successively  more  difficult.  Tenderness  is  found  over 
most  of  the  bones,  and  the  incurvations  of  the  spine,  the  ribs,  and  the  extremities 
are  usually  present  in  sufficient  degree  to  be  found.  On  the  pelvis  the  most  decided 
changes  are  chscoverable,  the  most  notable  being  the  beaked  pubis,  the  narrow  pubic 
arch,  which  in  the  author's  case  hardly  permitted  two  fingers  to  pass;  the  sharply 
curved  sacrum  and  low  promontory-.    All  the  external  measurements  are  diminished. 


688 


THE    PATHOLOGY    OF   LABOR 


In  the  differential  diagnosis  the  pseudo-osteomalacic  rachitic  pelvis  need  be  men- 
tioned, but  the  history,  the  disease  appearing  in  childhood,  will  at  once  eliminate 
this.     Spondylolisthesis  is  also  easily  determined. 


DOUBLE  DISLOCATION  OF  THE  HIPS 

Congenital  dislocation  of  the  hips  is  not  a  very  rare  deformity,  and  only  recently 
have  the  efforts  of  the  orthopedists  been  successful  in  correcting  it.     When  such 


Fig.  630. — Double  Dislocation  of  Hips. 


Fig.  631. — Right  Elevatiom  of  Pklvih.    Docblk  Dis- 
location  OF   HlI'W. 
Shows  new  acetabulum. 


Fig.  C32. — I/Eft  Elevation  of  Pelvis.     Double  Dis- 
location OF  Hips. 
Shows  contracted  acetabulum  and  new  socket. 


a  child  begins  to  walk,  the  trunk  pressure  forces  the  whole  pelvis  onto  the  iliofemoral 
and  capsular  ligaments,  the  line  of  gravity  is  anteposcd,  the  spinal  column  is  thrown 


CONTRACTED    PELVIS 


689 


back  to  preserve  the  balance,  the  result  of  all  this  being  a  forward  tilting  of  the 
pelvic  girdle  and  increase  of  pelvic  inclination.  Since  the  transverse  pressure 
exerted  by  the  heads  of  the  femora  fails,  distinct  flattening  of  the  pelvis  results 
(Fig.  (il-JO).     Tli(>  outlet  is  very  large. 

Diagnosis. — In  the  accompanying  photographs  the  characteristic  appearance 
of  such  a  woman  is  to  be  seen.  The  high  trochanters,  the  broad  hips,  the  lordosis 
with  increasetl  pelvic  inclination,  the  folding  of  the  skin  at  the  hips,  the  loose- 


FiG.  633. — Double  Dislocation  of  Hips. 


Fig.  634. — Double  Dislocation  of  Hips. 

Shows  downward  and  backward  rotation  of    head    of 

femur  when  leg  is  flexed. 


jointed  gait — all  strike  the  eye  at  once.  On  internal  examination  the  shortening, 
if  there  is  any,  of  the  conjugata  vera  is  easily  determinable.  Labor  has  the  char- 
acteristics of  that  in  fiat  pelves. 

For  the  sake  of  completion  may  be  mentioned  the  pelvis  split  at  the  pubis, 
an  accompaniment  of  ectopic  bladder, — gastroschisis, — and  the  case  of  absence  of 
the  sacrum,  both  scientific  curiosities. 

Literature 

Brcus  und  Kolisko:  Die  pathologische  Beckenformen,  1902  to  1912. — Klien:  Volkmann's  Samnil.  klin.  Vort.,  N.  F.,  No. 
169,  1S96. — Williams:  Amer.  Jour.  Obstet.,  July,  1911. — "The  Rhomboid  of  Michaelis,"  L'Obstetrique, 
January,   1910,  p.  6o. — "Spondylolisthesis,"  Arch.  f.  Gyn.,  vol.  Hi,  p.  101. 


44 


CHAPTER  LV 
CLINICAL  ASPECTS  OF  CONTRACTED  PELVES 

During  Pregnancy. — Certain  varieties  of  contracted  pelvis  may  interfere  with 
coitus,  for  example,  the  double  coxalgic,  with  ankylosis.  Very  large  pelves  allow 
the  uterus  to  sag  do^vn  onto  the  pelvic  diaphragm,  and  such  women  show  increased 
pelvic  floor  projection.  It  has  seemed  to  me  that  they  suffer  larger  tears  in  labor 
and  are  liable  to  develop  prolapsus  uteri.  Retroversion  of  the  uterus  may  be 
maintained  by  an  overhanging  promontory,  and  if  pregnancy  supervenes,  an 
operation  may  be  needed  to  restore  the  uterus  to  its  place. 

As  a  rule,  it  is  later  in  pregnancy  that  the  effects  of  pelvic  obstruction  become 
apparent.  Since  there  is  no  room  in  the  pelvis  for  the  growing  uterus,  it  forces 
itself  upward,  the  abdomen  is  overdistended,  the  anterior  wall  stretches,  or  the 
recti  part  and  the  fundus  uteri  falls  forward,  the  condition  being  known  as  pendu- 
lous abdomen  (Fig.  353,  p.  399). 

If  the  muscles  retain  their  integrity,  the  uterus  is  forced  upward  against  the 
ribs  and  forms  here  a  high  plateau.  Another  effect  of  contracted  pelvis  is  the  con- 
ferring of  a  great  degree  of  mobility  on  the  uterus.  The  organ,  since  its  pelvic 
attachments  are  overstretched  and  it  lacks  the  support  of  the  side  walls  of  the  pelvis, 
is  free  to  sag  from  side  to  side  with  every  turn  of  the  patient.  Some  women  com- 
plain much  of  this,  and  require  the  support  of  a  firm  binder.  From  the  same  causes 
the  position  and  presentation  of  the  fetus  change  readily  and  frequently.  The 
cephalic  pole  does  not  remain  so  constantly  over  the  inlet,  hence  when  labor  begins 
quite  often  the  child  is  found  in  an  unfavorable  attitude  and  presentation,  which, 
becoming  confirmed  by  the  uterine  contractions,  causes  serious  dystocia.  Vari- 
cose veins  of  the  vulva  and  limbs,  especially  if  one  or  more  severe  operative  de- 
liveries have  preceded,  are  often  particularly  marked. 

During  Labor. — General  Considerations. — Labor  is  likely  to  be  a  little  prema- 
ture in  contracted  pelves  of  the  flat  variety,  and  to  be  prolonged  in  those  of  the 
generally  contracted,  funnel,  and  masculine  types.  Reasons  for  this  I  cannot 
advance,  but  such  has  been  my  experience.  When  labor  has  frankly  declared 
itself  in  a  woman  with  contracted  pelvis  and  at  term,  it  early  becomes  evident  that 
the  process  is  not  going  as  it  should,  and  the  observant  accoucheur  soon  perceives 
that  it  is  not  alone  the  spacial  disproportion  which  causes  dystocia,  but  many  other 
factors — abnormal  presentations,  positions,  attitude,  the  size  and  hardness  of  the 
fetal  head,  irregular  uterine  action,  premature  rupture  of  the  bag  of  waters,  etc. 

Abnormal  presentations— breech,  face,  brow,  shoulder — are  four  times  as 
frequent  with  contracted  pelvis,  Litzmann  having  found  the  cephalic  pole  pre- 
senting normally  in  only  84  per  cent,  of  his  cases  (usually  in  96  per  cent.).  The 
reason  for  this  is  that  the  head,  finding  the  entrance  into  the  superior  strait 
blocked,  glides  off  into  one  iliac  fossa,  producing  an  obliquity  of  the  fetal  axis  to 
that  of  the  inlet.  It  is  now  easy  for  a  partial  or  even  a  complete  rotation  of  the 
fetal  ovoid  to  occur,  and  the  pains  coming  on,  the  child  is  locked  in  its  unfavorable 
position.  Prolapse  (jf  the  arm,  foot,  and  cord  are  also  much  more  common  in  all 
forms  of  pelvic  contraction,  but  particularly  in  the  flat  varieties.  The  reason  for 
this  is  that  the  head  does  not  lie  firmly  in  apposition  on  the  lower  uterine  segment, 
but  is  held  away  by  the  jutting  promontory  of  the  sacrum,  which  leaves  unfilled 

690 


CLINICAL   ASPECTS    OF   CONTRACTED    PELVES  691 

spaces  at  tho  sides,  throusli  which  tlic  small  parts  easily  slip.  All  these  accidents 
are  commoner  in  multipara;  with  their  flaccid  and  flabby  uteri. 

A  great  deal  depends  on  the  size  and  moldability  of  the  fetal  head  and  of  the 
trunk.  If  the  bones  are  soft,  they  easily  give  themselves  to  the  shape  of  the  inlet, 
and  apparentl}^  great  tlisproi:)ortion  may  thus  be  overcome.  If  the  child  is  small, 
the  pelvis,  relatively,  may  not  be  at  all  contracted,  while  if  the  infant  is  large,  the 
contraction  of  the  pelvis  must  be  rated  higher. 

Of  prime  significance  in  all  labors  with  contracted  pelvis  is  the  action  of  the 
uterus.  Speaking  broadly,  the  strength  of  the  uterus  is  proportionate  to  the  amount 
(jf  work  required  of  it.  In  some  cases  the  uterus  acts  regularly  and  with  increasing 
power  as  it  finds  that  the  child  does  not  progress  through  the  birth-canal.  Within 
well-defined  limits  this  augmented  action  of  the  uterus  is  healthy  and  very  desirable, 
because  by  this  means  nature  often  overcomes  spacial  disproportion  between  the 
head  and  tlie  pelvis  which  no  one  would  have  thought  possible.  The  recurring 
])ains  adjust,  compress,  mold,  and  propel  the  head  through  the  narrowed  canal 
in  a  fashion  that  the  finest  art  absolutely  fails  to  imitate.  Further,  good  pains 
dilate  the  cervix  and  prepare  the  soft  parts  for  the  passage  of  the  fetus.  Weak 
pains  are  a  most  unwelcome  complication  of  labor  in  contracted  pelvis.  They  may 
be  primary  or  secondary.  Primarily  weak  pains  freciuently  accompany  generally 
contracted  pelvis  and  are  another  expression  of  the  infantilism  w^hich  caused  it. 
Again,  other  causes  of  weak  pains  may  exist.  Weak  pains  from  exhaustion, 
tetanus,  or  infection  of  the  uterus  are  much  more  significant  and  correspondingly 
serious.  To  weak  uterine  action  are  often  added  weak  abdominal  muscles,  so 
common  with  pendulous  belly,  a  frequent  complication  of  contracted  pelvis.  If 
the  passage  is  not  too  markedly  contracted  and  the  child  is  of  moderate  size;  if 
the  presentation  and  position  are  good  and  the  pains  strong,  the  large  majority  of 
labors  will  terminate  spontaneously  and  happily  for  both  mother  and  child.  Even 
experienced  accoucheurs  will  often  be  surprised  to  see  what  nature  can  accomplish 
if  properly  supported  and  not  interfered  with.  On  the  other  hand,  the  contraction 
of  the  pelvis  may  be  negligible,  as  far  as  spacial  chsproportion  is  concerned,  but  it 
has  caused  an  abnormal  presentation — for  example,  brow  or  shoulder,  which  results 
in  perhaps  fatal  dystocia. 

The  First  Stage. — At  the  beginning  of  labor  the  head  is  high  up,  not  engaged, 
as  so  often  happens  in  healthy  primiparse  and  in  multiparse  with  strong  abdominal 
walls.  It  does  not  even  project  into  the  pelvis  with  a  large  segment,  but  floats 
high,  almost  out  of  reach  of  the  finger.  It  does  not  fit  the  lower  uterine  segment 
accurately,  hence  the  membranes  over  the  os  are  exposed  to  the  full  force  of  the 
yterine  contraction.  If  they  are  delicate,  they  burst  and  the  liquor  amnii  drains 
away;  if  they  are  tough,  they  are  stripped  off  the  lower  uterine  segment  and  pouch 
down  into  the  vagina  or  even  to  the  vulva,  stocking  shaped,  and  are  of  little  service 
as  a  fluid  dilating  wedge.  The  evil  consequences  of  early  rupture  of  the  sac  are: 
Loss  of  the  hydrostatic  cervical  dilator;  (2)  increased  danger  of  pressure  necrosis 
of  soft  parts  lying  between  head  and  pelvis;  (3)  increased  possibilities  of  prolapse 
of  cord,  arm,  and  feet;  (4)  infection  may  gain  entrance  to  uterine  cavity  and  cause 
physometra,  fetal  death,  and  sepsis.  If  the  membranes  rupture  before  complete 
dilatation  has  been  secured,  the  lower  uterine  segment  and  cervix  collapse,  and  it 
requires  prolonged  effort  on  the  part  of  the  uterus  to  open  the  passage  again.  Von 
Herft''s  experience  must  have  been  contrary  to  that  of  most  observers,  for  he  finds 
that  rupture  of  the  bag  of  waters  in  contracted  pelvis  is  not  an  event  to  be  feared; 
that  the  dilatation  progresses  just  as  satisfactorily  as  before,  or  often  better. 

True,  the  pains  may  be  stronger  after  the  waters  have  drained  away,  but  ex- 
perienced accoucheurs  will  find  it  hard  to  admit  that  the  head  makes  as  eflRcient 
and  as  safe  a  cervical  dilator  as  the  bag  of  waters,  or  that  the  mother  and  child  are 
not  in  more  danger  after  the  sac  has  been  opened,  and  they  will  be  loath  to  dispense 


692  THE    PATHOLOGY    OF   LABOR 

with  the  natural  water-bag  dilator  until  the  cervix  is  open  enough  to  permit  natural 
or  operative  delivery. 

jNIany  differences  are  observed  in  the  way  the  lower  uterine  segment  is  formed 
and  the  cervix  dilated  in  cases  of  obstructed  labor.  In  a  healthy  primipara  the 
usual  mechanism  occurs,  but  in  a  multipara,  especially  if  she  has  had  several 
difficult  labors,  the  contraction  ring  ascends  very  early,  the  lower  uterine  segment 
quickly  forms  under  the  influence  of  the  pains,  and  the  os  soon  dilates.  Now, 
unless  the  head  quickly  passes  into  and  through  the  pelvis,  the  expanded  parturient 
canal  wnll  give  way  and  allow  the  fetus  to  escape  into  the  peritoneal  cavity.  If  the 
cervix  is  tough,  it  may  long  resist  the  action  of  the  uterus  and  require  the  inter- 
vention of  art.  Sometimes  the  cervix  is  compressed  between  the  head  and  the  pelvis. 
The  part  below  the  area  of  compression  then  may  become  edematous  and  even 
slough  off.  Particularly  the  anterior  lip,  in  flat  pelves  with  pendulous  belly,  is 
liable  to  be  caught  between  the  head  and  the  pubis,  becoming  enormously  swollen 
(sometimes  to  the  size  of  one's  wrist),  suggillated,  even  necrotic,  leaving  cervico- 
vesical  fistula.  Previous  deep  lacerations  of  the  cervix  and  of  the  lower  uterine 
segment  predispose  to  fresh  rupture.  Dilatation  of  an  old,  much-lacerated  cervix 
is  usually  rapid  unless  the  scars  are  very  extensive. 

The  Second  Stage. — Up  to  this  point  labor  in  nearly  all  forms  of  contracted 
pelvis  is  the  same.  When  the  head  is  to  pass  through  the  inlet,  different  mechanisms 
are  developed,  and  these  will  be  considered  separately  later.  Certain  general 
features  are  common  to  all  obstructed  labors,  and  they  may  be  divided  into  two 
groups:  first,  the  absolutely  impossible  labor,  where  the  disproportion  is  so  great 
that  the  child  cannot  pass,  and,  second,  the  labors  where  the  child  can  pass,  but 
it  requires  prolonged  effort  on  the  part  of  nature,  without  or  with  the  help  of  art. 

If  the  head  is  arrested,  the  uterus  is  stimulated  to  redoubled  vigor,  the  pains 
become  stronger  and  stronger,  the  intervals  shorter,  but  no  advancement  is  per- 
ceptible. A  large  caput  succedaneum  replaces  the  bag  of  waters,  and  the  scalp 
may  be  visible  at  the  vulva  when  the  head  has  not  yet  passed  the  inlet.  The  vagina 
becomes  hot,  swollen,  blue,  and  dry,  the  vulva  dark  blue  and  edematous,  often 
with  small  suggillations,  and  in  much  neglected  cases  gangrenous.  The  child  dies 
because  the  violently  acting  uterus  cuts  off  its  oxygen  supply,  and  sometimes  also 
from  cerebral  injury  or  hemorrhage,  the  result  of  nature's  attempt  to  crowd  the 
head  through  a  passage  too  small  for  it.  If  aid  is  not  rendered,  the  woman  in- 
evitably dies  and  death  occurs  from  rupture  of  the  uterus,  with  intraperitoneal 
hemorrhage  or  shock,  from  sepsis,  or  exhaustion.  (For  the  symptoms  of  rupture 
of  the  uterus  the  reader  is  referred  to  Chapter  LIX.)  Infection  during  prolonged 
labor  may  be  autogenous  or  exogenous.  In  the  vast  majority  of  cases  the  phy- 
sician introduces  the  infection  from  the  vulva,  or  from  without  entirely,  or  by  re- 
peated examinations  inoculates  the  patient  with  the  bacteria  normally  present  in 
the  vagina,  the  frequency  of  the  various  modes  being,  in  the  author's  opinion,  in 
the  order  given.  In  a  small  percentage  of  the  cases  the  bacteria  wander  upward 
from  the  vagina  through  the  opened  membranes  into  the  uterine  cavity.  In 
either  event  the  woman  develops  fever,  the  first  effect  of  which  is  to  stimulate  the 
pains,  but  soon  the  uterus  is  paralyzed,  with  or  without  the  formation  of  gas  in  its 
cavity  (physometra).  Women  in  labor  stand  infection  not  at  all  well,  and  the 
temperature  and  pulse  rapidly  mount  high,  while  delirium,  subicterus,  and  pros- 
tration quickly  follow.  There  is  a  foul  discharge  from  the  vagina,  and  the  vulva 
is  swollen,  reddened,  and  superficially  necrotic  in  places.  Acute  dilatation  of  the 
heart  is  a  not  rare  termination  of  too  prolonged  labor. 

Exhaustion  is  an  infrequent  cause  of  death,  but  without  doulit  it  will  explain 
many  cases  of  shock  and  of  gradual,  uncontrollaljle  asthenia  terminating  fatally 
after  operative  delivery.  The  operation  may  have  been  quick  and  skilful,  without 
undue  hemorrhage,  and  with  little  anesthetic,  but  the  woman  does  not  rally,  the 


CLINICAL    ASPECTS    OF    CONTRACTED    PELVES 


693 


pulse  mounts  higher  and  hi^;h('r,  the  vital  ])()\v('i-s  shnvly  sink,  and  in  from  four  to 
twenty-four  hours  death  supervenes  in  quiet  coma.  In  the  (Ufferential  diagnosis 
internal  hemorrliage,  uremia,  and  shock  from  injury  are  to  be  considered. 

If  the  disi)roi)ortion  is  not  aljsolute,  nature  often  accompHshes  the  delivery, 
and  even  tlie  experienced  ol)stetrieian  must  marvel  when  lie  sees  all  his  jjrecon- 
ceived  notions  set  at  naught. 

At  first  the  head  is  high  up,  separated  from  the  bony  inlet  by  a  pad  of  thick 
cervix,  the  bases  of  the  l)road  ligaments,  the  bladder,  and  the  pelvic  connective 
tissue  in  general.  After  the  uterus  has  been  in  action  for  a  while  all  these  structures 
except  the  base  of  the  bladder  are  drawn  upAvard  with  the  retraction  of  the  lower 
uterine  segment  out  of  the  pelvis,  thus  allowing  the  head  to  apply  itself  to  the  inlet. 
If  one  examines  the  woman  now  during  a  pain,  peculiar  phenomena  are  observed. 
The  heatl  flexes  and  deflexes,  and  sometimes  rotates  on  its  transverse  axis,  or  even 
in  a  hor-izontal  plane,  and  one  feels  the  large  fontanel  advance,  recede,  turn  from 
behind  forward,  and  the  head  rolls  on  either  shoulder.     It  is  important  for  the 


Fig.  G3o. — Head  After  Four  Days'  Labor  ix  a  Generally  Contracted  and  Fl.\t  Pelvis. 
Arrows  show  direction  of  compression  and  point  to  areas  where  the  scalp  subsequently  sloughed  out. 


accoucheur  to  study  these  motions  with  great  care,  because  they  are  the  evidences 
of  the  intended  mechanisms  of  the  head,  that  is,  that  manner  in  which  the  head  is 
to  overcome  the  resistances  of  the  passage.  Nature  seems  to  be  fitting  the  head  to 
the  pelvis  as  a  key  is  fitted  to  the  wards  of  a  lock,  until  a  combination  is  secured 
which  will  best  allow  the  head  to  pass. 

Now  the  process  of  mokhng  or  configuration  begins,  and  the  general  intra- 
uterine pressure,  together  with  the  fetal  axis  pressure,  gradually  forces  the  head 
through  the  narrowed  superior  strait.  Owing  to  the  nature  of  things  the  head 
cannot  be  reduced  in  size  by  compression,  and  only  a  minute  quantity  of  cerebro- 
spinal fluid  can  escape  through  the  foramen  magnum  into  the  spinal  canal — not 
enough  appreciably  to  affect  the  size  of  the  head.  Now,  owing  to  the  softness  of 
the  cranial  bones  and  their  movability  on  each  other  at  the  sutures,  the  head  is 
capable  of  being  changed  in  form  so  that  it  accommodates  itself  to  the  shape  of 
the  superior  strait.  That  parietal  bone  which  first  meets  with  resistance  is  pressed 
mider  the  other,  and  the  plate  of  the  occipital  bone  lies  under  the  two  parietals. 


694  THE    PATHOLOGY    OF   LABOR 

The  overlapping  may  be  so  marked  that  the  dura  mater  begins  to  strip  off,  and  a  row 
of  minute  hemorrhages  will  be  found  on  either  side  of  the  longitudinal  sinus.  Fig. 
635  shows  the  head  of  a  child  spontaneously  delivered  after  four  days'  labor.  This 
length  of  time  is  very  seldom  required  for  the  process;  indeed,  nowadays  such  cases 
are  not  allowed  to  take  so  long,  but  interference  is  thought  necessary  after  giving 
the  natural  powers  reasonable  opportunity  to  show  how  much  they  can  accomplish. 
From  four  to  ten  hours  of  good  strong  pains  will  almost  always  suffice  for  the  test, 
l.^ut  even  here  great  watchfulness  is  incHcated  lest  mother  or  babe  suffers  harm  from 
the  experiment. 

As  soon  as  the  head  has  been  molded  so  that  it  is  ready  to  pass  through  the 
inlet  the  pains  assume  an  expulsive  character — the  parturient  bears  down,  the 
head  drops  into  the  excavation,  and  the  occiput  begins  to  rotate  to  the  front. 

Three  signs  indicate  that  the  head  is  descending:  (1)  The  patient  begins  to 
bear  do^vn;  (2)  feces  are  discharged,  or  the  woman  expresses  a  desire  to  go  to  stool; 
(3)  cramps  of  the  muscles  of  the  legs  occur — usually  the  left  leg  in  left  occiput 
positions  and  vice  versa.  The  first  two  symptoms  are  due  to  the  pressure  of  the 
head  upon  the  rectum ;  the  last  one,  to  irritation  of  the  sacral  plexus  by  contact  of 
the  advancing  head.  In  flat  pelves,  in  which  the  resistance  is  met  only  at  the  inlet, 
this  part  of  the  labor  is  completed  with  surprising  quickness.  In  multiparse  one 
or  two  powerful  expulsive  pains  procure  anterior  rotation  and  the  birth  of  the  head; 
in  primiparse  the  soft  parts  have  to  be  overcome,  and  this  requires  the  usual  time. 
The  head  may  be  given  a  shape  different  from  that  acquired  in  the  passage  of  the 
inlet  by  the  molding  caused  by  the  pelvic  floor.  If  the  pelvis  is  generally  contracted, 
the  resistance  continues  all  the  way  to  the  outlet,  and  labor  is  unduly  prolonged  and 
tedious.  In  addition  the  uterine  action  in  this  class  of  pelvis  is  often  weak,  the 
uterus  partaking  of  the  general  hypoplasia.  Women  with  funnel  and  masculine 
pelves  are  also  prone  to  uterine  inertia.  Occipitoposterior  positions,  imperfect 
dilatation  of  the  cervix,  and  strictura  uteri  (hour-glass  contraction)  are  also  more 
common  in  them. 

After  the  head  is  delivered  the  main  difficulty  is  overcome,  but  if  the  child  has 
broad  shoulders,  they  may  cause  much  trouble,  especially  in  the  generally  and 
transversely  contracted  pelves.  Many  an  infant  has  been  lost  during  the  pro- 
longed attempts  to  deliver  impacted  shoulders.  At  any  point  the  uterus  may  give 
out  and  labor  comes  to  a  standstill,  requiring  the  assistance  of  art.  It  is  as  often 
the  nervous  system  of  the  Avoman  or  the  condition  of  the  baby  which  demands  inter- 
ference as  the  uterus  proving  default. 

The  third  stage  does  not  present  any  conditions  which  are  peculiar.  Post- 
partum hemorrhage  is  rare  if  the  pains  have  been  good,  but  if  the  delivery  has  been 
operative,  lacerations  and  bleeding  must  be  expected. 


riTAPTl^R  T.VT 

MECHANISM  OF  LABOR  IN  FLAT  PELVES 

An  experienced  accoucheur  can  diagnose  the  nature  of  the  pelvis  by  observing 
the  mechanism  with  which  the  head  passes  through  it.  Many  of  its  motions  are 
characteristic  of  flat  and  of  generally  contracted  types.  In  flat  pelves  abnormalities 
of  position  and  jiresentation  are  very  common.  Owing  to  ihv  jutting  forward  of 
the  promontory,  the  head  may  not  enter  the  pelvis  antl,  therefore,  slips  off  to  one 
side,  which  often  allows  the  cord  to  prolapse  in  the  free  space  thus  provided.     The 


Fig.  G3G. — Anterior  Parietal  Bone  Presentation.     Head  Molding  its  Wat  Into  Fl.vt  Pelvis  (adapted  from 

SmellieJ . 
Dotted  line  shows  caput  succedaneum. 

head  tries  to  enter  the  pelvis  flexed,  as  in  the  usual  mechanism  of  labor,  but  the 
biparietal  diameter  is  too  large  to  pass  through  the  conjugata  vera,  the  diameter 
of  greatest  contraction.  As  a  result  the  head  shdes  off  to  the  side,  the  bitemporal, 
a  smaller  diameter,  comes  to  lie  in  the  conjugata  vera,  while  the  biparietal  lies 
in  the  larger  space  opposite  the  sacro-iliac  joint.  As  soon  as  the  head  sinks  the 
forehead  descends,  because  the  resistance  offered  the  occiput  is  greater — deflexion, 
instead  of  flexion,  the  first  movement,  occurs.  Q-wdng  to  the  long  transverse  and 
short  sagittal  diameters  of  the  inlet  the  head  seeks  the  position  which  will  easiest 

695 


696 


THE    PATHOLOGY    OF   LABOR 


allow  it  to  advance — that  is,  the  sagittal  diameter  of  the  head  will  lie  in  the  trans- 
verse of  the  pelvis. 

A  third  and  most  important  abnormality  of  the  mechanism  is  the  almost 
constant  lateroflexion  of  the  head,  that  is,  the  parietal  bone  is  inclined  on  one  or  the 
other  shoulder,  or,  in  other  words,  the  head  enters  the  pelvis  in  exaggerated  asyn- 
clitism. This  is  called  parietal  bone  presentation.  Normally,  although  some 
authorities  deny  it,  the  head  often  enters  the  pelvis  with  slight  anterior  asynclitism, 
that  is,  obliquity  of  Naegele.  In  flat  contracted  pelves  this  is  exaggerated,  and 
sometimes  the  lateroflexion  is  so  great  that  the  anterior  ear  is  palpable  behind  the 
pubis — ear  presentation.  In  the  subsequent  course  of  labor  the  posterior  parietal 
bone  rolls  over  the  promontory  into  the  pelvis,  the  anterior  bone  forming  a  sort 


Fig.  637. — Next  Stage  of  the  Molding.     Po-stehior  Parietal  Rolls  Over  the  Promontory.     Head  Now  En- 
gaged. 
Sagittal  suture  comes  near  middle  line. 


of  sliding  fulcrum  on  the  posterior  wall  of  the  pubis.  The  amount  of  molding  of 
the  cranial  bones  needed  to  allow  the  descent  of  the  head  according  to  this  mechan- 
ism depends  on  the  size  and  hardness  of  the  head  and  the  roominess  of  the  inlet, 
and  the  time  required  depends  also  on  these  factors  plus  the  strength  of  the  uterine 
contractions.  The  process  may  be  completed  in  a  few  hours,  or  may  last  over  a 
day  (Figs.  636,  637,  and  638).  That  part  of  the  head  which  rubs  over  the  promon- 
tory often  shows  a  pressure  mark — a  red  streak.  In  right  positions  the  red  mark 
(in  bad  cases,  real  pressure  necrosis)  lies  over  the  right  parietal  bone,  parallel  with 
the  coronary  suture;  in  left  positions,  in  a  corresponding  location  over  the  left 
parietal  bone.  The  configuration  of  the  head  is  sometimes  remarkable.  In  one 
of  the  author's  cases  the  head,  viewed  from  above,  had  the  shape  of  a  kidney,  and 
was  almost  a  mold  of  the  pelvic  inlet.     If  the  head  remains  long  in  the  pelvis  after 


MECHANISM    OF    LABOR    IX    FLAT    PELVES 


697 


liaving  passed  the  superior  strait,  it  acquires  another  sliape  from  the  secondary 
m()l(Unp;  {jnjduced  by  the  pelvic  floor. 

As  soon  as  the  greatest  periphery  of  the  head  lias  passed  the  region  of  tlie  inlet, 
or  even  just  as  it  is  about  to  pass,  the  occiput  sinks,  the  large  fontanel  ascends, 
descent  of  the  liead  takes  place,  and,  as  a  rule,  anterior  rotation  follows  at  once. 
The  head  undergoes  a  complicated  movement,  consisting  of  descent,  flexion  fthe 
chin  on  the  sternum),  laterodeflexion,  that  is,  the  synclitic  movement  and  anterior 
rotation  of  the  occiput  all  sinmltaneously.  Now  the  mechanism  is  as  usual — 
flexion,  descent,  extension,  external  restitution.  Even  in  primipara^  a  few  pains 
often  accomplish  the  delivery;   in  multiparse  it  is  usually  done  with  one  or  two. 

Findings. — Abdominally,  one  may  d(>termine  the  deflexion  of  the  head  by 
noting  the  straightening  of  the  fetal  spine.     The  lateroflexion  at  the  neck  may 


r^- 


Fig.  G3S.— Head  Has  Sunk  onto  Pelvic  Floor  and  Has  Almost  Completely  Rotated  to  Front. 
Some  lateroflexion  of  head  persists  even  as  late  as  this. 


also  be  felt.  On  internal  examination  the  sagittal  suture  lies  in  the  transverse 
diameter,  but  very  close  to  the  sacrum;  the  small  is  on  the  same  level  as  the  large 
fontanel,  sometimes  even  higher,  so  that  the  brow  comes  down;  the  sutures  are 
at  first  plainly  felt,  because  the  cranial  bones  overlap  so  strongly,  but  later  in  labor 
the  caput  succedaneum  obliterates  the  lines  (Fig.  639). 

Another  mechanism,  and  an  important  variation,  is  the  posterior  parietal 
bone  presentation  (Fig.  640).  Here  the  head  is  inclined  on  the  anterior  shoulder; 
the  posterior  parietal  bone  occupies  the  vault  of  the  pelvis, — posterior  asynchtism, 
— and  if  the  lateroflexion  is  very  decided,  the  posterior  ear  may  be  palpable  in 
front  of  the  promontory— "posterior  ear  presentation."  The  mechanism  here  is 
the  reverse  of  that  just  considered.  The  posterior  parietal  stems  on  the  promontory 
and  the  anterior  rolls  down  from  behind  the  pubis  into  the  pelvis. 

Findings. — In  posterior  parietal  bone  presentation  one  can  often  feel  the  angle 


698 


THE    PATHOLOGY    OF   LABOR 


which  the  shoulder  makes  with  the  head  just  above  the  pubis,  and  often  the  round 
parietal  bone  can  be  felt  here — in  one  case  the  ear  was  indistinctly  outlinable. 


Fig.  639. — Touch  Picttike.     Anterior  Parietal  Bone  Presentation.     Naegele's  Obliquity. 
Sagittal  suture  near  sacrum,  ear  near  pubis.     Note  ear  near  pubis  and  how  empty  rear  part  of  pelvis  is. 


Fig.  040. — Posterior  Parietal  Bone  Presentation.     Flat  Pelvis. 
Dotted  lino  is  caput  succodaneum. 


MECHANISM    OF    LABOR    IN    FLAT    PELVES 


699 


Internally,  the  sagittal  sutuic  runs  just  hcliiud  the  pubis,  usually  transverse,  or 
the  least  bit  ol)liquely,  the  small  and  large  fontanels  on  a  level  or  the  small  one  up 
high,  out  of  reach,  and,  l)y  passing  the  fingers  well  uj)  above  the  promontory,  the 
ear  is  sometimes  to  be  felt.  As  the  head  descends  the  sagittal  suture  leaves  the 
pubis  and  comes  to  lie  nearer  the  sacrum,  but  then  descent  and  anterior  rotation  of 
the  occiput  bring  the  sagittal  suture  into  an  oblique.  Sometimes  the  lateroflexion 
is  kept  up  until  the  head  escapes,  and  then  the  occiput  is  likely  to  remain  in  the 
oblique  and  the  nape  of  the  neck  stems,  not  directly  behind  the  pubis,  but  behind 
one  ramus,  and  the  head  is  delivered  in  the  oblique.  Use  may  be  made  of  this  fact 
in  the  conduct  of  such  a  labor,  and  the  processes  of  nature  imitated  by  art. 

Why  the  head  enters  the  pelvis  in  one  or  the  other  of  these  attitudes  is  not 
known.  Probably  pendulous  abdomen  will  explain  the  anterior  parietal  variety, 
but  I  have  seen  the  posterior  parietal  present,  and  pendulous  belly  was  also  a 
complication.  A  high  sacrum  might  predispose  to  the  anterior  parietal,  especially 
if  there  is  a  double  promontory.  Litzmann  says  that  the  anterior  parietal  Ijone 
presentation  is  three  times  more  frecjuent  than  the  posterior.  In  general  the  more 
contracted  the  pelvis,  the  closer  the 
sagittal  suture  runs  to  either  promon- 
tory or  the  pubis. 

Labor  is  much  more  difficult  and 
more  often  impossible  in  posterior 
parietal  bone  presentation,  since  in 
the  latter  the  child  is  bent  almost  to 
a  right  angle  at  the  neck.  The  uterus 
acts  at  a  great  disadvantage  also,  and 
is  liable  to  excessive  thinning  on  the 
posterior  wall,  a  point  of  utmost  prac- 
tical importance,  since  here  sponta- 
neous rupture  may  occur,  and  the 
greatest  danger  from  traumatism  lies. 


Fio. 


641. — Head  About  to   Enter  a  Gexerally  Con- 
tracted Pelvis.     Partial  Flexion. 


MECHANISM    OF   LABOR    IN    GENER- 
ALLY CONTRACTED  PELVES 

Labor  in  this  class  of  pelves  also 
bears  marked  characteristics.  Since 
the  head  fits  the  inlet  well,  abnormal 
attitudes,  presentations,  and  positions 
are  not  so  frequent  as  in  flat  pelves. 
Prolapse  of  the  cord  is  rare  because  the 
head  fits  the  lower  uterine  segment  ac- 
curatel}^  Early  in  labor  one  notes  that 
the  head  lies  in  flexion,  and  as  soon  as 
descent  begins  this  flexion  becomes  ex- 
treme, the  small  fontanel  being  the  first  reached  by  the  finger,  and  the  sagittal  suture 
lying  in  an  oblique  diameter  of  the  pelvis  and  running  almost  perpendicularly.  After 
labor  has  been  in  progress  for  some  time  and  molding  is  advanced,  the  small  fontanel 
lies  almost  in  the  center  of  the  pelvis,  and  is  covered  by  the  caput  succedaneum.  The 
extreme  flexion  is  due  to  an  exaggeration  of  the  same  mechanism  which  produces 
flexion  in  normal  labor — the  sincipital  end  of  the  lever,  being  longer,  meets  with 
greater  resistance  and  rises  higher.  Nature  finds  this  the  easiest  way  to  force  a  head 
through  a  pelvis  contracted  in  all  diameters.  Generally  contracted  pelves,  unlike  flat 
ones,  have  the  narrowing  all  the  way  do^Mi,  and,  therefore,  progress  is  not  rapid 
after  the  inlet  has  been  passed,  ])ut  the  head  has  to  bore  its  way  slowly  dovMi  (Figs. 
641,  642,  and  643). 


702 


THE    PATHOLOGY    OF    LABOR 


the  perineum  and  sacrum,  if  the  latter  does  not  curve  forward  too  much,  there  will 
still  be  plenty  of  room  for  the  passage  of  the  hyperflexed  head — only  the  soft  parts 
will  be  much  endangered.     If  the  bi-ischiatic  diameter  is  less  than  8  cm.,  it  is  the 


Fig.  644. — He.\d  Arrested  at  Outlet  by  Contraction. 
Note  how  head  stems  against  descending  ramus  of  pubis  and  is  thrown  against  coccyx. 


Fig.    645. — Head  Passing   the  Transversely  Con- 
tracted Outlet. 
Space  under  arch  of  pubis  cannot  be  utilized.     Peri- 
neum much  endangered.     P.S.,  Posterior  sagittal  diam- 
eter 


Fia.  646. — Absolutely  Impossible  Labor.  Head 
Stopped  by  Narrowing  Outlet.  Sacrum  Juts 
Forward  and  Prevents  Head  from  Escaping 
IN  the  Posterior  S.\gittal  Diameter. 


rule  to  experience  trouble  with  the  delivery  and  forceps  are  often  needed.  If, 
in  addition,  the  posterior  sagittal  (Fig.  646)  is  less  than  9  cm.,  labor  is  very  difficult 
or  even  impossible,  and  craniotomy  is  usually  finally  resorted  to.     Williams  and 


MECHANISM    OF    LABOR    IN    FLAT    PELVES 


703 


Klicn  soom  agreed  that  a  j)('lvis  with  a  (nanictcr  of  loss  than  8.5  cm.  botwoon  the 
tuberosities  and  a  posterior  »aj2;ittal  less  tlian  9  cm.  offers  insuperable  obstruction 
to  labor  and  demands  cesarean  section,  pubiotomy,  or  craniotomy. 

Breech  labors  are  especially  bad  in  funnel  and  transversely  contracted  pelves, 
l)ecause  the  head  has  no  time  to  mold,  and  forceps  on  the  after-coming  head  are  very 
often  reciuired.  Even  then  many  babies  are  lost.  If  the  patient  is  a  very  old 
primipara,  and  if  it  seems  likely  that  the  present  will  be  the  only  pregnancy,  the 
high  infantile  mortality  and  the  severe  pelvic  injuries  which  are  inevitaVjle  with 
forceps  deliver\'  should  be  given  great  weight  when  deciding  for  or  against  cesarean 
section.  Forced  ojjerative  delivery  in  such  cases  often  results  in  deep  lacerations 
of  the  vagina,  jiclvic  floor,  and  rectum,  even  rupture  of  the  pubis,  and  shows  a  pain- 
fully high  infant  mortality. 


LABOR  IN  OBLIQUELY  CONTRACTED  PELVIS 

Everything  depends  on  the  amount  of  contraction  of  the  conjugata  vera,  and, 
of  course,  on  the  forward  protrusion  of  the  promontory.  If  the  promontory  pro- 
jects low  toward  one  iliopul)ic  tubercle,  it  will  eliminate  that  half  of  the  pelvis, 
as  far  as  using  it  for  the  passage  of  the  head  is  concerned  (Figs.  647  and  648).     This 


Fig.  047. 


Fig.  648. 

Figs.  647  and  64S. — Di.\gr.\ms  Showing  how,  when  the  Promontory  Juts  into  the  Pelvis  on  one  Side,  that 
Side  is  Rendered  Useless  for  the  Entry  of  He.vd,  and  Changes  the  Inlet  to  one  of  the  Highly 
Generally  Contracted  Type.     Shaded  Portion  is  Useless  for  Labor. 


is  equivalent  to  a  generally  contracted  pelvis  of  highest  degree.  A  very  sharp  clinical 
distinction  must  be  made  Ijetween  pelves  which  are  simply  distorted,  but  with  little 
or  no  reduction  in  the  area  of  the  inlet  and  those  which  are  actualh'  contracted  or 
are  so  much  distorted  that  actual  contraction  results.  Generally  it  is  best  for  the  oc- 
ciput to  come  down  in  the  large  half  of  the  pelvis  (Figs.  648  and  649),  but  sometimes 
it  is  best  for  it  to  enter  pointing  toward  the  contracted  half.     Then  the  biparietal 


702 


THE    PATHOLOGY    OF    LABOR 


the  perineum  and  sacrum,  if  the  latter  does  not  curve  forward  too  much,  there  will 
still  be  plenty  of  room  for  the  passage  of  the  hyperflexed  head — only  the  soft  parts 
will  be  much  endangered.     If  the  bi-ischiatic  diameter  is  less  than  8  cm.,  it  is  the 


Fig.  644. — Head  Arrested  at  Outlet  by  Contraction. 
Note  how  head  stems  against  descending  ramus  of  pubis  and  is  thrown  against  coccyx. 


Fio.    64.5. — Head  Passing   the  Transversely   Con- 
tracted Outlet. 
Space  under  arch  of  pubis  cannot  be  utilized.     Peri- 
neum much  endangered.     P.S.,  Posterior  sagittal  diam- 
eter 


Fig.  646. — Absolutely  Impossible  Labor.  Head 
Stopped  by  Narrowing  Outlet.  Sacrum  Juts 
Forward  and  Prevents  Head  prom  Escaping 
IN  THE  Posterior  Sagittal  Diameter. 


rule  to  experience  trouble  with  the  delivery  and  forceps  are  often  needed.  If, 
in  addition,  the  posterior  sagittal  (Fig.  646)  is  less  than  9  cm.,  labor  is  very  difficult 
or  even  impossible,  and  craniotomy  is  usually  finally  resorted  to.     Williams  and 


MECHANISM    OF    LABOR    IN    FLAT    PELVES 


703 


Klien  seem  agreed  lluit  a  jx'Ivis  with  a  diaiiiclci-  (if  less  lliaii  .S.r>  ciii.  between  the 
tul)('r()siti(>s  and  a  posterior  .sa<^ittal  less  than  \)  ciii.  oilers  insupei'ahle  obstruction 
(o  labor  aiul  demands  cesarean  section,  pubiotcjmy,  or  cranioloniy. 

Brcedi  labors  are  especially  bad  in  lunnel  and  transversely  contracted  pelves, 
because  the  head  has  no  time  to  mold,  and  forceps  on  the  after-coming  head  are  very 
often  required.  Even  then  many  babies  are  lost.  If  the  patient  is  a  very  old 
priniipara,  and  if  it  seems  likely  that  the  present  will  be  the  only  pregnancy,  the 
high  infantile  mortality  and  the  severe  pelvic  injuries  which  are  inevitable  with 
forceps  delivery  shoukl  be  given  great  weight  when  deciding  for  or  against  cesarean 
section.  Forced  operative  delivery  in  such  cases  often  results  in  deep  lacerations 
of  the  vagina,  pelvic  floor,  and  rectum,  even  rupture  of  the  pubis,  and  shows  a  pain- 
fully hiiih  infant  mortality. 


LABOR  IN  OBLIQUELY  CONTRACTED  PELVIS 

Everything  depends  on  the  amount  of  contraction  of  the  conjugata  vera,  and, 
of  course,  on  the  forward  protrusion  of  the  promontory.  If  the  promontory  pro- 
jects low  toward  one  iliopubic  tubercle,  it  will  eliminate  that  half  of  the  pelvis, 
as  far  as  using  it  for  the  passage  of  the  head  is  concerned  (Figs.  647  and  G48).     This 


Fig.  04  7 


Fig.  648. 

Figs.  647  axd  G4S. — Diagrams  Showing  how,  when  the  Promontory  JrT.s  into  the  Pelvis  on  one  Side,  that 
Side  is  Rendered  Useless  for  the  Entry  of  Head,  and  Changes  the  Inlet  to  one  of  the  Highly 
Generally-  Contracted  Type.     Shaded  Portion  is  Useless  for  Labor. 


is  equivalent  to  a  gcncrallj'  contracted  pelvis  of  highest  degree.  A  very  sharp  clinical 
distinction  must  be  made  between  pelves  which  are  simply  distorted,  but  with  Httle 
or  no  reduction  in  the  area  of  the  inlet  and  those  which  are  actually  contracted  or 
are  so  much  distorted  that  actual  contraction  results.  Generally  it  is  best  for  the  oc- 
ciput to  come  down  in  the  large  half  of  the  pelvis  (Figs.  648  and  649),  but  sometimes 
it  is  best  for  it  to  enter  i)ointing  toward  the  contracted  half.     Then  the  biparietal 


704  THE    PATHOLOGY    OF   LABOR 

diameter  will  lie  in  promonto-iliopubic  diameter,  and  the  forehead  come  down  over 
the  opposite  sacro-ihac  joint.  In  Naegele  pelves  the  labor  is  further  complicated  by 
the  reduction  in  size  of  the  passage  all  the  way  to  the  outlet.  In  rachitic  pelves  this 
does  not  obtain,  and,  once  the  head  passes  the  inlet,  labor  is  quickly  ended. 

In  several  of  the  author's  cases  the  occiput  did  not  rotate  to  the  front,  but  re- 


FiG.  649. — Head  Molding  Into  an  Obuqtjely  Distobtbd  Pelvis. 
Case  from  which  the  i-ray  plate  was  made,  Fig.  594. 

mained  in  the  oblique,  and  the  head  escaped  over  one  or  the  other  ramus  pubis, 
the  latter  acting  as  the  fulcrum  against  which  the  nape  of  the  neck  stemmed,  while 
forehead  and  face  appeared  from  behind  the  opposite  ischial  tuberosity.  Breech 
labors  are  unwelcome  in  obliquely  contracted  pelves,  and  it  is  most  desirable  for 
the  occiput  to  come  down  on  the  side  not  contracted.  Such  a  mechanism  should  be 
brought  about,  if  possible,  during  operative  delivery. 

Literature 

Williams:  Surg.,  Gyn.,  and  Obstet.,  June,  1909,  and  Amer.  Jour.  Obstet.,  also  July,  1911.     Literature. 


CHAPTER  LVII 
PROGNOSIS  OF  LABOR  IN  CONTRACTED  PELVES 

The  Mother. — Niiturally,  it  is  impossible  to  present  figures  of  the  mortality 
of  labor  in  contracted  pelvis,  and  the  morbidity  will  always  remain  indeterminable. 
Mild  degrees  of  pelvic  contraction  may  not  have  much  effect  on  the  labor  except 
by  the  production  of  malprcsentations,  etc.,  which  demand  interference,  and  opera- 
tive measures  all  carry  a  certain  mortality  and  morbitlity.  In  general,  the  prog- 
nosis of  a  given  labor  depends  upon,  first,  the  degree  of  pelvic  contraction;  second, 
the  size  and  hardness  of  the  child,  especially  of  its  head;  third,  the  presentation, 
position,  and  attitude;  fourth,  the  strength  of  the  pains.  If  a  complication,  as 
eclampsia  or  placenta  praevia,  is  superadded,  the  prognosis  is,  of  course,  altered, 
and,  finally,  much  dejiends  on  the  cleanliness  and  skill  of  the  attendants. 

The  mother  is  exposed  to  the  following  dangers :  (1)  Obstructed  and  impossible 
labor,  which  eventuates  in — (a)  Rupture  of  the  uterus;  (6)  septicemia;  (c)  ex- 
haustion and  shock,  with  or  without  operation;  (2)  pressure  necrosis  of  the  walls 
of  the  genital  tract;  (3)  injuries  of  the  genital  tract,  for  example,  spontaneous 
rupture  of  the  uterus,  cervix,  vagina,  symphysis  pubis,  and  traumatic  rupture  of 
the  same;  (4)  infection  in  labor,  with  physometra  (tympania  uteri)  or  general 
septicemia;  (5)  exhaustion  and  shock. 

If  the  labor  is  completely  obstructed,  the  head  wedges  itself  into  the  narrow 
canal  and  becomes  firmly  fixed  (paragomphosis),  the  vagina  and  vulva  become 
enormously  swollen,  suggillated,  and  almost  black,  sometimes  sloughing  out 
entirely.  In  the  less  severe  cases  the  constant  pressure  produces  areas  of  necrosis 
which  later  make  deforming  scars  or  slough  out,  leaving  fistulas, — rectovaginal, 
vesicovaginal,  uterovaginal,  etc., — depending  on  the  part  of  the  pelvic  viscera  which 
underwent  the  severest  compression  l)etween  the  head  and  the  pelvis.  Flat  pelves 
cause  more  fistulas  than  generally  contracted,  because  in  the  latter  the  pressure 
is  more  evenly  distributed.  Pressure  necrosis  of  the  posterior  cervical  wall  may 
cause  adhesion  of  the  peritoneum  over  the  uterus  and  that  covering  the  promontory, 
retrofixation  of  the  uterus  resulting.  The  fistulas  are  often  not  apparent  for  a  few 
days,  that  is,  it  requires  this  time  for  the  slough  to  separate  and  estal^lish  com- 
munication between  the  two  cavities. 

Injuries  usually  are  the  result  of  operative  delivery,  but  sometimes  the  uterus 
itself,  acting  with  terrific  force,  may  force  the  child  through  its  own  walls,  or  through 
the  unprepared  cervix  or  perineum,  or  may  even  l^urst  the  pubic  symphysis.  Rarely 
the  sacro-iliac  joints  are  separated.  Traumatic  injur}'  of  the  soft  parts  is  due  to  too 
early  and  too  forcible  attempts  at  delivery,  and  even  a  skilful  accoucheur  maj-  cause 
it  when  the  tissues  are  softened  and  brittle  from  disease  or  long  labor.  The  scars 
from  these  injuries  may  distort  the  pelvic  viscera,  causing  malpositions  of  the  uterus, 
chronic  pelvic  congestion,  dislocation  of  the  liladder,  pulling  open  the  sphincter 
vesicae  causing  incontinence,  etc. 

Infection  in  labor  may  come  from  without, — the  usual  way, — the  phj'sician 
carrying  the  bacteria  either  on  undisinfected  hands  or  transferring  them  from  the 
vulva  and  vagina  into  sterile  regions,  and  it  may  occur  spontaneously,  the  result 
of  the  reduction  of  local  and  general  immunity.  Local  immunity  is  destroyed  in 
prolonged  labor  by  the  loss  of  the  epithelium,  its  weakening  by  imbibition,  by  the 
alteration  of  the  secretions  of  the  parturient  tract,  the  clear  mucus  being  replaced 
45  705 


706  THE    PATHOLOGY   OF   LABOR 

by  serum  and  blood,  and,  third,  the  local  traumatisms.  The  liquor  amnii  is  very 
prone  to  decomposition,  and  once  the  interior  of  the  uterus  is  infected,  the  general- 
ization is  rapid.  Tympania  uteri  is  sometimes  due  to  the  Bacillus  aerogenes  cap- 
sulatus,  but  more  often  to  the  Bacterium  coli  commune.  General  immunity  is 
weakened  by  the  exhaustion  and  shock  of  the  prolonged  labor,  anesthetics,  and 
operations.  Tetanus  uteri  is  of  grave  omen.  While  it  does  not  favor  rupture  of 
the  uterus,  labor  comes  to  an  absolute  stop,  and  unless  aid  is  rendered,  mother  and 
child  are  lost  from  exhaustion  and  sepsis. 

Exhaustion  and  shock  must  not  be  forgotten  as  complications  of  prolonged 
lal3or,  and  too  much  given  the  patient  to  overcome.  In  women  of  gracile  type,  the 
highly  polished  output  of  our  finishing  schools,  with  one  or  several  generations  of 
overcivilized  ancestors,  the  shock  of  hard  labor  is  badly  borne,  and  the  nervous 
system  may  suffer  permanent  damage.  While  contracted  pelves  are  uncommon  in 
this  class  (perhaps  a  tendency  to  general  smallness  may  be  noted),  the  children  are 
usually  well  grown,  and  since  the  uterine  action  is  nearly  always  deficient,  operative 
interference  is  frequently  required.  It  is  important  to  watch  the  effect  of  labor  on 
the  nervous  system  and  interfere  before  serious  inroads  have  been  made  on  it. 

Breech  and  shoulder  presentations,  in  some  respects,  are  better  for  the  mother 
than  the  head,  because  they  do  not  cause  pressure  necrosis,  and  early  attention  is 
called  to  the  anomalous  pelvis.  The  passage  of  the  child  in  delivery  is  rapid,  and 
experience  shows  that  intense  compression  of  short  duration  is  less  dangerous  to  the 
tissues  than  a  mild  pressure  kept  up  for  a  long  time. 

The  Child. — In  the  highest  degrees  of  pelvic  contraction  the  child  has  the  oest 
chances  for  its  life,  because  the  absolute  disproportion  is  usually  early  recognized 
and  cesarean  section  performed.  In  the  very  slight  pelvic  contractions  the  infant 
mortality  is  not  much  higher  than  usual,  but  anomalies  of  the  mechanism  of  labor 
must  be  remembered.  Many  children  still  are  lost  in  the  cases  where  the  pelvis 
is  contracted  enough  to  show  in  the  course  of  labor,  and  this  is  because  the  ac- 
coucheur has  not  carefully  studied  his  patient.  Too  many  women  are  blindly  al- 
lowed to  go  into  labor,  and  only  after  the  good  time  for  cesarean  section  or  pubiot- 
omy  has  gone  by  is  the  spacial  cUsproportion  discovered.  Often  it  is  found  only 
after  the  accoucheur  has  failed  to  deliver  with  forceps. 

Asphyxia  causes  the  largest  number  of  fetal  deaths,  and  it  is  brought  about  by 
— (1)  Interference  with  the  placental  circulation,  the  result  of  the  frequent  and 
powerful  uterine  contractions — the  blood  is  forced  out  of  the  uterus  by  the  pains; 
(2)  compression  of  the  brain  as  the  head  is /jammed  through  the  inlet — the  pressure 
irritates  the  pneumogastric,  slows  the  pulse,  and  compromises  still  further  the  oxy- 
genation of  the  fetal  blood;  (3)  as  the  effect  of  the  early  rupture  of  the  membranes 
and  the  escape  of  the  liquor  amnii  the  uterus  retracts,  the  placental  area  is  diminished, 
and  abruption  of  the  organ  is  favored;  (4)  prolapse  of  the  cord  is  common,  espe- 
cially in  flat  pelves,  and  this  is  always  a  very  serious  affair  for  the  child.  As  long 
as  the  bag  of  waters  is  intact  these  dangers  hardly  exist,  but  it  would  be  wrong  to 
say  they  never  threaten  the  child,  because  I  have  seen  deaths  of  the  fetus  occur  by 
the  above  mechanisms  with  an  intact  amniotic  sac. 

Injuries  of  the  brain,  of  the  cranium,  and  of  the  body  of  the  child  are  very  com- 
mon. Many  children  die  from  cerebral  compression  without  external  injury,  and 
not  a  few  die  from  concussion  of  the  brain  from  forceps  or  breech  delivery.  More 
often  death  is  due  to  intracranial  hemorrhage  from  skull  fracture.  This  may  be  in 
the  form  of  fissures  radiating  from  the  center  of  ossification  of  the  flat  bones  toward 
the  sutures  of  the  skull.  jNIany  times  cephalhematoma  is  due  to  such  fissures,  the 
clot  in  these  instances  being  outside  the  skull,  under  the  periosteum.  Depressed 
skull  fractures  occur  with  forceps,  but  particularly  with  breech  deliveries,  and  they 
look  as  if  the  bone  had  been  pressed  in  with  a  spoon  (Fig.  650).  They  are  sometimes 
attended  by  intracranial  hemorrhage,  and  are  then  usually  fatal.     They  are  most 


PROGNOSIS  OF  LABOR  IN  CONTRACTED  PELVES 


707 


often  located  between  the  parietal  bosses  and  the  coronary  sutures,  but  one  of  my 
cases  showed  the  depression  right  behind  and  above  the  left  ear. 

If  not  primarily  fatal,  the  child  may  recover  and  show  no  signs  of  permanent 
damage  to  the  brain,  the  deformity  becoming  less  with  time,  but  never  disappearing. 
Another  form  of  skull  dei)ression,  not  always  a  fracture,  because;  the  bone  is  soft 
and  flexible,  is  the  groove  (Fig.  651).  This  deformity  is  due  to  the  molding  of  the 
head  by  th(^  sharp  iiromontory,  and  disappears  almost  entirely  in  a  few  months. 
It  is  harmless  of  itself,  l)ut  may  be  serious  if  large,  deep,  or  complicated  Ijy  fracture 
oi-  intracranial  hemorrhage.  These  fiat  depressions  usually  parallel  the  coronary 
suture.  They  require  no  treatment.  Separation  of  the  flat  bones  at  the  basilar 
sutures  is  one  of  the  worst  of  the  birth  injuries,  because  the  large  cerebral  blood- 
sinuses  lie  in  the  neighborhood,  and  if  torn,  allow  fatal  intracranial  hemorrhage. 


\ 


>■;> 


hf 


Fig.  650. — Spoon-shaped  DEpnEssioN.     Extraction-  by 

BuEEfH. 

Three  successive  children  had  the  same  injury. 


Fig.  651  — Groove  Depression.     Forceps  Case. 


The  parietal  bone  may  tear  away  from  the  squamous  portion  of  the  temporal 
bone  at  the  anterior  lateral  fontanel — the  sutura  squamosa;  the  occipital  plate 
may  separate  from  the  condyles.  In  the  latter  instance  the  plate  then  may  be 
dislocated  directly  onto  the  medulla,  causing  immediate  death. 

The  morbidity  of  children  delivered  through  contracted  pelves  is  also  very 
large. 

Pressure  necrosis  of  the  scalp  has  been  already  mentioned.  This  may  he  in 
all  degrees  from  a  simple  desquamation  with  redness  to  actual  sloughing  of  the 
tissues,  with  laying  bare  of  the  bone  and  exfoliation  of  sequestra — in  a  few  instances 
followed  by  meningitis.  These  pressure  marks  are  made  by  the  promontory,  but 
sometimes  by  an  exostosis  on  the  posterior  surface  of  the  pubis,  and  are  the  external 
evidence  of  long  labor.     Fistulas  in  the  mother  usually  result  at  the  same  time. 


708  THE    PATHOLOGY    OF   LABOR 

Cephalhematoma  is  a  complication  of  fractures  of  the  skull.  The  clot  lies  under 
the  external  periosteum,  is  limited  always  by  the  sutures,  may  be  single  or  mul- 
tiple, external  and  internal  combined,  and  may  cover  a  depressed  fracture.  These 
hematomata  alone  are  not  fatal,  but  require  many  months  for  complete  resorption, 
and  leave  a  ridge  of  bone  at  the  edges  for  many  weeks  more. 

Caput  succedaneum  occurs  in  its  greatest  proportions  in  contracted  pelves. 
It  may  be  visible  at  the  vulva  while  the  head  has  not  yet  passed  the  inlet.  Since 
the  caput  succedaneum  is  due  to  the  fact  that  the  pressure  inside  the  uterus  is 
greater  than  that  in  the  vagina,  it  indicates  strong  uterine  action.  It  does  not  show 
that  the  head  fits  the  inlet  tightly,  and  it  does  not  do  much  to  aid  in  the  dilatation 
of  the  cervix,  as  some  writers  state. 

In  generally  contracted  pelves  the  caput,  by  lengthening  the  head  wedge, 
may  assist  the  labor,  but  little  is  thus  accomplished.  Of  great  chnical  importance 
is  the  proper  estimation  of  the  c^-put,  because  if  the  scalp  is  visible  at  the  vulva, 
the  accoucheur  may  hastily  conclude  that  the  head  is  engaged  and  be  misled  into 
unfortunate  operating,  while  in  reality  the  head  may  be  above  the  inlet.  The  caput 
also  covers  up  the  landmarks  of  the  head  and  renders  the  diagnosis  of  position  very 
difficult. 

Fractures  of  the  clavicle,  the  humerus,  and  the  femur  and  disruption  of  the 
vertebral  column  are  almost  invariably  due  to  brute  force,  exhibited  during  oper- 
ative delivery.  The  same  may  be  said  of  tearing  of  the  nerves  of  the  cervical  plexus 
— Erb's  paralysis,  etc.  Fracture  of  the  long  bones  and  of  the  skull  may,  however, 
occur  during  spontaneous  labor. 

The  author  is  convinced  that  many  children  carry  the  effects  of  minor  injuries 
received  at  birth  all  their  lives.  It  stands  to  reason  that  the  innumerable  and 
thickly  sown  minute  hemorrhages  found  in  the  brain  after  forceps  and  other  hard 
deliveries  must  leave  at  least  a  fibrosis  behind.  These  thickenings  may  explain 
cases  of  epilepsy,  idiocy,  paralyses,  pareses,  chronic  headache,  tic  douloureux,  retinal 
lesions,  strabismus,  and  some  other  focal  nerve  diseases  in  later  life.  Even  abnor- 
mal moral  and  mental  conditions  might  be  explained  as  due  to  injuries  sustained  at 
birth,  though  at  present  there  is  little  evidence  to  support  the  theory.  Such  a 
belief  would  increase  the  burden  of  responsibility,  already  too  heavily  laid,  on  the 
shoulders  of  the  accoucheur. 

The  outlook  for  the  child  depends,  of  course,  on  the  degree  of  pelvic  contrac- 
tion, the  severity  of  the  operative  delivery,  the  skill  of  the  accoucheur,  and  the 
nature  of  the  operation. 


CHAPTER  LVIII 
TREATMENT  OF  CONTRACTED  PELVIS 

No  sul)ject  in  meclicinc  presents  greater  difficulties  in  all  its  aspects  than  this 
one,  and  none  demands  so  much  art  or  practical  skill.  Science  aids  little  here. 
Kn()\vled<i,e  of  the  passages,  of  the  powers,  of  the  passengers,  of  the  mechanism  of 
labor,  all  help  a  great  deal,  but  more  depends  on  experience  and  judgment.  Even 
large  experience  is  fallacious  and  judgment  is  difficult — the  words  of  Hippocrates, 
the  truth  of  which  is  often  proved  when  the  accoucheur  finds  that  a  fetus  he  said 
could  not  pass  through  a  certain  pelvis  is  delivered  before  he  can  reach  the  bedside, 
and  another  which  he  confidently  predicted  would  be  born  easily  requires  a  grave 
operation.  Alany  factors  besides  the  pelvic  contraction  enter  mto  the  course  of  the 
labor,  and  success  in  treatment  depends  on  the  proper  valuation  of  each  and  the 
proper  placement  of  their  relations  to  each  other.  Some  of  these  factors  can  be 
accurately  evaluated  before  or  during  labor,  others  partly,  and  a  few  not  at  all. 
These  factors  are  the  attitude,  presentation,  and  position  of  the  child,  the  size  and 
hardness  of  its  head,  the  shape  of  its  body,  whether  there  are  one  or  two  fetuses, 
the  shape  of  the  pelvis,  that  is,  the  distribution  of  the  available  space,  the  height 
of  the  promontory,  the  inclination  of  the  inlet,  the  movability  of  the  pelvic  syn- 
chondroses, the  state  of  the  soft  parts,  the  character  of  the  uterine  contractions 
(strong  pains  being  able  to  accomplish  wonderful  results),  the  presence  or  absence 
of  infection  in  the  parturient  canal,  the  nervous  temperament  of  the  parturient,  and 
her  general  health.  Outside  factors  must  also  often  be  considered:  (1)  The 
environment,  whether  the  parturient  is  in  a  squalid  tenement,  in  the  country,  in  a 
home  where  every  appliance  is  obtainable,  or  in  a  well-equipped  maternity;  (2) 
whether  in  the  hands  of  the  general  practitioner  or  a  trained  specialist;  (3)  if 
the  patient  is  a  Catholic,  all  medically  indicated  procedures  not  being  permitted; 
(4)  the  age  of  the  parturient  and  the  probability'  of  her  having  more  children. 
Even  with  this  enumeration,  the  possible  factors  which  might  influence  a  labor  or 
our  decision  regarding  the  course  to  pursue  have  not  all  been  mentioned.  It  must 
always  be  borne  in  mind  that  nature  is  able  to  overcome  the  difficulties  of  contracted 
pelves  in  the  majority  of  cases.  Ludwig  and  Savor  found  that  75  per  cent,  of  such 
cases  terminate  spontaneously  when  the  conjugata  vera  is  not  less  than  9.5  cm.; 
that  58  per  cent,  with  a  conjugata  vera  of  9  cm.,  50  per  cent,  with  one  of  8.5  cm., 
and  25  per  cent,  with  one  of  8  cm.,  require  no  aid  from  art.  A  course  of  watchful 
expectancy  was  all  that  was  needed  in  these  labors. 

Diagnosis  of  Disproportion. — In  all  cases  the  first  thing  to  determine  is  the 
existence  and  degree  of  disproportion  between  the  child  and  the  pelvis;  in  other 
words,  the  question  must  be  answered,  will  the  child  go  through  the  pelvis?  The 
routine  measurement  of  the  pelvis  of  every  pregnant  woman  coming  under  his  care 
will  have  directed  the  accoucheur's  attention  to  the  existence  of  obstruction  in  the 
birth-canal.  When  labor  begins,  another  examination  should  be  made  because 
it  is  much  easier  to  obtain  the  internal  measurements  at  this  time.  (See  p.  240.) 
The  history  of  previous  labors  is  of  great  value,  but  it  must  be  carefully  sifted.  A 
woman  may  have  had  severe  dystocia,  even  craniotomy  or  cesarean  section,  and 
yet  have  a  normal  pelvis  which  would  give  no  trouble  in  the  present  labor.  It  is 
possible,  with  moderate  experience  and  thorough  application  of  our  present  meth- 
ods, to  obtain  a  quite  accurate  knowledge  of  the  actual  size  of  the  pelvic  lumen. 

709 


710 


THE    PATHOLOGY    OF   LABOR 


Not  SO  much  may  ])e  said  of  the  child.  It  is  harder  to  form  an  opinion  of  its  size, 
and  still  harder  to  estimate  the  ossification  and  configurability  of  its  head.  The 
intra-uterine  length  of  the  child  is  easily  measured  (p.  267).  With  the  cephalometer 
the  transverse  or  the  oblique  diameters  of  the  head  can  be  obtained,  and  by  de- 
ducting 23/^  or  13^2  cm.,  the  biparietal  diameter  is  approximately  estimated — at 
least,  one  gains  a  fairly  accurate  idea  of  the  size  of  the  head.  By  grasping  the  child 
from  the  outside  and  placing  the  fingers  against  the  head  per  vaginam,  one  may 
balance  its  body  between  the  two  hands  and  guess  its  weight  and  size.  If  the 
accoucheur  will  make  this  little  manoeuver  a  part  of  his  routine  in  every  labor, 
checking  up  his  guesses  by  weighing  the  children  after  delivery,  he  will  be  surprised 
to  find,  after  a  few  years,  how  accurately  he  can  estimate  their  weight.     One  de- 


FiG.  652. — Palpating  Head  and  its  Relatiu.ns  to  the  Postebior  SunFACE  of  the  Pubis. 
This  head  would  jjrobably  not  enter  the  pelvis. 


termines  the  hardness  of  the  fetal  head  bj^  the  general  impression  of  firmness  of  the 
bones  conveyed  to  the  fingers,  the  sharpness  of  the  contour  of  the  parietal  bosses, 
the  size  of  the  fontanels  (if  almost  obliterated,  it  shows  hyperossification) ,  the 
extent  to  which  the  bones  overlap  during  the  pains,  and  the  breadth  of  the  dome  of 
the  cranium.  If  the  bones  are  soft,  the  dome  is  acute,  while  a  hard  calvarium  is 
more  fiat.  Previous  children  may  have  been  large  or  small,  with  hard  or  soft 
heads,  and  the  length  of  the  present  pregnancy  must  also  be  taken  into  considera- 
tion.    Children  that  are  carried  overterm  usually  have  large  hard  heads. 

After  getting  as  good  a  general  idea  as  possible  of  the  size  and  consistence 
of  the  child,  the  accoucheur  tries  to  determine,  by  more  direct  means,  if  the  head 
is  likely  to  go  through  the  pelvis.  For  this  purpose  it  is  better  if  the  woman  has 
been  in  actual  labor  until  the  cervix  is  effaced  and  pulled  up  out  of  the  pelvis,  thus 


TREATMENT  OF  CONTRACTED  PELVIS 


711 


allowing  the  fetal  hoad  to  apjily  itself  more  elosely  Ut  the  inlet.  However,  such 
conditions  are  not  always  met,  and  one  has  to  form  his  judgnjent  by  allowing  duly 
for  disturbing  factors.  Fig.  G52  shows  the  first  mana-uvcr.  The  head  is  forced 
down  onto  the  inlet,  the  fingers  inside  steadying  it,  and  it  is  then  easy  to  find  if  the 
anterior  i)arietal  boss  ijrojects  in  front  oi  the  i)osterior  surface  of  the  puljis  and  how 
imich.  If  tiie  child  presents  with  the  occiput  posterior,  the  forehead  will  1)6  quite 
l^ronunent  in  front,  and  this  point  must  not  be  forgotten.  A  full  rectum  will  also 
push  the  head  forward.  jMiiller's  procedure  consists  in  having  an  assistant  force 
the  head  down  into  the  inlet 
while  the  inside  fingers  deter- 
mine how  far  it  enters  the  pel- 
vis. It  has  value  only  after 
the  cervix  is  out  of  the  way,  be- 
cause the  soft  parts  will  prevent 
the  head  from  engaging  under 
the  amount  of  downward  pres- 
sure it  is  possible  safely  to  exert 
])y  the  two  hands.  The  most 
valual)le  of  all  is  the  determina- 
tion of  the  degree  of  engage- 
ment. Reference  has  already 
been  made  to  the  criteria  of  en- 
gagement of  the  fetal  head.  If 
the  vault  of  the  pelvis  is  empty, 
the  head  being  high  and  float- 
ing, in  the  absence  of  other 
causes  for  non-engagement  the 
pelvis  is  probably  much  con- 
tracted; if  the  head  enters  the 
region  of  the  inlet  with  a  large 
segment  projecting  into  the 
excavation  and  is  more  or  less 
fixed,  the  accoucheur  may  feel 
fairly  sure  that  the  pains  "svill  suc- 
ceed in  molding  it  sufficiently 
for  spontaneous  delivery. 

Passing  the  fingers  around 
the  head  and  alternately  touch- 
ing the  walls  of  the  pelvis  it  is 
not  hard  to  form  a  quite  accur- 
ate conception  of  the  degree  of 
disproportion.  Combined  pal- 
pation of  the  head,  like  that 
used  in  estimating  the  size  of  the 
uterus,  gives  useful  information. 

If  the  lowest  portion  of  the  head  has  reached  the  interspinous  line  (Fig.  653),  engage- 
ment is  usualh'  certain.  In  fiat  rachitic  pelves  the  side  walls  are  so  low  tliat  this 
sign  must  be  qualified.  Here  the  lowest  portion  of  the  head  must  have  passed  this 
line  by  a  little.  The  other  signs — the  covering  of  the  sacrum  and  of  the  pubis — 
are  also  valuable,  particularly  the  former. 

Now  a  minute  diagnosis  of  presentation,  position,  and  attitude  must  be  made. 
If  the  child  presents  in  a  franiv  O.L.A.,  the  probabilities  of  a  disturbing  degree  of 
pelvic  contraction  are  not  so  strong.  If  tlie  anterior  or  posterior  parietal  bone  pre- 
sents and  the  attitude  does  not  correct  itself  under  the  influence  of  the  pains,  usually 


Fig.  653. — Determixing  if  Head  has  Reached  Interspinous  Line. 

The  fingera  touch  the  left  ischial  spiae,  then  swing  around  pelvis  to 

the  right  one,  then  touch  the  lowest  portion  of  head. 


712  THE    PATHOLOGY    OF   LABOR 

a  badl}^  contracted  pelvis  exists.  The  presence  of  anterior  or  posterior  parietal 
bone  presentation  generally  must  be  taken  as  an  indication  of  grave  dystocia,  though 
nature  often  terminates  such  cases  happily.  However,  in  deciding  beforehand 
whether  a  given  head  will  pass  through  a  given  pelvis  these  abnormal  presentations 
are  very  sig-nificant,  because  if  they  are  very  marked,  the  hkelihood  of  a  successful 
spontaneous  delivery  is  remote. 

A  careful  study  of  the  uterine  action  is  now  in  order.  Good  regular  pains  may 
overcome  great  resistances.  Weak,  infrequent,  irregular,  or  cramp-like  pains  may 
be  unable  to  terminate  a  labor  otherwise  normal.  The  nervous  constitution  of  the 
woman  will  also  require  some  attention.  A  nervous,  impatient,  unruly  disposi- 
tion, or  even  acute  nervous  prostration,  may  be  the  cause  for  interference  when  the 
mechanical  disproportion  is  not  great.  , 

Finally,  we  have  the  test  of  labor,  but  the  attendant's  decision  regarding  his 
conduct  of  the  case  must  be  made  before  he  trusts  the  case  to  nature. 

For  purposes  of  discussion  it  is  customary  to  divide  contracted  pelves  into  four 
classes.  It  must  be  emphasized,  at  the  very  start,  that  such  a  division  is  purely 
arbitrary,  because  the  size  of  the  child  is  not  considered,  nor  are  any  of  the  above- 
mentioned  factors  allowed  for,  but  some  common  basis  for  discussion  must  be  had. 

I.  Pelves  with  a  conjugata  vera  less  than  53/^  cm.  in  the  flat,  and  6  cm. 

in  the  generally  contracted,  variety.     These  are  absolutely  contracted. 

II.  Pelves  with  a  conjugata  vera  of  5J4,  to  73^2  cm,  in  flat,  and  6  to  8  cm. 

in  the  generally  contracted,  types.     These  are  relatively  contracted. 

III.  Pelves  with  a  conjugata  vera  of  73^  to  9  cm.  in  flat,  and  8  to  9^2  cm. 
in  the  generally  contracted.     These  are  moderately  contracted. 

IV.  Pelves  with  a  conjugata  vera  over  9  and  9^  cm.  respectively,  and 
are  border-line  cases. 

I.  In  the  absolutely  contracted  pelvis  no  difficulty  is  met  in  deciding  on  treat- 
ment. A  full-sized  child  cannot  be  delivered  through  it,  and  for  this  reason  cesarean 
section  is  indicated  whether  or  not  the  child  is  living.  This  is  the  absolute  indication 
for  the  operation.  If  the  woman  is  seen  early  in  pregnancy,  therapeutic  abortion 
comes  up,  but  the  author  does  not  recommend  it,  prefering  cesarean  section  at 
term,  under  the  ideal  conditions  always  obtainable  when  the  pelvic  contraction 
is  so  timely  recognized.  If  the  accoucheur  is  called  late  in  labor,  when  infection  is 
probably  present,  Porro  cesarean  section  is  indicated. 

II.  In  the  relatively  contracted  pelvis  (conjugata  vera,  5^/2  and  6  to  7}4,  and  8 
cm.)  decision  also  is  not  very  difficult.  If  the  child  is  dead,  craniotomy  is  inchcated. 
A  full-sized  child  cannot  be  gotten  through  the  pelvis  alive,  and  the  question  to 
decide  is  shall  the  mother  be  subjected  to  the  risks  of  cesarean  section  in  order  to 
save  the  infant?  This  is  the  relative  indication  for  cesarean  section,  and  it  may  be 
allowed  only  under  certain  conditions.  If  the  woman  has  been  in  active  labor  a 
long  time;  if  the  membranes  have  been  ruptured  for  many  hours;  if  frequent  in- 
ternal examinations  have  been  made,  and  by  hands  whose  asepsis  cannot  be  assured ; 
if  operative  delivery  has  been  attempted;  if  infection  has  begun  or  is  suspected — 
certainly  if  the  woman  has  fever  or  fetid  discharge,  cesarean  section  from  the  relative 
indication  is  prohibit(>d.  If  these  conditions  do  not  exist,  but  the  case  has  come  early 
into  the  hands  of  a  man  capable  of  his  task,  uninfected,  and  in  suitable  surround- 
ings, the  cesarean  section  is  the  operation  of  election.  In  the  first  instance  crani- 
otomy is  not  alone  justifiable,  ])ut  demanded,  and  in  the  second  instance  the  ac- 
coucheur must  recommend  the  abdominal  delivery.  The  facts  are  to  be  laid  before 
the  patient,  the  husband,  and  the  family,  and  they  must  decide.  Naturally,  the 
accoucheur  should  guide  them  in  the  decision,  and  if  they  do  not  agree  with  him, 
he  should  not  be  constrained  to  sacrifice  the  child  when  the  conditions  are  ideal  for 
cesarean  section.     Nor  should  he,  when  convinced  that  the  disproportion  is  too 


TREATMENT  OF  CONTRACTED  PELVIS  713 

great,  allow  the  woman  to  labor  until  the  right  time  for  the  abdominal  delivery  has 
gone  by.  He  is  at  liberty  to  retire  from  the  eaae  und(!r  either  circumstance,  but 
must  first  provide,  or  see  that  the  family  provitles,  other  medical  assistance.  Extra- 
jjcritoneal  cesarean  section  has  not  yet  proved  its  superiority  over  the  classic 
method.     Its  consideration  will  l^e  reserved  for  a  separate  chapter. 

If  craniotomy  has  to  be  performed  because  of  pelvic  contraction,  the  woman, 
the  husband,  and  the  family  must  be  instructed  that  in  the  event  of  a  subsequent 
pregnancy  medical  aid  is  to  be  provided  early,  and  arrangements  made  for  the 
(•cesarean  section  under  ideal  conditions.  The  accoucheur  should  not  be  asked  to 
perform  craniotomy  a  second  time  on  the  same  woman.  Such  an  operation  to- 
(la>'  is  unjustifiable,  owing  to  the  perfection  of  obstetric  art. 

An  immense  mass  of  literature  has  been  accumulated  on  the  (juestion  of  the  justifiabihty  of 
craniotomy  on  the  living  child.  In  a  paper  published  in  11)01  (American  Journal  of  Obstetrics, 
vol.  xliv,  No.  4)  the  author  considered  the  subject  in  all  its  aspects,  and  has  changed  his  opinions 
but  little  .since. 

Ko.ssmann,  Mann,  Leopold,  Olshausen,  Schauta,  Chrobak,  and  Knapp  have  written 
exhaustively  on  it  and  reached  the  same  general  conclusions.  The  stand  taken  by  the  Catholic 
Church  is  well  known.  Under  no  circumstances  may  human  life  be  deliberately  taken  even  when 
it  is  don(>  to  save  another  life.  In  Catliolic  families,  therefore,  the  accoucheur  is  in  duty  bound 
to  consider  this  aspect  of  the  case,  and  the  author  makes  it  an  invariable  rule  to  remind  the  patient 
and  family  of  this  view  of  the  Church,  and  to  ask  that  the  family  priest  be  summoned  to  aid  in 
their  tleliberations. 

With  few  exceptions,  all  experienced  writers  are  agreed  that  the  sacrifice  of  the  living  child 
is  still  justifiable.  The  cases  in  which  this  is  necessary  are  very  scarce  and  becoming  scarcer 
each  year,  there  having  been  so  much  improvement  in  obstetric  teaching  and  practice  that 
severe  dystocia  is  more  often  recognized  early — in  time  for  life-saving  operations.  Neglected 
and  unrecognized  cases  do  still  occur,  mistaken  and  unsuccessful  operations  are  still  attempted, 
aseptic  care  of  parturients  is  still  not  universal,  and  infection  is  still  common,  so  that  wlien  the 
accoucheur  finally  has  to  complete  the  delivery,  he  is  usually  glad  to  be  able  to  save  one  life. 
Again,  a  woman  may  absolutely  refuse  to  endanger  her  own  life  for  her  child,  and  this  she  has  a 
perfect  right  to  do.  On  the  other  hand,  the  necessity  of  sacrificing  a  perfectly  healthy  child 
almost  never  arises.  When  the  patient  reaches  this  point  the  child  has  nearly  always  been  injured 
by  long  labor,  by  attempts  at  delivery,  by  being  infected  or  having  inspired  infected  liquor  amnii, 
and  it  very  often  dies  within  a  few  days,  even  if  delivered  alive.  Furthermore,  30  per  cent,  of 
all  children  die  before  they  are  five  years  old.  In  comparing  the  life  values  of  mother  and  child, 
this  point  must  be  considered. 

Without  doubt,  in  former  years  too  many  children  were  sacrificed  and  infantile  life  was 
held  too  cheaply.  Nowadays  we  are  saving  a  great  many  by  means  of  cesarean  section  and  pubi- 
otomy,  but  there  is  a  tendency,  as  Chrobak  observes,  to  go  to  the  other  extreme,  and  expose  the 
mothers  to  greater  dangers  than  the  end  justifies.  As  Chrobak  says,  ''it  almost  seems  we  must 
protect  the  mothers  against  the  children  and  that  we  forget  that  salus  matris  suprema  lex."  Since 
tiie  vast  majority  of  births  occurs,  not  in  the  large  cities,  where  matei-nities  and  specialists  are 
obtainable,  but  in  towns,  villages,  and  in  the  country,  it  will  follow  that  manj^  children  will  have 
to  be  sacrificed  to  save  the  mothers,  and  the  accoucheur  will  deserve  congratulations  if,  under 
trjing  circumstances  and  amid  unfavorable  conditions,  he  saves  the  mother.  Every  accoucheur, 
however,  breathes  one  prayer — speed  the  day  when  craniotomy  of  the  living  child  can  be  abolished! 

III.  In  the  moderately  contracted  pelves,  those  with  a  conjugata  vera  of  7}^  to 
9  cm.,  and  8  to  93  2  cm.  (in  the  flat  and  generally  contracted  types  respectively), 
the  most  delicate  questions  and  the  greatest  difficulties  arise. 

Treatment  During  Pregnancy. — Induction  of  Premature  Labor. — Since  a  small 
infant  with  a  soft  small  head  can  usually  pass  through  a  moderately  contracted 
pelvis  and  survive,  we  may  make  use  of  this  knowledge  and  induce  labor  at  a  period 
of  pregnancy  when  the  child  has  not  yet  attained  a  size  sufficient  to  block  the  pelvis. 

Louise  Bourgeois  (born  1.563,  died  1636),  midwife  to  Marie  de  Medicis,  first  recommended 
and  practised  the  induction  of  premature  labor  to  save  the  life  of  the  mother,  and  gave  as  indication 
intractable  hemorrhage.  Roussel  de  Vauzclme,  in  1778,  recommended  the  operation  in  contracted 
pelvis,  saying  that  Petit  had  practised  it  many  years.  In  the  middle  of  the  nineteenth  century 
the  operation  had  a  good  vogue,  and  deserved  it,  because  the  mortality  of  cesarean  section,  sym- 
physiotomy, and  craniotomy  was  so  high.  As  the  technic  and  results  of  these  operations  imjiroved 
the  preference  went  to  them,  because  of  the  high  infant  mortahty  and  dangers  and  troublesome 
complications  of  induced  labor,  but  even  today  the  majority  of  authorities  agree  that  the  induction 
of  labor  after  viability  of  the  cliild  is  a  valuable  operation. 

If  the  contraction  of  the  pelvis  is  known  early  in  pregnancy,  the  course  of 


714  THE    PATHOLOGY    OF   LABOR 

treatment  to  be  pursued  must  be  at  once  decided  upon.  Many  women  consider  a 
previous  difficult  labor  sufficient  indication  for  the  induction  of  abortion,  and  come 
to  the  physician  with  this  request.  In  the  first  place,  a  previous  difficult  labor 
may  have  been  due  to  entirely  different  causes  or  even  incompetent  medical  care, 
and  in  the  class  of  pelves  under  consideration  this  indication  will  never  arise,  be- 
cause, if  necessary,  labor  can  be  induced  after  fetal  viability,  with  no  more  danger 
than  abortion  and  with  over  60  per  cent,  chances  of  saving  the  infant.  The  facts 
are  to  be  laid  before  the  family,  but  the  accoucheur's  decision  not  to  do  an  abortion 
should  be  final.  Primarily,  it  must  be  stated  that  a  large  number — perhaps  75 
per  cent. — of  labors  in  such  pelves  terminate  spontaneously  at  or  near  term;  second, 
that  cesarean  section  performed,  as  it  can  be,  when  the  need  for  it  is  known  so  far 
beforehand,  has  a  very  low  mortality — less  than  2  per  cent. ;  third,  that  should  the 
event  prove  that  labor  will  not  terminate  spontaneously,  in  pubiotomy  we  have  an 
operation  that  will  still  save  the  child  and  not  seriously  endanger  the  mother; 
fourth,  that  should  all  our  plans  fail,  craniotomy  could  still  be  performed  as  a  last 
resort  after  the  test  of  labor  has  been  faithfully  tried. 

On  the  other  hand,  the  operation  of  induced  labor  is  not  absolutely  safe. 
Statistics  give  the  maternal  mortality  as  1  to  2  per  cent.,  but  nowadays,  in  the  hands 
of  a  capable  accoucheur,  there  should  be  no  mortality.  From  20  to  30  per  cent, 
of  the  children  are  lost  in  labor,  and  another  portion  dies  within  a  few  weeks,  in 
spite  of  the  incubator,  good  nursing,  etc.  Then,  too,  the  uterus  is  sometimes  very 
sluggish  and  torpid,  requiring  much  stimulation,  instrumentation,  frequent  ex- 
aminations, etc.,  lasting  several  days  to  even  a  week.  Although  our  calculations 
have  been  as  careful  as  is  humanly  possible,  and  our  decisions  logical,  mistakes  often 
creep  in;  for  example,  the  child  is  too  large  to  come  through,  or  it  is  too  small  to 
live  after  being  born.  Accidents  also  complicate  the  process;  for  example,  the  posi- 
tion and  presentation  are  unfavorable,  the  cord  prolapses,  the  nervous  condition 
of  the  patient  requires  interference  before  the  os  is  open,  fever  arises,  which  forces 
our  hand,  or,  indeed,  the  child,  while  large  enough,  is  atelectatic  or  deformed,  so 
it  cannot  live.  All  these  conditions  have  been  observed  by  the  author  and  have 
much  reduced  his  enthusiasm  for  the  induction  of  premature  labor  in  contracted 
pelves,  though  he  occasionally  still  performs  it. 

If  the  family  elects  the  induction  of  premature  labor  as  being  less  dangerous, — 
and  in  private  practice  they  usually  do  choose  it, — the  accoucheur  has  to  decide 
on  the  right  time  to  begin  it.  A  period  must  be  selected  when  the  child  is  not  too 
large  to  pass  through  the  pelvis  and  yet  developed  enough  for  extra-uterine  exist- 
ence. The  best  time  is  between  the  thirty-second  and  thirty-fourth  week.  After 
the  thirty-sixth  week  the  child  is  too  large ;  before  the  thirtieth  week  its  chances  of 
survival  are  poor.  Added  to  the  difficulties  of  determining  the  exact  period  of 
pregnancy — and  errors  of  three  weeks  either  way  are  not  uncommon — is  the  fact 
that  some  children  develop  faster  than  others,  and  are  as  large  at  eight  months  as 
the  others  are  at  term.  My  practice,  in  cases  set  aside  for  premature  labor,  is  as 
follows :  The  date  of  conception  is  fixed  as  accurately  as  possible,  using  the  dates  of 
menstruatioUj  coitus,  and  cjuickcning  as  a  basis.  At  the  sixth  month,  and  every 
two  weeks  thereafter,  the  child  is  carefully  palpated  and  measured  (p.  267).  If, 
as  the  thirty-third  week  approaches,  the  child  is  found  to  be  getting  too  large  to 
pass  through  the  pelvis,  labor  is  started.  If  possible,  the  day  is  selected  which 
would  correspond  to  the  time  of  the  menstrual  period,  ])ecause  at  such  periods  the 
uterus  is  more  sensitive  and  reacts  quicker  to  stimulation.  Miiller's  procedure — 
pressing  the  head  into  the  pelvis  to  see  if  it  can  enter — has  proved  valueless  in  my 
hands.  The  women  will  not  tolerate  the  small  amount  of  pain  thus  caused,  and, 
further,  the  soft  parts  may  prevent  the  engagement  of  a  head  which  a  few  labor 
pains  can  force  through  very  easily.  The  decision  as  to  the  right  time  to  begin  is 
one  of  experience,  and  everything  depends  on  the  judgment  of  the  accoucheur. 


TREATMENT  OF  fOXTRACTED  PELVIS  715 

In  priniiparcR  labor  is  seldom  induced,  since  I  i)refor  to  see  what  the  woman  can 
ucconiplish  at  term;    in  multipara;,  the  early  operation  is  often  performed. 

OUiver,  about  1S5S,  rocoiiiiiiciKlcd  symphysiotomy  in  prognancy,  to  providf  the;  oiilar^e- 
ment  of  the  pelvis  for  delivery,  and  Frank  i)ractised  it  shortly  before  term.     It  is  not  advisable. 

I'rochownick's  Dicl.—hy  reducinK  the  earbohydrates  and  fluids  inK<'Sted  during  the  last  two 
months  of  jirej^inaney  Proehowniok  hoped  to  restrain  the  growth  of  the  ehild,  and  also  to  retard 
the  o.ssification  of  its  bones,  so  that  it  would  mold  throufih  ihe  pelvis  easier.  The  diet  ho  pre- 
scribed is  jiresented  here,  but  my  few  exjjeriences  with  it  have  l^een  absolutely  negative,  and, 
indeed,  daily  observation  in  other  cases,  for  example,  tuixTculosis,  carcinoma,  hyperemesis 
gravidarum,  show  that  the  nutrition  of  the  mother  has  little  effect  on  the  growth  of  the  child, 
which  is,  in  fact,  a  parasite. 

Breakfast. — Small  cup  of  coffee.     One  ounce  of  toast. 

Dinner. — Small  piece  of  meat  or  fish,  or  an  egg,  a  little  sauce,  a  vegetable  prepared 

with  fat,  lettuce,  a  small  piece  of  cheese. 
Supper. — The  same  with  a  few  slices  of  bread  and  butter  and  a  little  milk. 
Water,  soup,  pastries,  potatoes,  sugar,  and  beer  are  forbidden.     About  one  pint  of  water 
daily  is  allowed. 

Patients  living  on  this  dietary  require  constant  medical  supervision.  Xephritics  may  not 
be  put  on  such  a  diet. 


Treatment  of  Moderately  Contracted  Pelves  During  Labor. — In  the  first  stage 
the  question  to  decide  is,  shall  we  interfere  at  once  or  shall  we  await  the  test  of 
labor? — interference  or  watchful  expectanc}'?  In  primipara,  when  the  parturient 
is  not  quite  at  term,  in  cases  where  the  child  does  not  seem  very  large,  or  where  the 
pelvic  contraction  is  near  the  upper  limit,  with  the  conjugata  vera  9  to  93^  cm., 
and  where  the  probability  of  good  strong  pains  seems  good,  my  advice  is  to  wait 
and  see  what  nature  will  accomplish.  The  pains  slowly  mold  the  head  into  the 
inlet,  and  disproportion  that  seemed  insuperable  is  finally  overcome,  or  the  head 
forced  so  low  that  it  can  be  easily  extracted  by  the  forceps.  We  can  hope  for  such 
a  termination  in  75  per  cent,  of  the  cases. 

"When  the  conditions  are  the  opposite;  w^hen  the  careful,  complete  examination 
shows  that  the  disproportion  between  the  child  and  the  pelvis  is  one  that  is  not 
likely  to  be  overcome  by  the  natural  forces;  if  the  presentation  and  position  are 
bad;  w^hen  the  history  of  previous  labors  is  unfavorable  or  the  general  constitution 
of  the  woman  such  that  a  severe  parturition  cannot  be  borne — cesarean  section  is 
the  operation  of  choice. 

If  the  expectant  treatment  is  selected,  an  extraordinary  degree  of  w^atchfulness 
is  demanded.  The  rupture  of  the  membranes  is  to  be  prevented  by  keeping  the 
patient  on  her  side,  forbidding  bearing-do wm  efforts,  care  during  internal  examina- 
tions, and  by  the  insertion  of  a  soft  colpeurynter,  not  tightly  filled,  in  the  vagina. 
When  dilatation  of  the  cervix  is  complete,  the  membranes  may  be  allowed  to  rupture 
in  order  to  permit  the  head  to  apply  itself  snugly  to  the  inlet  and  complete  the 
molding  process.  jNIolding  may  begin  in  an  intact  sac.  Should  the  membranes 
rupture  before  the  cervix  is  completely  dilated,  the  colpeurynter — now^  preferably  a 
Voorhees  bag  with  flat  top — is  placed  inside  the  cervix.  This  keeps  the  head  from 
exerting  injurious  pressure  on  the  bladder,  prevents  incarceration  of  the  anterior 
lip  of  the  cervix  between  the  head  and  symphysis,  preserves  the  liquor  amnii  left 
in  the  uterus,  strengthens  the  pains,  and  helps  to  dilate  the  cervix.  During  the 
first  stage  an  attempt  may  be  made  to  bring  the  head  into  a  good  position  over  the 
inlet.  For  example,  it  may  be  possible,  by  manually  correcting  a  posterior  or  an- 
terior parietal  bone  presentation,  to  place  the  head  in  a  way  to  enter  the  pelvis 
easily.  By  using  the  crouching  position,  vdth  one  knee  up,  a  head  which  has  slid 
off  the  inlet  into  one  ihac  fossa  maj'  be  led  back  over  the  inlet  (Fig.  654).  Hof- 
meier's  impression  of  the  head  from  the  outside  may  also  be  tried,  but  I  have 
never  thus  succeeded  in  accomplishing  any  real  results.  It  is  not  entirely  safe. 
The  hands  may  bruise  the  lower  uterine  segment  or  compress  the  cord  lying  around 


716 


THE    PATHOLOGY    OF   LABOR 


the  neck.  Naturally,  in  such  prolonged  labors,  and  with  so  frequent  vaginal 
manipulations,  the  dangers  of  infection  are  increased.  Special  attention  must 
be  paid  to  the  bowels,  since  a  full  rectum  may  prevent  engagement.  The  same  is 
to  be  said  of  the  bladder.  Bloody  urine  and  frequent  desire  to  urinate  indicate 
injurious  pressure  on  the  bladder,  which  perhaps  will  result  in  gangrene  and  fistula. 
At  the  end  of  the  first  stage,  and  in  the  beginning  of  the  second  stage,  the  par- 
turient maj'  be  placed  in  the  Walcher  position  (Fig.  655) .  Walcher  chscovered  that 
the  conjugata  vera  could  be  lengthened  by  hyperextension  of  the  thighs  with  the 
pelvis  fixed.  The  softening  of  the  pelvic  joints  in  pregnancy  permits  the  sacrum  to 
become  movable,  and  by  dropping  the  legs,  for  example,  over  the  edge  of  the  table 
on  which  the  sacrum  is  fixed,  the  innominate  bones  rotate  downward,  enlarging  the 
inlet.     Owing  to  the  oblique  direction  of  the  articular  processes  of  the  sacrum,  this 


^^ 


Fig.  054.- 


-Crouching  or  Ln'dian  Attitude. 
Only  one  knee  is  up. 


motion  naturally  causes  the  lower  ends  of  the  innominates  to  approach  each  other 
and  narrow  the  outlet. 

Mercurio,  in  1589,  and  Melli,  in  1738,  used  this  position  to  facilitate  delivery. 
The  true  conjugate  may  be  lengthened  from  6  to  12  mm.,  especially  in  flat  pelves. 
In  practice  the  woman's  legs  are  warmly  covered,  the  pelvis  brought  to  the  very 
edge  of  the  bed,  and  the  feet  dropped  out  straight  onto  a  soft  pillow.  In  a  few  cases 
I  have  gotten  the  head  to  enter  the  pelvis  by  this  procedure,  but  it  is  very  painful, 
and  few  women  can  be  compelled  to  keep  it  up  over  twenty  to  forty  minutes. 

My  results,  curiously,  have  been  better  by  the  use  of  the  exaggerated  lithotomy 
position  (Fig.  495,  p.  571),  which  is  theoretically  contraindicated  because  it  contracts 
the  inlet.  The  thighs  force  the  uterus  up,  correcting  the  pendulous  belly  so  com- 
mon with  contracted  pelvis;  the  uterus  and  child  are  straightened  out,  the  former 
being  thus  allowed  to  act  with  more  directness,  and  the  latter  being  brought  into 


TREATMENT  OF  CONTRACTED  PELVIS 


717 


better  position  over  the  inlet.  It  is  also  possible  that  an  occasional  parietal  bone 
or  ear  j)rescntati()n  is  (•(jrrcclcd.  The  exaggerated  lithotomy  position  may  be  kept 
up  for  several  lunirs  or  repeated  at  intervals.  When  the  head  projects  into  the 
pelvis  with  :i  lar<2;e  segnuMit,  the  patient  is  instructed  to  Ix'ar  down,  to  aid  in  the 
moldini;.  Three  dangers  nnist  now  be  watched  for — asphyxia  of  the  child,  ex- 
haustion of  the  mother,  and  rupture  of  the  uterus.  The  advance  signs  of  these 
dangers  will  be  tlescriljed  in  appropriate  chapters.  How  long  the  parturient  may 
Ix!  allowetl  to  labor  depends  on  the  judgment  of  the  accoucheur.  Every  two  or 
three  hours  an  examination  is  to  be  made  to  measure  the  progress,  and  if  there  is  a 
little,  with  none  of  the  three  dangers  impending,  it  is  safe  to  w^ait.  It  is  unwase  to 
allow  the  second  stage  to  continue  much  over  five  hours  if  the  pains  are  strong  and 


Fig.  G55. — The  Walcher  Position. 


the  head  w^edged  into  the  inlet.  Fistulas  are  apt  to  result,  and  the  child's  brain 
may  suffer  injury. 

If  spontaneous  labor  does  not  occur,  there  are  four  operations  that  come  up  for 
consideration — version,  followed  by  extraction;  high  forceps;  hebosteotomy;  and 
craniotomy. 

Version  is  performed  only  wlien  the  head  is  freely  movable,  before  the  lower 
uterine  segment  has  thinned  out  enough  to  invite  the  danger  of  rupture  during  the 
manipulation  and  in  cases  of  al)normal  presentation,  position  and  attitude,  for  ex- 
ample, shoulder,  face,  brow,  anterior  and  posterior  parietal  bone  presentation,  and 
prolapse  of  the  cord.  Prophylactic  version  means  version  by  the  breech  during  or 
at  the  end  of  the  first  stage  of  labor  in  contracted  pelves.  The  term  was  introduced 
by  Fritsch.  Simpson  showed  that  the  after-coming  head  passes  through  the  pelvis 
easier  than  when  the  blunt  vertex  precedes.     The  wedge  is  longer,  and  the  head 


718  THE    PATHOLOGY    OF   LABOR 

adapts  itself  better  to  the  inlet.  The  accoucheur  also  has  a  handle  to  pull  on. 
Whether  the  small  amount  of  cerebrospinal  fluid  which  escapes  under  pressure 
from  the  cranium  into  the  spinal  canal  reduces  to  any  extent  the  volume  of  the  head 
is  very  doubtful.  Experience  confirms  the  theory,  but  the  results  are  not  much 
better,  if  at  all,  than  leaving  the  head  to  mold  its  way  through  the  pelvis.  True, 
with  molding  there  are  the  dangers  of  prolonged  cerebral  compression,  fracture 
and  necrosis  of  the  skull,  and  vesicovaginal  and  other  fistulas,  and  peritonitis  in 
the  mother.  On  the  other  hand,  with  prophylactic  version  and  extraction  the  child 
sometimes  suffers  severe  injury  in  being  dragged  quickly  and  forcibly  through 
a  narrow^  passage,  and  fracture  of  the  skull,  separation  of  the  occipital  plate  from 
the  condyles,  intracranial  hemorrhage,  disruption  of  the  cervical  vertebrae,  fracture 
of  the  clavicles  and  humeri — all  these  and  more  have  repeatedly  occurred. 

Pare,  in  1585,  recommended  version  in  contracted  pelvis,  but  this  was  before 
the  invention  of  the  forceps,  and  today,  while  used  occasionally,  it  is  giving  way  to 
expectancy  followed  by  pubiotomy,  or  high  forceps  and  craniotomy.  In  primiparae 
with  contracted  pelvis  version  is  contrainclicated,  the  rigidity  of  the  soft  parts 
usually  defeating  all  attempts  to  save  the  baby,  and  deep  and  dangerous  lacerations 
almost  always  resulting. 

Version  may  be  useful  in  multiparse  with  weak  pains,  or  those  who  will  not 
work,  or  when  an  indication  on  the  part  of  the  mother  or  child  arises  which  demands 
immediate  delivery.  If  version  is  attempted,  one  must  be  prepared  to  perform 
craniotomy  on  the  after-coming  head,  because  if  it  does  not  come  through,  this  is 
the  only  alternative.  It  has  been  suggested  to  place  the  hebosteotomy  saw  around 
the  bone,  then  to  perform  the  version,  and,  if  in  the  extraction  the  head  is  arrested, 
to  cut  open  the  pelvis.  This  suggestion  has  obtained  little  recognition,  and  does 
not  appeal  to  me.  On  the  other  hand,  when  forceps  are  applied  and  fail,  we  have 
another  operation  which  may  save  the  child — hebosteotomy.  This  is  an  argument 
against  version  in  contracted  pelvis.  Version  and  the  forceps  are  not  competing 
operations.  When  the  conditions  for  forceps  exist,  version  is  contraindicated.  The 
results  for  the  mother  and  babe  are  about  the  same  in  the  two  operations,  and,  the  re- 
fore,  individual  preference  will  determine  the  selection. 

The  Forceps. — When  the  head  has  molded  so  that  it  seems  about  ready  to 
slip  down  into  the  pelvis  and  the  powers  give  out,  or  another  indication  arises  to 
terminate  labor,  the  forceps  may  be  employed.  The  instrument  is  brutal — it 
overcomes  resistance  with  force,  and  in  all  cases  either  the  mother  or  the  babe, 
or  both,  suffer.  Before  beginning  the  operation  the  family  must  be  advised,  first, 
that  the  instrument  is  applied  as  a  matter  of  trial,  an  experiment,  and,  second, 
that  if  it  fails  they  must  decide  whether  hebosteotomy  or  craniotomy  should  follow. 
Pinard,  in  Paris,  Schauta,  in  Vienna,  and  Kronig,  in  Freiburg,  insist  that  the  selec- 
tion of  the  operation  is  not  the  right  of  the  patient  or  her  family,  but  solely  of  the 
accoucheur.  In  most  countries,  to  perform  any  operation  on  another  person  with- 
out his  consent,  even  to  save  his  life,  is  a  tort.  Further,  the  right  of  a  mother  to  re- 
fuse to  endanger  herself  for  the  child  should  be  self-evident.  The  physician  can  and 
should,  in  favorable  cases,  throw  the  weight  of  his  influence  to  save  the  child,  and 
very  few  families  will  refuse  to  follow  his  advice.  Preparations  are  made  for  both 
operations.  When  the  patient  is  anesthetized,  a  complete  examination  will  deter- 
mine if  the  forceps  offer  any  hope  of  success.  If  they  do,  a  few  traction  efforts, 
certainly  not  over  three,  will  demonstrate  it.  Failing  the  forceps,  hebosteotomy 
should  follow  if  the  child  is  in  prime  condition,  and  craniotomy  if  it  is  not.  The 
operation  is  termed  high  forceps,  and  carries  with  it  a  fetal  mortality  ranging  from 
15  to  40  per  cent.,  and  a  maternal  mortality  of  2  to  4  per  cent.  Much  confusion 
exists  as  to  the  exact  definition  of  "  high  forceps."  Most  authors  apply  it  to  the  use 
of  forceps  when  the  largest  circumference  of  the  head  has  not  yet  passed,  but  is 
just  about  to  pass,  the  region  of  the  inlet,  and  this  seems  the  best  to  me.     Some 


TREATMENT  OF  CONTRACTED  PELVIS 


719 


writers  wisli  the  term  hijili  to  mean  the  head  fully  above  the  inlet;  some,  on  the 
other  haiul,  call  the  operation  higii  after  the  head  has  engaged,  hut  has  not  yet 
reached  the  second  parallel  plane  of  Hodge.  The  difficulty  of  appraising  the  values 
of  statistics  offered  for  the  operation  is  thus  made  apparent,  because  the  dangers  of 
the  various  oi)erations  are  vastly  dilferent. 

In  fiat  pelves,  after  the  head  has  passed  the  inlet,  delivery  is  usually  easily 
accomplished,  either  by  the  natural  powers  or  by  the  use  of  forceps,  and  the  dangers 
to  the  mother  and  babe  are  very  sliglit.  In  generally  contracted  and  in  funnel 
pelves  the  trouble  is  not  over  when  the  head  is  engaged — it  may  begin  at  this  point, 
and  if  spontaneous  tielivery  does  not  occur,  the  worst  forms  of  dystocia  may  result. 
The  forceps  here  are  equal  almost  to  the  old-fashioned  cephalotribe ;  the  child  often 
dies,  is  always  seriously  injured,  and  the  mother  never  escapes  without  extensive 
damage.  It  is  all  the  more  important,  therefore,  for  the  accoucheur  to  determine 
the  nature  of  the  pelvis  with  which  he  has  to  deal,  and  avoid  forceps  and  version 
in  those  with  general  or  funnel  contraction.  Cesarean  section  and  hebosteotomy — 
the  latter  rarely — come  more  to  the  front  in  these  conditions. 


Fig.  656. — Enlargement  op  the  Pelvis  in  Symphysiotomy  (from  Farabeuf  and  Varnier). 
The  area  of  inlet  is  augmented  about  50  per  cent.     Note  how  the  head  may  utilize  the  gap  between  the  severed  bones. 


Sjrmphysiotomy  and  Hebosteotomy,  or  Pubiotomy. — By  cutting  the  pelvic 
girdle  it  is  possible  to  enlarge  the  pelvic  cavity  in  all  its  diameters.  If  the  pelvic 
joints  are  loosened  more  than  usual,  the  enlargement  is  very  marked.  Section  at 
or  near  the  pubis  allows  the  bones  to  separate  2  or  23^  cm.,  and  when  the  head  passes 
through,  they  part  even  G  or  7  cm., — the  latter,  however,  not  without  some  danger 
to  the  sacro-iliac  joints.  The  innominates  roll  downward  and  outward,  but  the 
separation  of  the  lower  portions  is  less  than  in  the  upper,  hence  the  operation  is 
not  so  useful  in  contraction  of  the  outlet.  With  a  separation  of  6  cm.  the  conjugata 
vera  lengthens  1  to  13^^  cm.,  the  transversa  2.5  to  3  cm.,  and  the  obliques  about  same. 
An  important  gain  in  space  is  obtained  l)y  the  anterior  parietal  bone  fitting  into  the 
gap  between  the  divided  ends  of  the  ramus  pubis.  In  flat  pelves  the  greatest  gain  is 
obtained  (Fig.  .656).  Section  of  the  s>nnphysis  pubis  (symphysiotomy)  has  been  re- 
placed almost  entirely  by  the  Stolz-Gigli  operation  of  pubiotomy,  or,  more  correctly, 
hebosteotomy,  the  sa^^^ng  through  of  the  ramus  pul^is  alongside  the  joint.  The  gain 
in  space  is  the  same  AAdth  the  two  operations  (Cusmano).     Symphysiotomy  had  a 


720  THE    PATHOLOGY    OF   LABOR 

mortality  varying  from  3  to  12  per  cent,  for  the  mothers,  and  9  to  19  per  cent,  for  the 
children,  and,  taking  the  results  of  nine  of  the  best  operators  together,  6.78  per  cent, 
for  the  mother  and  10.6  per  cent,  for  the  children.  At  the  operation  severe  hemor- 
rhage from  the  wound,  particularly  when  there  were  varicose  veins,  extensive  injury 
of  the  anterior  vaginal  wall  and  the  perineum,  tearing  of  the  levator  ani  from  the  rami 
pubis,  the  lacerations  communicating  with  the  joint,  tearing  of  the  bladder  and 
urethra,  overstretching  of  the  sacro-iliac  joints,  with  rupture  of  their  anterior  liga- 
ments, hematoma  around  the  joint  (more  with  hebosteotomy),  were  reported  with 
great  frequency.  In  a  few  cases  bony  union  of  the  pubis,  requiring  the  saw,  and  anky- 
losis of  the  sacro-iliac  joints,  necessitating  final  resort  to  craniotomy  and  cesarean 
section,  were  met.  Convalescence  was  frequently  interrupted  and  prolonged  by  in- 
fection of  the  wound  and  pyemia,  because  of  poor  drainage,  the  poor  healing  qualities 
of  the  cartilaginous  joint,  the  proximity  of  the  septic  vagina,  and  the  frequent  com- 
munications with  it.  Hematomata;  thrombosis  in  the  veins  and  embolism;  slow 
healing  of  the  joint,  with  prolonged  sickness  in  bed  and  difficulty  of  locomotion  later 
(in  two  of  the  author's  cases  locomotion  was  impaired  two  and  eight  months  respec- 


FiG.  657. — X-RAY  Eighteen  Months  After  Hebosteotomy. 

tiveh^) ;  loss  of  control  of  the  bladder;  descensus  and  prolapse  of  the  uterus;  dislo- 
cation and  distortion  of  the  base  of  the  bladder  and  deforming  scars  of  the  soft  parts; 
and  hernia  between  the  bones  were  other  accidents  and  sequelae.  The  union  of  the 
joint  was  never  bony,  \mt  after  several  months  a  sufficient  degree  of  firmness  was  at- 
tained. A  good  feature  of  this  fibrous  union  of  the  joint  became  evident  in  subse- 
quent labors.  The  softening  and  relaxation  of  the  symphysis  were  so  great  that 
spontaneous  delivery  was  allowed.     This  occurred  in  two  of  my  cases. 

Hebosteotomy  aims  to  avoid  some  of  these  dangers,  and,  indeed,  the  mortality 
is  less  for  the  mother,  though  about  the  same  for  the  child,  and  the  morbidity  is 
less.  Since  the  cut  in  the  bony  ring  is  made  at  the  side  of  the  joint,  the  structures 
around  the  latter,  the  urethra,  the  bladder,  the  clitoris,  the  large  venous  plexuses, 
etc.,  are  a  little  less  liable  to  injury.  It  is  said  that  by  making  the  operation  prac- 
tically subcutaneous,  the  danger  of  infection  is  lessened;  tears  communicating 
with  the  vagina  are  rarer;  severe  hemorrhage  is  rare;  the  operation  requires  less 
skill  (?);    convalescence  is  cjuicker  and  simpler. 

Schlafli,  in  1908,  reported  700  hebosteotomies  with  a  maternal  mortality  of 
4.96  per  cent,  and  a  fetal  of  9.18  per  cent.,  but  individual  operators  (Williams, 
Stoeckel)  have  had  series  of  25  and  24  cases  without  a  maternal  death  (Roemer). 


TREATMENT  OK  CONTRACTED  PELVIS  721 

.ScilLAl-1,1    (IIIOH)    IN   700  ROKMKU    (1!»11) 

Casks  Found:  Eounu 

Severe  liemonliiiKO 1 ").()()  per  cent,  10.40  per  cent. 

F;it:il  lieiiiorrhiit^e,  two  ca.s(;.s O.OO     "       "  OM'.i    "      " 

lleiiKituiiKi 17.00    "      "  14.00    "      " 

Vagina  tore  into  wound lo.OO    "      "  7.00    "      " 

Dcatlis  of  these  latter 12.()0    "      "  3.90    "      " 

Injury  to  Madder 12.:i0    "      "  o.20    "      " 

Fever  p()sl|)artuin 31.70    "      "  20.G0    "      " 

Tliroinbophlel)itis 8.00    "       "  3.50    "       " 

iMcoMtii.eMce  of  urine 4.00    "       "  0.00    "       " 

(ieneral  (eorreeted)  mortality 4.37    "      "  2.6(5    "       " 

General  (corrected)  fetal  mortality.  .  .  .  9.18    "      "  6.00    "      " 

Operators  of  tlic  l:irj;cst  (experience  have  discarded  hebosteotomy  in  primiparae, 
and  will  not  pcrt'orni  it  in  cases  complicated  by  heart  and  kidney  diseases,  infection 
of  the  parturient  canal,  extreme  obesity,  colossal  varicosities  of  the  genitals,  and 
extremely  large  chikl. 

On  the  Continent  the  enthusiasm,  wliich  reached  its  acme  at  the  Dresden 
Congress  of  German  Gynecologists,  has  undergone  a  complete  reversal,  and  at  the 
Strasboiu-g  Congress  a  few  years  later  not  a  voice  was  raised  for  hebosteotomy. 

While  the  mortality  is  not  very  high,  the  bladder  and  urethral  injuries,  the 
hemorrhage  from  the  wound,  the  hematomata,  the  extensive  lacerations,  the 
frequency  of  fever  in  the  puerperium,  of  thrombosis  of  the  pelvic  and  crural  veins, 
the  delayed  convalescence,  and  the  troubles  of  locomotion  (more  frecjuent  than 
reports  show)  explain  the  loss  of  popularity  of  the  operation.  My  own  experience 
with  both  operations  is  small,  and  while  none  of  the  mothers  or  babies  died,  the 
impressions  of  them  are  not  encouraging  for  further  experiment.  Lately  successful 
series  have  been  reported  by  Stockel,  Williams,  and  a  few  English  and  American 
accoucheurs,  and,  without  cloubt,  the  operation  has  been  too  quickly  condemned. 
Performed  under  proper  restrictions,  for  the  correct  indication,  and  by  a  competent 
accoucheur,  it  Avill  hold  a  permanent  place  in  obstetric  surgery.  In  general,  its 
field  will  be  limited  to  pelves  having  a  true  conjugate  of  not  less  than  7.5  cm.  w^hen 
the  conditions  for  cesarean  section  are  not  ideal. 

When,  in  a  multipara,  in  a  case  of  the  tyj^e  under  consideration, — of  moderate 
pelvic  contraction,- — expectancy  has  shown  that  the  head  is  too  large  to  go  through 
spontaneously,  and  a  gentle  trial  with  the  forceps  has  proved  the  cUsproportion  to  be 
greater  than  was  expected,  hebosteotomy  is  the  operation  of  choice,  provided  both 
mother  and  child  are  in  good  condition.  The  best  time  for  cesarean  section  is  gone 
by,  but  the  section  of  the  pubis  offers  excellent  chances  of  saving  the  two  patients. 
This  is  an  advantage  of  pubiotomy — it  enables  us  to  subject  the  woman  to  the  test 
of  labor. 

Extraperitoneal  Cesarean  Section, — This  is  an  operation  witli  an  incision  just 
above  the  puliis,  l)y  -svhich  access  is  gained  to  the  lower  uterine  segment  and  the 
child  delivered  without  entering  the  peritoneal  cavity.  (See  p.  1000  for  details.) 
The  reception  the  new  operation  got  in  1907,  1908,  and  1909  was  very  enthusiastic, 
because  the  hope  was  revived  that  at  last  it  w^ould  be  possible  to  do  away  with 
craniotomy  on  the  living  child  when  the  conditions  were  not  good  for  the  classic 
cesarean  section.  Experience,  however,  has  shown  that  these  dangers  beset  the  new 
operation :  (1)  The  peritoneum  is  sometimes  opened  unintentionally :  (2)  the  bladder 
is  sometimes  torn;  (3)  hemorrhage  from  the  veins  may  be  alarming;  (4)  the  im- 
mense space  in  the  connective  tissue  is  liable  to  hematoma  formation  or  infection, 
with  al^scess,  which  may  break  into  the  peritoneal  ca\'ity;  (5)  thromlwsis  of  the  im- 
mense veins  laid  bare  and  embolism;  (6)  infection  and  peritonitis,  the  thin  layer  of 
peritoneum  not  offering  an  efficient  barrier;  (7)  difficulty  of  teclmic ;  (8)  subsequent 
lalwrs  1)ring  the  danger  of  rupture  of  the  uterus,  the  scar  being  in  the  thinnest 
portion,  and  that  which  is  distended  during  the  formation  of  the  parturient  canal; 
(9)  retroversio  uteri  is  common;  (10)  the  fetal  mortality  is  high. 
46 


722  THE    PATHOLOGY    OF   LABOR 

It  is  settled  that  the  operation  should  not  be  performed  on  infected  cases  (foul 
liquor  amnii,  fever,  rapid  pulse,  gray  exudate  on  vulvar  wounds),  and  the  procedure 
is  nearly  as  certainly  contraindicated  when  infection  is  suspected  (dirty  mid  wives, 
prolonged,  exhausting  labor,  attempts  at  delivery  by  questionable  hands).  Under 
these  circumstances  even  hebosteotomy  is  too  dangerous.  There  is  a  field  now 
claimed  by  hebosteotomy  where  labor  has  advanced  to  a  point  which  demonstrates 
that  the  head  will  not  enter  the  contracted  pelvis.  Dilatation  is  complete,  the 
lower  uterine  segment  drawn  up,  and  the  case  clean.  Our  advice  is  trial  of  the  for-- 
ceps,  followed  by  hebosteotomy  or  craniotomy,  if  exacted;  but  several  recent  writers 
urge  the  extraperitoneal  or  the  suprasymphyseal  transperitoneal  cesarean  section. 
It  is  too  early  to  decide,  but  at  the  present  writing  both  operations  are  losing  favor. 
Early  in  labor,  as  a  primary  operation,  the  classic  cesarean  section  is  still  the  oper- 
ation of  choice  as  against  its  modifications. 

Craniotomy. — When  the  child  is  dead,  craniotomy  should  be  performed  as 
soon  as  the  cervix  is  large  enough  to  permit  it.  If  the  child  is  dying,  or  if,  in  the 
judgment  of  the  accoucheur,  its  life  has  been  compromised  by  prolonged  compres- 
sion in  labor,  or  it  has  been  damaged  by  attempts  with  forceps  or  version,  craniot- 
omj^  should  be  done.  The  accoucheur  may  not  plume  himself  on  the  success  of 
having  delivered  the  child  alive,  when  it  succumbs  in  a  few  hours  or  a  few  days 
to  the  results  of  labor. .  The  mother  has  invariably  suffered  severe  injury,  and  has 
often  been  killed  b}'  the  forced  delivery,  and  these  accidents  must  be  charged  against 
the  attendant.     Craniotomy  is  much  safer,  and  the  end-result  for  the  baby  the  same. 

With  the  child  in  good  condition,  craniotomy  should  be  the  rarest  of  all  oper- 
ations, but — and  practically  all  authors  agree — a  few  conditions  arise  where  it 
must  be  resorted  to  as  the  ultimate  refuge:  (1)  If  the  patient  absolutely  refuses 
to  incur  any  danger  to  herself  for  the  sake  of  the  infant.  The  operation  is,  however, 
not  to  be  repeated  in  a  subsequent  labor.  (2)  If  labor  has  been  prolonged  and 
infection  is  positively  or  possibly  present.  (3)  Where  expectancy  and  high  forceps 
have  failed  and  the  conditions  are  not  good  for  hebosteotomy — for  example,  an 
ankylotic  pelvis,  immense  varicosities  of  the  vulva,  extreme  obesity  of  the  patient. 

IV.  Treatment  of  Labor  in  Pelves  only  Slightly  Contracted. — Pelves  Contracted 
at  the  Inlet. — In  pelves  with  a  conjugata  vera  of  93^  to  11  cm.  labor  almost  always 
terminates  spontaneously,  unless  the  child  is  very  large,  in  which  case  the  pelvis 
is  thrown  back  into  the  class  of  the  "moderately"  contracted,  just  considered. 
Variations  in  the  mechanism  of  labor,  however,  are  very  common,  and  the  cause 
for  breech,  face,  brow,  and  shoulder  presentations,  for  occipitoposterior  and  other 
malpositions,  and  for  errors  of  attitude,  as  prolapse  of  the  cord,  the  hand,  etc.,  is 
often  to  be  found  in  a  slight  pelvic  contraction  which  would  otherwise  pass  un- 
noticed. Operative  deliveries,  which  in  normal  pelves  would  be  simple,  easy,  and 
typical,  become,  when  slight  contraction  exists,  unexpectedly  a,nd  unexplainedly 
difficult  and  complicated.  When  dystocia  arises  in  such  a  pelvis,  the  treatment  is 
the  same  as  that  just  described. 

Pelves  Contracted  at  the  Outlet. — As  a  rule,  the  obstruction  offered  by  the 
narrow  bony  outlet  is  not  recognized  until  the  head  has  been  arrested  at  this  point 
for  several  hours,  and  often  the  forceps  are  applied  in  ignorance  of  true  conditions. 
Engagement  of  the  head  is  the  rule,  unless,  in  addition  to  a  narrow  outlet,  the 
pelvis  is  roofed  over  by  a  projecting  spinal  co\umn,^pelvis  obtecta, — as  in  the 
kyphotic  and  the  spondylolisthetic  forms.  It  is  wise,  before  every  forceps  opera- 
tion, to  measure  the  distance  between  the  tuberosities  and  see  how  far  the  sacrum 
and  the  coccyx  encroach  on  the  anteroposterior  diameter  of  the  outlet. 

If  the  anomaly  is  discovered  in  pregnancy  or  early  in  labor,  what  was  said 
under  the  general  heading  applies  here  also.  If  it  is  found  only  after  dystocia  is 
manifest,  the  following  is  suggested:  (1)  The  exaggerated  lithotomy  position, 
recommended  by  the  author  more  than  twelve  years  ago  (Fig.  495,  p.  571).     This 


TUKA'rMKNT    OF    CONTltACTKI)    I'KLN  IS 


723 


opens  the  bony  oulld  iind  (iftcii  produces  ciioiia;!!  ctilarKcmcnt,  Experiments  on 
the  cadaver  show  a  j;ain  of  M'  2  '<*  ■"'  nun.  in  tlio  Iran.svcrsc  dianictor,  and  also,  accord- 
iiif;  to  Williams,  decided  enlar<2;enient  of  the  antoroj)o.sterior.  (2)  Jonge's  position, 
the  same  but  with  the  legs  extended  (Fig.  658),  is  said  to  enlarge  the  outlet  still 
Tuoro — even  9  mm.  Krug  suggested  pulling  the  tuberosities  apart  directly  with  the 
hands.  (3)  Prolonged  expectancy — l)ut  during  the  period  of  molding  the  possibility 
of  pressure  necrosis  of  the  maternal  parts  and  injury  to  the  brain  of  the  fetus  must 
be  borne  in  mind.  (4)  The  forceps — in  mild  degrees  of  contraction  this  instrument 
will  usually  succeed,  but  a  large  number  of  babies  are  killed  by  the  operation,  and 
the  mother  almost  alwa^'s  suiters  severe  lacerations,  which  may  extend  through  the 


Fig.  60S. — JoxoE's  Posture  (L'Obstetrique,  June,  1910,  p.  587). 
A  photograph  taken  at  the  Chicago  Lying-in  Hospital. 

vaginal  walls  into  the  ischiorectal  fossa  and  down  to  the  bone.  In  one  case  it  was 
possible  to  put  the  hand  into  a  wound  which  extended  up  into  the  false  pelvis, 
the  soft  parts  having  been  dragged  off  their  pelvic  attachments.  Rupture  of  the 
symphysis  pubis  has  been  frequently  reported,  and  occurs  oftener  than  published. 
If  the  child  is  in  good  condition  when  the  first  real  difficulties  of  the  operation  are 
experienced,  hcbosteotomy  is  the  operation  of  choice;  if  it  is  not  in  good  condition, 
craniotomy  is  to  be  done.  Primiparse  suffer  the  worst  from  this  anomaly.  In 
multiparip,  the  resistance  of  the  soft  parts  being  absent,  a  small  amount  of  outlet 
contraction  may  cause  little  trouble — indeed,  may  pass  unnoticed. 

Complicated  Labors  in  Contracted  Pelves. — Labors  complicated  by  abnormal 
presentations  and  attitudes  of  the  child  require  many  modifications  in  the  treat- 
ment.    In  breech,  shoulder,  brow,  and  face  presentations  it  is  impossible  to  await 


724  THE    PATHOLOGY    OF   LABOR 

the  test  of  labor  and  also  to  fit  the  head  to  the  pelvis  as  we  do  in  vertex  presentations. 
It  is,  therefore,  necessary  to  estimate  the  degree  of  spacial  disproportion  from  the 
pelvic  measurements  and  the  adjudged  size  of  the  child.  The  choice  of  the 
operation  will  lie  between  prophylactic  version,  cesarean  section,  and  hebosteot- 
omy.  ^''on  Franque  suggested  applying  the  hebosteotomy  saw  provisionally 
around  the  joint,  to  perform  extraction,  or  version  and  extraction  as  indicated,  and, 
if  the  after-coming  head  is  arrested  at  the  inlet,  the  bone  could  be  immediately 
sawn  through  and  delivery  thus  quickly  effected  in  time  to  save  the  infant.  This 
is  an  ingenious  suggestion,  but,  in  my  opinion,  impractical  and  dangerous.  If 
hebosteotomy  is  to  be  done  at  all,  it  should  be  the  primary  operation.  Version  is 
particularly  unfavorable  to  the  child,  because,  unless  the  narrowing  of  the  passage 
is  very  slight,  the  after-coming  head  will  be  stopped  at  the  inlet,  the  infant  will  die, 
and  craniotomy  will  have  to  be  performed.  Therefore,  in  breech,  shoulder,  and 
deflexion  presentations,  unless  the  accoucheur  is  convinced  that  the  child  will  go 
through  the  pelvis,  cesarean  section  should  be  performed  as  a  primary  operation- 
given,  of  course,  good  conditions. 

Placenta  praevia  complicating  contracted  pelvis  demands  cesarean  section  if 
the  child  is  alive,  and  craniotomy  if  it  is  dead.  It  is  doubly  dangerous  to  drag  a 
large  child  forcibly  through  the  thinned  lower  uterine  segment.  Abruptio  placentae 
demands  cesarean  section  if  the  cervix  is  closed.  Even  rigid  soft  parts  may  render 
the  abdominal  delivery  safest. 

Eclampsia  seems  to  be  a  little  more  frequent  in  contracted  pelvis.  It  also  makes 
cesarean  section  more  readily  chosen,  and  the  same  may  be  said,  speaking  broadly, 
of  all  other  complications  requiring  rapid  delivery. 

Hospital  versus  Home  Practice. — The  foregoing  presentment  of  the  subject 
gives  the  treatment  of  contracted  pelvis  in  the  author's  own  and  hospital  practice. 
Without  question  great  differences  in  treatment  must  exist  between  that  of  the 
specialist,  aided  by  maternity  facilities,  and  that  of  the  general  practitioner,  caring 
for  his  patient  in  a  flat,  or  a  farm-house,  or  even  a  '' lean-to,"  with  no  help  but  a 
nurse  or  the  neighbors.  In  cities  and  towns  the  parturient  can  and  should  be  trans- 
ported to  a  well-equipped  maternity,  but  under  the  conditions  surrounding  the 
birth  of  the  majority  of  children  this  is  seldom  practicable,  and,  unless  the  mater- 
nity facilities  can  be  closely  imitated  in  the  home,  the  accoucheur  will  have  to  adapt 
his  treatment  to  the  environment  he  finds.  This  is  particularly  unfortunate  for  the 
child,  because  cesarean  section  and  hebosteotomy  are  very  dangerous  performed 
under  such  conditions,  and,  therefore,  inadvisable. 

Prolonged  expectancy  is  the  best  treatment  for  all  but  the  absolutely  contracted 
pelves,  followed  by  a  trial  with  the  forceps,  failing  which  craniotomy  is  the  horrible 
ultimate.  If  the  head  is  movable,  or  if  the  presentation  and  attitude  are  abnormal, 
version  is  indicated.  A  high  infant  mortality  is  to  be  expected,  but  the  informa- 
tion gained  will  warn  the  attendant  to  provide  ideal  arrangements  for  subsequent 
labors,  and,  in  the  end,  a  larger  number  of  children  will  be  saved  than  if  the  attend- 
ant tries  to  force  the  conditions  in  a  bad  environment.  The  same  statement  should 
apply  to  prolonged  and  ])rutal  attempts  at  delivery  with  the  forceps.  A  short  trial 
will  convince  the  operator  that  they  are  powerless  to  effect  delivery,  and  if  the  trac- 
tions are  persisted  in,  they  can  result  only  in  irreparal)le  damage  to  the  mother,  and 
the  object  sought,  a  living  child,  is  almost  always  defeated  by  the  attempt  itself. 
Craniotomy  is  more  humane.  A  careful  study  of  his  pregnancy  cases  will  enable 
the  accoucheur  to  foresee  the  above  dangers,  and,  by  proper  provision,  avoid  them. 

Literature 

Frank:  Arch.  f.  Gyn.,  1910,  vol.  Ixxxvi,  p.  263. — King:  Now  York  Med.  Jour.,  1909,  vol.  xc,  p.  1054. — Knapp: 
"Xon  Occides,"  Volkmann's  Samml.  klin.  Vortriigc,  1910,  N.  F.,  No.  584. — Peham:  Die  Geburtsleitung  bei 
erigem  Becken,  Vienna,  1908. — Pinard:  Annaloa  d.  Gyn.,  1902,  vol.  ii,  p.  165. — Roemer:  Zeitschr.  f.  Geb.  u.  Gyn., 
1911,  vol.  Ixviii,  H.  2,  p.  SlO.—Rolh:  Arch.  f.  Gyn.,  1910,  vol.  xci,  Bd.  2,  p.  398.— Schlajli:  Zeitschr.  f.  Geb.  u. 
Gyn.,  1908,  vol.  Ixiv. — Stoeckel:  Praktische  Ergebni.sse  der  Geb.,  1911,  vol.  iii,  H.  1. —  Watcher:  Centralbl.  f. 
Gyn.,  1889,  p.  S02.— Williams:  Amer  Jour.  Obst.,  May,  1910. 


CHAPTER  LIX 


THE  ACCIDENTS  OF  LABOR 


Split  of  clitoris 


Para-urethral 
laceration  in- 
volving cms 
clitoridii? 


Injuries  to  the  Parturient  Canal 
the  vulva 

All  primipariP  and  many  niultiparic  suffer  from  injuries  of  the  parturient 
canal.  Tliese  are  generally  considered  normal,  but  why,  the  author  cannot  under- 
stand— no  other  function  of  the  body  is  always  attended  by  injur3\  In  primiparse 
the  most  frequent  lesions  arc  found  about  the  vulvar  orifice.  Fig.  659  shows  the 
most  connnon  vulvar  lacerations.  They  are  seldom  deep,  but  if  they  involve 
important  structures,  serious 
results  may  follow.  If  the  tear 
extends  through  a  crus  of  the 
clitoris,  or  even  through  the 
organ  itself,  severe  and  even 
fatal  hemorrhage  may  ensue. 
If  a  varicose  vein  is  opened, 
the  patient  may  die  from  loss 
of  blood.  If  the  duct  of  the 
gland  of  Bartholin  is  torn 
across,  a  cyst  may  form.  If 
the  urethra  is  involved,  a 
stricture  may  follow.  These 
wounds  often  become  the  seat 
of  puerperal  ulcers,  and  if  the 
infection  is  virulent  or  the 
woman's  resistance  low,  inva- 
sion of  the  connective  tissue, 
even  general  septicemia,  may 
be  the  outcome.  These  lesions 
are  often  associated  with  vag- 
inal tears.  Superficial  wounds 
— simply  splitting  the  skin  and 
mucosa — require  suturing  but 
seldom,  since  their  edges  usu- 
ally lie  in  apposition  when 
the  legs  are  brought  together. 
Hemorrhage  from  clitoris  tears 
and  those  involving  varicose 
veins  is  easily  stopped  tempo- 
rarily by  pressure  between  the  finger  and  thumb,  or  In'  a  gauze  sponge,  and  perma- 
nently by  a  draw-string,  fine  catgut  suture  through  the  ]3ase  of  the  wound.  Often 
compression  is  enough.     Frenulum  tears  should  be  sutured. 

Rupture  of  the  urogenital  septum  is  an  inevitable  injury  in  labor,  and  it  can- 
not be  fully  repaired.  Some  relaxation  and  descensus  of  the  anterior  vaginal  and 
urethral  wall  is  an  invarial^le  sequence,  and  it  not  seldom  leads  to  a  slight  catarrh 
at  the  neck  of  the  bladder— the  so-called  "irrita]:)le  bladder"  of  the  older 
writers.     During  labor  attempts  to  push  the  protruding  urethra  back  out  of  the 

725 


Vagina  wiped 
off,  the  four- 
chet  being 

split 


Fig.  659. — Typical  Vulvar  Injuries. 


726 


THE    PATHOLOGY    OF   LABOR 


AA-ay  of  the  advancing  head  always  fail,  and  the  urethra  is  wiped  off  its  pubic 
attachments. 

THE  PERINEUM  AND  PELVIC  FLOOR 

If,  with  the  index-finger  in  the  rectum  and  the  thumb  in  the  fourchet,  the 
perineal  body  be  squeezed  together,  the  examiner  will  be  surprised  to  find  how  very 
little  tissue  there  is  in  it.  Indeed,  it  is  composed  only  of  a  little  fat  and  connective 
tissue, — the  centrum  tendineum, — with  the  rudimentary  muscles,  the  constrictores 
cunni,  the  musculi  bulbi  cavernosi,  a  few  levator  ani  fibers,  and  the  trans  versus 
perinei.  The  fingers  will  easily  outline  the  sphincter  ani,  the  important  closing 
muscle  of  the  rectum.     Lacerations  of  the  perineal  body  occur  in  the  majority  of 


Pubococcygeus  portion. 
Tears  at  either  side  of  raphe. 

Fig.  660. — Retrorectal  Separation  op  Levator  Ani. 


primiparous  labors,  and  while  they  have  considerable  importance,  it  is  decidedly 
less  than  tears  of  the  pelvic  floor — of  the  levator  ani  and  the  fascia  in  which  it  is 
set.  When  the  perineal  body  is  torn,  the  urogenital  septum  is  destroyed,  the  ante- 
rior wall  of  the  vagina  sags,  the  posterior  vaginal  wall  begins  to  roll  out,  and  the 
vulva  is  permanently  open,  inviting  infection,  which  almost  always  results  in  a 
vaginal  and  cervical  catarrh.  Late  effects  are  descensus  uteri  and  chronic  metritis. 
If  the  tear  is  deeper,  it  may  involve  part  or  all  the  sphincter  ani,  or  even  run  up 
the  rectal  wall  more  or  less.  I  have  seen  the  rectum  torn  for  a  length  of  three  inches 
beyond  the  sphincter.  Complete  incontinence  of  feces  is  the  first  effect  of  such 
tears,  but  if  they  are  not  so  extensive  and  the  levator  ani  is  not  seriously  injured, 
the  latter  muscle  assumes  vicarious  control  of  the  bowel,  and  the  patient  may  be 
able  to  hold  the  hard  feces.  Soft  feces  and  gas,  however,  will  usually  pass  off  in 
spite  of  the  woman's  efforts. 

The  levator  ani  is  always  injured  in  labor.     Either  it  is  overstretched,  which 


TIIK    ACCIDENTS    OF    LAIJOK 


727 


moans  that  thero  an^  innumcraljlc  niicroscopic  tears  of  tlio  niuscular  fibers,  or 
some  of  the  museiilar  huiulles  are  torn,  or  there  is  a  (lee|)  hieeration  of  one  or  l)oth 
sitles  of  the  sHnji;-like  st I'lict  iirc.     'I'he  last   kind  of  injui'\'  may  he  discovered  after 


Subpubic  tc:ir. 
of  l<'V:(|r)r  :iiii 


Lateral  tear  of 
sphincter 


Lateral,  usual, 
tear  of  levator 
ani  and  vulvar 
muscles 


Posterolateral 
sphincter  tear 


Fig.  CGL — Sites  of  Rupture  of  the  Muscles  in  the  Pelvic  Flooi?.     Note,  Seldom  Median. 

hibor,  but  the  other  two  usually  pass  unnoticed  because  they  are  unattended  by  a 
laceration  of  the  vagina.  The  latter  is  too  elastic  to  tear,  but  the  muscle  gives  way 
untk^r  the  mucous  membrane.     Such  cases  come  to  the  accoucheur  later  with  the 


Episiototny 


Fig.  662. — Diagr.vms  of  the  Typical  Perineal  Injuries. 
1,  First  degree,  2,  2,  2,  second  degree,  tears. 


history  of  no  tear  during  lalior,  and  he  diagnoses  them  "relaxation  of  the  pelvic 
floor."  On  several  occasions  I  have  attempted  to  shorten  up  the  stretched  muscle 
after  labor  by  deep  sutures  tied  across  the  intact  vaginal  mucous  membrane.  Rare 
instances  of  submucous  laceration  of  the  sphincter  ani  are  on  record. 


728 


THE    PATHOLOGY    OF   LABOR 


Lacerations  of  the  tendinomuscular  pelvic  floor  may  be  unilateral  or  bilateral, 
and  the  puborectal  portion  of  the  muscle  is  usually  involved.  In  a  large  number  of 
cases,  I  am  convinced,  the  two  halves  of  the  muscle  separate  at  their  junction  behind 
the  rectum  in,  or  alongside,  the  raphe  which  leads  from  the  coccyx  to  the  anus. 
(See  Fig.  181,  p.  160.)  This  allows  the  anus  to  fall  back  toward  the  coccyx,  and 
leaves  the  two  halves  of  the  levator  as  pillars  on  each  side  of  the  gaping  vagina 
(Fig.  660).  Perfect  anatomic  repair  of  such  a  rupture  is  not  possible  with  our 
present  methods  of  operation.  It  will  be  necessary  to  gain  access  to  the  torn  ends 
of  the  muscle  from  behind  the  rectum. 

Sometimes  the  muscle  is  torn  directly  away  from  its  attachments  to  the  pos- 
terior surface  of  the  pubis  (Fig.  661),  such  injuries  being  usually  the  result  of  forced 
forceps  deliveries,  attended  by  attempts  to  rotate  the  head  with  the  instrument. 


Fig.  063.- 


-Central  Rupture  op  Perineum.    Anus  and  Vulva  Intact. 
Child  emerged  through  rent. 


When  a  tear  of  this  kind  is  extensive,  the  ])ladder  lies  naked  at  the  top  of  the  wound. 
In  the  lateral  tears  the  mucous  membrane  of  the  vagina  is  also  torn  in  the  sulci, 
and  if  both  sides  are  affected,  the  columna  rugarum  lies,  tongue-shaped,  at  the 
bottom  of  the  wound.  Fig.  662  shows  the  various  forms  of  the  perineal  and  pelvic 
floor  injuries  as  they  appear  after  labor.     All  the  figures  were  drawn  from  life. 

Etiology. — Perineal  tears  occur  with  a  frequency  varying  from  9  to  34  per  cent., 
as  put  by  different  authors.  Forceps  labors  show  54  to  85  per  cent,  of  tears.  In 
my  own  experience  an  absolutely  anatomically  intact  perineum  is  a  great  rarity,  but 
extensive  lacerations  are  uncommon,  because  I  use  episiotomy  often. 

The  mo.st  common  cause  of  perineal  lacerations  is  disproportion  between  the 
child  and  the  soft  parts — either  the  head  is  too  large  or  the  canal  too  small,  as  occurs 
with  infantile  genitalia,  or  the  head  presents  unfavorable  diameters  to  the  passage, 


THE   ACCIDENTS    OF   LABOR 


729 


I'li:.  004. — Instruments  Needed  for  Perineorrhaphy. 

3  sfisaors;    G  artery  clamps;    2  8-inch  clamps;    2  needle-holders;    2  cervix  ring  forceps;    2  vulsellurn  forceps;    3  tissue 

forceps;    3  specula;    1  uterine  packing  forceps;   6  needles;   silkworm-gut  and  catgut. 


Fiii.  Oi;."). — Tissue  Forceps  with  Spoon-shaped  Ends. 
Holds  tissues  firmly  without  injuring  them,  and  also  removes  one  source  of  danger  to  rubber  gloves. 


Sphincter  ani  torn  at  pos- 
terior raphe  and  pulled 
out  of  its  bed 


End  of  the  lateral  sulcus  tear 


Empty  bed  of  sphincter 
ani 


Fig.  660. — Critical  Survey  of  the  Wound. 
Shows  the  depth  of  the  wound  and  how  the  flap  of  the  vagina  mav  be  raised.     The  split  in  the  rectum  and  the  sphinc- 
ter, torn  out  of  its  bed  and  ruptured  at  the  side  (not  in  the  middle  line,  as  is  commonly  thought),  are  plainly  shown. 


730 


THE    PATHOLOGY    OF    LABOR 


as  in  occipitoposterior  positions  and  brow  presentations.  Too  rapid  delivery,  either 
spontaneous  or  operative,  by  not  giving  the  parts  time  to  dilate,  causes  many  tears. 
Therefore  we  see  the  most  extensive  injuries  after  extraction  by  the  breech  or  by  for- 
ceps. Sometimes  the  forceps  directly  crush  the  perineum,  or  it  is  torn  by  introduc- 
ing the  hand  alongside  the  baby's  body  in  breech  deliveries,  but  these  are  errors  of 
art.  Disease  of  the  soft  parts  must  also  be  mentioned ;  edema  from  prolonged  labor ; 
excessive  rigidity  from  advanced  age  (old  primiparse);  scars  from  previous  injury; 
sjiDhilitic  infiltration;  gonorrhea,  with  or  without  condylomata;  loss  of  elasticity 
from  general  illness  (for  example,  typhoid,  tuberculosis,  etc.),  and  sometimes,  from 
no  apparent  cause,  the  perineum  tears  like  wet  blotting-paper.     It  occurs  to  me 


Fig.  607. — Suturing  the  Rectal  Mucosa. 

With  a  fine  needle  and  No.  0  twenty-day  catgut 
the  rectal  mucosa  is  first  clo.sed.  The  needle  enters  and 
i-ssues  on  the  wounded  surface  of  the  rectum,  does  not 
pass  through  into  the  gut,  and  the  knots  are,  therefore, 
all  buried.  The  needle  is  putting  in  the  last  of  the  su- 
tures, %vhich  are  about  0..5  cm.  apart  and  interrupted.  If 
the  tear  is  ver>'  extensive,  a  second  row  is  inserted  to  re- 
inforce the  first. 


Fig.  668. — Reaching  Down  into  the  Bottom  of  the 
Sphincter  Pit. 
The  finger  searches  the  bottom  of  the  sphincter  pit, 
and  with  an  artery  or  tissue  forceps  the  retracted  end  of 
the  sphincter  ani  is  drawn  up. 


that  such  a  state  of  the  perineum  may  be  due  to  a  toxemia,  since  it  is  usually  asso- 
ciated with  hemorrhagic  tendencies  and  albuminuria. 

An  important  cause  of  perineal  tears  not  generally  recognized  is  a  narrow  pubic 
arch.  Unless  the  head  can  occupy  the  space  directly  under  the  subpubic  ligament,  it 
is  forced,  by  the  narrowing  rami  pubis,  downward  toward  the  coccyx,  of  course  thus 
overstretching  the  levator  ani  and  perin(>um.  Wc  find,  therefore,  the  most  extensive 
injuries  in  funnel  pelves  and  those  with  a  narrow  pubic  arch.  In  these  cases,  too, 
the  vagina,  around  its  outlet,  being-caught  between  the  head  and  the  bones,  is  forced 
or  dragged,  if  the  delivery  is  operative,  downward  and  outward,  and  if,  in  addition  to 
the  other  traumatisms,  rotation  movements  are  made  with  the  forceps,  the  vaginal 
walls  are  torn  completely  off  their  pelvic  attachments  and  arc  si)lit  in  several  direc- 
tions. 

The  deeper  lacerations,  involving  the  muscles  of  the  pelvic  floor,  take  place 


THK    ACCIDENTS    OF    LAllUK 


731 


from  within  outward,  first  the  muscle  tearing,  then  the  viif^inti,  which  is  first  visibly 
spunncd  transversely,  and,  finally,  the  skin.  S(jme1imes  the  skin  is  absolutely 
intact,  but  all  the  deeper  structures  down  to  and  exixjsinji;  the  rectum  arc  torn  apart, 


Fig.  (W'lK. — Uniting  the  Sphincter  .\ni. 


Fig.  C70. — Uniting  the  Sphincter  .\ni. 
To  insure  broad  apposition  of  the  torn  ends  of  the 
mu.scle  the  needle  should  pa.ss  well  to  the  side,  and  two, 
oven  three,  sutures  may  be  placed,  one  of  which  should 
unite  the  fascia  surrounding  the  muscle.  This  is  the 
most  important  part  of  the  operation,  and  plenty  of  time 
.■should  be  spent  on  it.     No.  2  twenty-day  catgut  is  used. 


Fig.  671. — Reinforcing  Suture  above  Sphincter  Axi. 
A  finger-cot  or,  better  still,  an  extra  rubber  glove,  is 
drawn  on,  the  index-finger  inserted  into  the  rectum,  and  a 
suture  is  now  passed  above  the  sphincter  ani  from  the  skin 
surface,  using  silkwonn-gut.  This  reinforces  the  catgut  su- 
ture and  brings  together  the  connective  tissue  of  the  centrum 
tendineum.  Sometimes  this  stitch  turns  the  anus  in  a  little, 
hence  the  edges  of  the  skin  where  it  joins  the  mucosa  are 
united  by  a  fine  catgut  suture.  The  rest  of  the  operation  is 
like  those  for  incomplete  tear. 


and  in  such  instances  the  superficial  observer  will  fail  to  discover  the  extent  of  the 
injury,  and  may  even  declare  that  no  lacerations  exist.  In  these  cases  I  have 
found  it  best  to  incise  the  thin  bridge  of  skin  medially  the  whole  length  of  the 
Avound,  which  gives  better  access  to  the  deeper  structures  for  suturing.     The 


732  THE    PATHOLOGY    OF   LABOR 

vagina  tears  in  one  or  both  of  the  sulci,  and  the  wound  may  extend  up  beyond  the 
spine  of  the  ischium,  even  under  the  broad  hgament.  The  superficial  lacerations — ■ 
those  of  the  perineal  body  alone — usually  occur  with  normal  labors,  or  forceps 
deliveries  after  the  head  has  nearly  dilated  the  vulva,  and  they  go  from  without 
inward.  Often  the  vulva  is  a  little  too  small.  First  the  skin  at  the  posterior  com- 
missure whitens  and  splits,  the  tear  running  down  the  raphe  as  the  head  emerges, 
or  the  skin  and  mucous  membrane  having  been  nicked,  the  posterior  shoulder 
plows  through  the  perineal  body. 

Perineal  tears  are  divided  into  three  classes  or  degrees:  In  the  first  class  are 
those  where  the  frenulum  or  posterior  commissure  is  torn  to  an  extent  not  exceed- 
ing ^  inch  toward  the  anus.     The  second  class  includes  all  other  tears  excepting 


■  ^K ^^^g.jMm  J^  '  Tongue  of  columna  rugarum 

^m  W  M  f  ^^ ' '-'" '  t'\  ?^  End  of  tear  in  lateral  sulcus 

Edge  of  levator  ani  ^^^^^^BI^mH^^^V    ^    '  ''■ 

V^Kv   1^ — s&^'i-.-- Exposed  outer  wall  of  rectum 


Sphincter  ani 


Fig.  672. — Critical  Survey  of  a  Second-degree  Tear. 
This  is  a  very  deep  and  extensive  tear,  involving  the  puborectal  portions  of  the  levator  ani,  exposing  the  rectum 
and  the  sphincter  "ani.  The  latter  can  be  seen  lying  at  tlie  lower  end  of  the  wound,  a  broad  ring  of  pink  muscle.  The 
levator  ends  lie  in  the  deep  recesses  at  the  sides  of  the  rectum.  Notice  how  the  anus  has  dropped  toward  the  coccyx. 
The  sutures  must  lift  it  up  toward  the  pubis.  The  transverse  perineal  muscles  have  pulled  the  walls  of  the  wound  to 
the  sides. 

those  in  which  the  anus  and  sphincter  ani  are  involved,  these  being  designated  as 
of  the  third  degree  or  complete  lacerations  (Fig.  G62). 

Fig.  663  shows  a  rare  form  of  perineal  laceration,  and  is  sketched  from  a  case 
observed  by  the  author.  It  is  called  central  rupture  of  the  perineum,  and  is  due 
to  a  high  and  very  resistant  perineum,  narrow  pubic  arch,  or  a  vulva  placed  too  far 
forward.  The  child  is  delivered  through  the  rent,  which  may  be  at  the  side  of  the 
vulvar  orifice  and  anus,  as  in  the  figure,  or  between  anus  and  vulva,  or  the  child 
may  escape  through  the  anus,  tearing  it  in  several  directions.  The  sphincter  ani 
and  part  of  the  rectovaginal  septum  may  tear  without  extensive  involvement  of 
the  perineum.  In  one  case  the  head  appeared  at  the  vulva  while  an  arm  protruded 
from  the  anus;  in  another — a  breech — one  leg  appeared  through  the  anus.  In  all 
such  cases  it  is  best  to  perform  episiotomy  to  prevent  extensive  destruction  of  the 
tissues. 


Fig.  674. — First  Tier  of  Sctckes. 
Shows  the  sides  of  the  deep  wound    brought    to- 
gether, and  the  anus  lifted  up  nearer  the  pubis. 


'mv 


Fig.  673. — Puttino  in  Deep  Levator  Ani  SurrREg. 
The  torn  levator  ani  is  first  repaired.  With  a  round- 
pointed,  full-curved  needle  and  Xo.  2  twenty-day  catgut  the 
fascia  over  the  rectum  and  the  deeper  portions  of  the  levator  ani 
are  united.  The  needle  passes  deeply  at  the  side  and  bottom  of 
the  wound,  and  very  superficially  over  the  rectum.  With  the 
finger  in  the  bowel  the  retracted  tissues  are  lifted  up  and  per- 
forations avoided.  Too  much  tissue  should  not  be  included  in 
this  tier  of  sutures,  since  the  larger  part  of  the  levator  ani 
muscle  and  fasciiae  are  to  be  united  by  the  deep  external  stitches. 
In  verj"  deep  tears  only  is  this  buried  suture  necessary,  but  it  is 
one  of  the  best  safeguards  against  future  rectocele. 

733 


Fig.  675. — Sewikg  the  V.^gin.\. 
Xow  the  mucous  membrane  of  the  vagina  is 
brought  together.  By  pulling  up  the  tongue  of  the 
columna  rugarum  the  torn  edges  of  the  sulcus  are 
straightened  and  a  simple  interrupted  line  of  silk- 
worm-gut sutures  is  placed  1  cm.  apart,  taking  care 
not  to  include  the  underlying  perineum.  Both  sides 
are  sewn  in  the  same  way.  Some  operators  prefer 
catgut,  but  I  find  it  is  often  too  soon  absorbed. 


734 


THE    PATHOLOGY    OF   LABOR 


Treatment. — Preventive. — Protection  of  the  perineum,  according  to  the  rules 
laid  down  in  the  Conduct  of  Labor,  wall  prevent  a  large  number  of,  but  not  all, 
pelvic  floor  injuries.  Even  episiotomy  does  not  always  suffice  to  overcome  the 
disproportion  between  the  head  and  the  outlet.  (See  p.  305,  Episiotomy.)  Most 
authors  advise  incisions  in  the  perineum  when  it  is  found  too  rigid  and  unelastic, 
but  a  few  condemn  episiotomy,  asserting  that  a  tear  is  better.  I  believe  that  the 
operation  should  be  often  resorted  to — that  it  will  save  the  lives  of  many  children 
and  often  preserve  the  sphincter  ani  from  injury. 

Slow  delivery  is  the  secret  of  success  in  preventing  tears  in  operations.     The 


i  r*\  ^ 


Fig.  676. — Drawing  out  Deep  Lateral  Structures  of  Pelvic 
Floor,  Including  Anterior  Bundles  of  Levator  Ani,  to 
GET  a  Large  Mass  for  Suture. 

Silkworm-gut  or  .silver  wire  is  used  for  the  external  sutures. 
By  pulling  out  the  side  walls  of  the  wound  the  needle  can  be  passed 
under  the  retracted  levator  ani  muscles,  and  they  may  thus  be 
brought  together.  The  needle — a  large  one — is  iniserted  J^  cm. 
from  the  skin-edge,  passes  out  toward  the  tuberosity  of  the  ischium 
under  the  muscle,  deeply  at  the  side,  then  superficially  across  in 
front  of  the  rectum,  and  in  a  reverse  direction  on  the  opposite  side. 
The  point  of  the  needle  describes  a  path  shaped  like  a  long  ellipse, 
710/  like  a  circle.  If  a  finger  is  put  in  the  rectum  an  assistant  may 
pull  out  the  tissues.  In  Fig  677  the  suture  numbered  5  is  the 
crown  stitch.  It  is  put  in  last,  passes  through  the  skin  near  the 
fourchet,  then  under  the  tip  of  the  columna  rugarum,  but  not 
through  it,  and  out  on  the  opposite  side.  If  preferred,  a  row  of 
buried  catgut  sutures  may  be  placed,  as  in  this  figure,  to  bring 
the  levator  ani  pillars  together.  Then  the  skin  is  united  with  su- 
perficial sutures. 


Fig.  677. — The  Last  Tier  of  Sutures  Readt 
TO  Tie. 


tendency  to  hurry  after  the  for- 
ceps are  applied  is  hard  to  resist, 
and  the  head  is  usually  extracted 
by  forcibly  overcoming  the  resist- 
ance of  the  pelvic  floor.  If  con- 
tinuous auscultation  of  the  heart- 
tones  shows  that  the  fetus  is  in 
good  condition,  the  forceps   ex- 


traction may  be  extended  to  from 
twenty  to  fifty  minutes,  and  in  this  time  the  perineum  can  be  dilated  safely.  To 
counteract  this  desire  to  hurry  it  is  my  custom  to  place  a  clock  in  front  of  the  oper- 
ating taVjle.  Should  threatening  fetal  or  maternal  danger  demand  haste,  a  deep 
episiotomy,  the  colpoperineotomy  of  Diihrssen,  should  be  performed.  Manual  dila- 
tation of  the  perineum  is  also  useful  as  an  operation  preparatory  to  forceps.  In 
several  cases  where  I  had  anticipated  the  necessity  for  rapid  delivery  I  have  used 
the  colpeurynter  to  dilate  the  vagina  and  levator  ani.  It  is  a  rather  painful  ex- 
pedient, but  the  results  arc  good.  When  the  child  is  exceptionally  large,  or  when 
the  head  must  come  through  with  unfavorable  diameters,  or  very  rapidly  (asphyxia 
foctalis,  etc.),  deep  epi.siotomy  is  indicated  (Fig.  662).     If,  during  delivery,  spon- 


THE    ACCIDENTS    OF    LAIKJH 


735 


tancous  or  operative,  the  accoucheur  notices  th(>  vagina  on  tlie  stretch  and  begin- 
ning to  spHt,  episicjtomy  is  indicatetl  to  save  the  si)hi!icter  and  rectum. 

Perineal  tears  seldom  bleed  profusely.  Occasionally  an  artery  requires  a 
clamp,  and  always  firm  compression  with  a  gauze  or  cotton  sponge  will  arrest  the 
bleeding  until  tiie  parts  may  be  closed  by  suture.  There  is  no  (|ueslion  l)ut  that 
every  tear  of  the  ])erineum  re(|uires  repair,  but  it  ma}'  not  be  advisable  to  do  it 
immediately  after  labor.  If  the  woman  is  collapsed  after  delivery  or  too  exhaust(.'d 
for  further  operation;  if  there  is  beginning  infection;  if  the  parts  are  battered  and 
l)ruised  so  that  necrosis  is  to  be  feared;  if  there  is  an  old  laceration  which  will 
nnjuire  extensive  dissection  for  its  repair — under  such  circumstances  it  may  be 


Fig.  678.— Ttinq. 


Fig.  679. — Keeping  Blood  Out. 
Figs.  678  and  679  show  the  technic  of  t>'ing. 
The  middle  fingers  force  the  tissues  together  from 
the  sides,  at  the  same  time  pushing  them  up  toward 
the  pubic  arch  while  tlie  thread  is  being  drawn.  If 
clots  are  left  in  the  wound,  primary  union  may  be 
defeated,  hence  it  is  a  good  plan  to  tie  the  sutures 
while  a  bit  of  gauze  soaks  up  the  blood.  .lust  how 
tightly  the  stitches  are  drawn  is  a  matter  of  experi- 
ence. They  should  not  be  pulled  so  tightly  that 
they  lie  in  deep  furrows,  because  the  swelling  which 
always  follows  will  cause  them  to  cut  through. 


best  to  postpone  the  operation.  My  owti 
practice  in  septic  cases  and  those  in  which 
the  parts  are  too  much  torn  to  hope  for  a 
good  result  is  to  put  one  or  two  catgut  su- 
tures in  the  sphincter  ani  and  one  external 
silkgut  stitch  to  support  this  muscle,  and 
leave  the  rest  of  the  wound  open  for  drainage  and  to  allow  for  eventual  sloughing. 
Several  accoucheurs  take  the  opportunity  of  labor  to  repair  old  lacerations, 
but  my  ex]:)crience  has  caused  me  to  cUscontinue  the  practice.  The  dissection 
sometimes  required  is  quite  extensive;  the  levator  ani  is  relaxed,  soft,  and  hard  to 
find;  hemorrhage,  especially  a  general  oozing,  is  very  troublesome;  small  subcutane- 
ous hematomata  from  injury  to  varicose  veins  are  not  uncommon — altogether  it  is 
not  possible  to  do  as  clean  and  typical  an  operation  as  eight  months  later,  which  I 
consider  the  best  time.  Clean  cases,  too  exhausted  for  immediate  operation,  are  al- 
lowed to  recover  and  are  repaired  A\athin  twentj^-four  hours,  never  later.  I  do  not 
approve  of  early  secondary  perineorrhaphy.     If  the  primary  operation  cannot  be 


736 


THE   PATHOLOGY    OF   LABOR 


done,  the  patient  is  instructed  to  return  after  six  or  eight  months  for  thorough  repair. 
Hirst  performs  the  secondary  suture  on  the  fifth  or  eighth  day,  but  my  experience 
has  been  unsatisfactory.  Capillary  oozing  is  always  troublesome;  the  tissues  are 
brittle  and  stiff;  it  is  almost  impossible  to  work  in  the  connective  tissue  and  to 
lay  bare  the  levator  ani  pillars, — the  crux  of  the  operation, — and  healing  is  not  so 
satisfactory  as  is  desirable. 

Lapthorn  Smith  has  revived  the  old  procedure  of  placing  the  sutures  in  the 
perineum  before  the  head  is  delivered.  Experience  with  this  operation  twenty 
years  ago  caused  me  to  give  it  up. 

It  is  not  advisable  to  place  the  sutures  before  the  placenta  has  been  delivered, 
because:  (1)  The  edges  of  the  wound  cannot  be  properly  coaptated;  (2)  during 
the  passage  of  the  placenta  blood  is  forced  into  the  wound;  (3)  the  stitches  may 
tear  out,  and,  further,  should  there  be  a  postpartum  hemorrhage  requiring  intra- 


FiG.  680. — Operation  Completed. 

After  all  the  sutures  are  tied  the  strands  are  divided  into  bundles, — the  vaginal  in  one  or  two,  the  perineal  in 
one, — and  knotted  together  smoothly  as  in  the  figure.  By  tying  the  knot  as  shown,  the  ends  will  not  catch  in  the  bed- 
linen  nor  drag  in  the  bed-pan,  and  by  cutting  close  to  the  knot  the  sharp  points  will  be  covered. 

Now  the  gauze  plug  is  removed  from  the  vagina,  the  parts  cleansed,  and  a  pad  applied.  As  the  last  precaution 
the  finger  is  inserted  into  the  rectum  to  make  sure  that  none  of  the  sutures  has  passed  through  the  bowel.  If  one  has,  it 
must  be  at  once  removed.  After  operative  deliveries  it  is  my  practice  to  catheterize  the  bladder  to  satisfy  myself  that 
it  has  suffered  no  injury. 


uterine  manipulation,  it  may  be  necessary  to  remove  the  sutures  to  allow  the  hand 
to  be  inserted.  Then,  too,  it  takes  the  accoucheur's  attention  away  from  the 
observation  and  conduct  of  the  third  stage  of  labor,  which  may  not  be  done  with 
impunity.  The  parturient  needs  the  undivided  attention  of  the  accoucheur  during 
the  placontal  stage;. 

Perineorrhaphy. — Anesthesia  is  seldom  necessary,  since,  owing  to  the  stretch- 
ing and  bruising  of  the  parts,  the  tissues  are  not  very  sensitive.  Nervous  patients 
require  ether,  but  sometimes  one  can  operate  with  a  sort  of  half  sleep,  aided  by 
suggestion,  giving  just  enough  ether  to  produce  the  first  stage  of  anesthesia. 
The  patient  should  lie  across  the  bed,  or,  Ijettcr,  and  to  be  obtained  wherever 
possible,  on  a  properly  prepared  table,  with  the  Ijuttocks  hanging  well  over  the 
edge  (Fig.  781).  The  same  instruments  are  needed  as  for  the  gynecologic  perineor- 
rhaphy— needle-holders,  needles,  artery  forceps,  specula,  tissue  forceps,  scissors. 


THE    ACCIDENTS    OF    LABOR 


737 


cervix  forceps,  and  uterine  piiekins  forceps  (Fifj;.  Ofil).  If  one  has  to  operate  with- 
out trained  assistance,  whicli  is  tlie  rule  in  <;('nei-al  practice,  everything — sterile 
sponges,  sterile  towels,  basins  with  antiseptic  solutions,  the  instruments,  etc., 
sliould  be  arranged  within  easy  reach  of  the  hand.  Abundant  light  is  essential  for 
good  work.  Where  the  laceration  is  complete,  the  accoucheur  should  insist  on 
having  sufficient  help,  and  should,  if  necessary,  postpone  the  operation  until  he 
can  get  it.     The  suture  of  a  complete  laceration  of  the  perineum  requires  great 


Fig.  6S1. — Repair  of  Episiotomy. 
In  superficial  cuts  a  few  external  sutures  applied 
from  the  skin  and  grasping  the  tissues  deeply  at  the  side 
will  bring  the  parts  together,  no  vaginal  sutures  being  re- 
(|uired.  Deeper  incisions,  and  those  involving  the  leva- 
tor ani,  are  reunited  like  extensive  lacerations.  The 
surfaces  of  the  torn  muscles  are  brought  together  with 
a  deep,  buried.  No.  2,  hardened  catgut  interrupted  su- 
ture. During  the  application  of  the  suture  the  anus  and 
rectum  are  to  be  lifted  up  toward  the  pubis  by  means  of 
the  finger,  in  order  to  unite  the  tissues  at  the  side  and 
beneath  them.  When  the  levator  ani  is  torn,  the  rec- 
tum and  anus  drop  toward  the  sacrum. 


Fig.  6S2. — Repair  op  Episiotomy. 
Levator  ani  has  been  sutured  and  finger  in  rectum  lifts 
up  this  organ  and  brings  it  to  a  proper  level  for  suture,  also 
protecting  it  from  needle.     Points  x-x  are  to  be  apposed. 


technical  skill  and  all  the  facilities  of  a 
modern  operating-room  if  good  results  are 
to  be  obtained. 

First  the  wound  and  adjoining  sur- 
faces are  to  be  cleansed,  care  being  taken 
not  to  wipe  anything  not  sterile  into  the  freshly  broken  tissues.  If  blood  comes 
down  from  above,  obscuring  the  field,  a  large  gauze  sponge  is  pushed  up  into  the 
posterior  fornix.  Do  not  forget  to  remove  it  afterward !  A  speculum  held  by  an 
assistant  retracts  the  anterior  vaginal  wall.  A  survey  of  the  whole  w^ound  is  now 
made,  and  its  extent  and  depth  are  determined.  Too  often,  in  a  hastj'  inspection, 
the  fact  that  the  pelvic  floor  muscles  are  torn  escapes  the  eye,  and  a  few  stitches  are 
put  in  to  close  the  skin  tear.  After  a  few  3'ears  descensus  uteri  shows  the  mistake. 
47 


738 


THE    PATHOLOGY    OF   LABOR 


Suturing  a  complete  laceration  will  be  described  because  it  comprises  all  minor  de- 
grees. (The  reader  may  study  all  steps  of  the  operation  in  detail,  Figs.  666-683.) 
The  after-care  does  not  vary  from  that  usually  pursued  in  puerperse.  The 
legs  need  not  be  bound  together  unless  the  woman  is  delirious.  When  the  lacer- 
ation has  been  complete,  special  instructions  are  to  be  given  the  nurse  regarding  the 
bowels.  I  do  not  give  opium  to  bind  up  the  bowels,  but  order  a  semisolid  diet, 
free  from  cellulose,  and  large  quantities  of  water.  On  the  third  day  a  dose  of  castor 
oil  is  given,  and  at  the  same  time  the  nurse  injects,  with  a  soft  rectal  tube,  8  ounces 
of  sterilized  warm  olive  oil  into  the  bowel,  to  be  retained.  The  patient  is  instructed 
not  to  strain  when  the  bowels  are  about  to  move.  If  the  nurse  observes  such  a 
desire  of  the  patient,  she  is  to  insert  the  sterile,  gloved,  and  oiled  finger  into  the 


Fig.  683. — Repair  of  Episiotomy. 
Putting   in    crown  suture.     It  passes  through  skin  at  edge  of  wound,  deeply  at  side,  to  gather  up  the  fibers  of 
the  constrictor  cunni  and  of  the  urogenital  septum,  then  under  (not  through)  the  vaginal  wall,  and  through  correspond- 
ing structures  on  the  other  side  of  the  wound. 


rectum,  and  gently  break  up  the  fecal  mass  by  pressing  it  against  the  sacrum.  Then 
a  salt  solution  enema  is  given,  and  the  woman  is  instructed  to  hold  it  as  long  as 
possible.  After  the  first  movement  a  daily  laxative  may  be  administered  and  an 
oil  enema  given,  if  possi})le,  before  each  evacuation.  If  the  accoucheur  has  no 
trustworthy  nurse,  he  should  not  risk  the  success  of  his  operation  in  incompetent 
hands,  but  should  attend  to  the  above  matters  himself.  The  vulvar  pad  should 
be  laid  loosely  against  the  vulva,  so  that  feces  issuing  from  the  anus  may  not  dam 
back  against  the  line  of  sutures. 

The  sutures  are  inspected  daily.  A  small  amount  of  cutting  through  may  ])e 
neglected,  or  the  spots  touched  with  tincture  of  iodin.  Deeply  cutting  stitches 
had  be.st  be  removed.  Marked  swelling  of  the  vulva  usually  subsides  under  a  warm 
moist  application  of  weak  lead-water  or  acetate  of  aluminum  solution  (sterilized). 


THE    ACCIDENTS    OF    LABOR  739 

The  stitchos  avo  rcMiiovcd  on  the  tenth  to  the  fourteenth  day,  being  left  longer 
in  tlie  larj^er  lacerations.  If  iiireiiion  (level()i:)s,  the  safest  course;  is  to  remove 
the  stitches  and  open  up  the  wound  \vid(l.\-  for  drainage.  Occasionally  excessive 
growth  of  granulation  tissue  occurs  at  the  margins  of  the  wounds,  and  after  several 
weeks  the  i)atient  returns,  comi)laining  of  ])ain,  burning  in  urination,  and  constant 
irritating  discharg(\  Som(>times,  especially  after  forceps  deliveries,  there  is  a 
periostitis  rami  pubis,  which  causes  difficulty  in  locomotion.  The  granulomata 
are  to  be  cauterized  away  with  a  nitrate  of  silver  stick.  Hot  applications  will  help 
heal  the  periostitis. 

LESIONS  OF  THE  VAGINA 

Rarely,  in  spontaneous  labor,  is  the  vagina  torn,  except  in  association  with 
perineal  lac(>rations,  alreatly  considered. 

Causation. — If  the  vagina  is  congenitally  too  small  (infantile)  or  rigid  (old 
primiparoi),  or  scarred  by  disease  (gonorrhea,  etc.)  or  previous  lacerations  or  oper- 
ations, it  may  tear  during  ordinary  labor,  and  certainly  will  give  way  during  arti- 
ficial (Unlivery.  Precipitate  laljors  occasionally,  but  forceps  and  rapid  l^reech 
extractions  particularly,  show  vaginal  tears.  Twisting  the  head  in  the  pelvis  by 
the  forceps — so-called  "rotation" — maj^  split  the  canal  the  whole  length  and  open 
up  the  perivaginal  spaces  down  to  the  bone.  Hemorrhage  in  such  cases  is  usually 
very  profuse,  may  tax  the  best  skill,  and  may  even  be  fatal.  Tears  of  the  posterior 
vaginal  wall  are  usually  due  to  perforation  by  the  tip  of  the  forceps  ])lade,  but  may 
be  spontaneous  and  may  even  go  through  into  the  rectum.  Perforating  tears  may 
be  produced  by  friction  of  the  vagina  between  the  head  and  prominent  bony  points, 
as  the  spines  of  the  ischia,  the  promontory  of  the  sacrum,  or  an  exostosis  on  the 
posterior  surface  of  the  pubis,  or.  from  stone  in  the  bladder.  The  forceps  also  may 
be  pushed  through  the  vaginal  wall.  Anterior  tears  may  result  from  traumatism 
in  delivery,  from  the  operation  of  hebosteotom}^,  when  the  vagina  may  communicate 
with  the  pubic  wound,  and  even  the  bladder  be  torn  open.  During  deliver}'^  after 
craniotomy  sharjD  spiculse  of  bone,  if  unprotected,  may  penetrate  the  vaginal  wall, 
or  even  open  up  the  bladder. 

Pressure  necrosis  of  the  vagina  may  occur,  as  was  described  under  Contracted 
Pelvis,  and  if  large  portions  of  the  mucous  membrane  slough  out,  lochiocolpos 
may  result  and  obstruction  from  stenosis  of  the  passage  in  a  subsequent  delivery. 

Description. — Usually  the  tears  are  longitudinal,  and  occupy  the  sulci  along- 
side the  anterior  or  posterior  columna.  In  the  former  case  the  bladder,  in  the 
latter  the  rectum,  is  exposed.  Anterior  lacerations  are  often  accompanied  by  a 
tearing  of  the  levator  ani  pillars  from  their  pubic  attachments.  The  edges  of  the 
tear  are  usually  straight,  except  when  necrosis  occurs,  and  the  connective  tissue  is 
often  widely  opened  up.  In  the  fornices  the  tears  are  generally  transverse,  unless 
they  connnunicate  with  cervix  tears.  Hemorrhage  is  free,  depending  on  the  loca- 
tion. Sometimes  the  tear  extends  more  or  less  circularly  around  the  vagina,  near 
the  cervix,  and  opens  up  the  peritoneal  cavity.  This  is  a  serious  accident,  is  called 
kolporrhexis,  is  closely  akin  to  rupture  of  the  uterus,  and  will  be  considered  together 
with  that  subject. 

Vaginal  tears  may  l)e  the  port  of  entry  for  infection,  with  paravaginal  abscess 
or  even  general  septicemia,  both  of  which  are  rare  unless  the  case  is  otherwise 
infected.  As  a  riile,  the  lacerations  of  the  upper  third  of  the  vagina  heal  without 
treatment.  Lacerations  of  the  lower  half  of  the  vagina  usuall}'  extend  into  the 
musculature  of  the  pelvic  floor,  and  should  be  treated  as  such,  because,  if  not, 
prolapsus  uteri  will  follow  sooner  or  later. 


740 


THE    PATHOLOGY    OF   LABOR 


LESIONS  OF  PELVIC  CONNECTIVE  TISSUE 

Overstretching  of  the  anterior  wall  of  the  vagina,  combined  with  tearing  of 
the  fascia  between  the  bladder  and  the  vagina,  is  responsible  for  the  majority  of 
cases  of  cystocele.  In  manj^  cases  the  urethra  and  base  of  the  bladder  are  pushed 
down  and  off  from  their  attachments  to  the  posterior  wall  of  the  pubis.  Over- 
stretching of  the  pelvic  connective  tissue,  downward  dislocation  of  the  vagina  and 
its  connective-tissue  supports,  are  causative  of  many  cases  of  procidentia  uteri. 
The  vagina  may  be  actually  torn  away  from  its  pelvic  attachments,  which  occurs 
invariably  when  forceps  are  applied,  or  breech  extraction  made  before  the  cervix 
is  completely  dilated,  and  before  it,  together  with  the  upper  fourth  of  the  vagina, 
is  drawn  up  out  of  the  pelvis.     If  the  accoucheur  wishes  to  verify  this  statement, 


Fig.  684. — Showing  how  the  Head,  Dragged  Through  an  Unprepared  Parturient  Canal,  Pulls  Down  the  Soft 

Parts,  Sometimes  Actually  Avulsing  them  from  their  Bony  Attachments. 

Arrows  show  direction  of  the  rupture. 


let  him  pull  the  head  down  into  the  pelvis  before  the  cervix  has  retracted  and  note 
what  a  large  pad  of  tissue  is  dragged  down  into  the  inlet  before  the  head.  Figs. 
684  and  685  show  the  differences  between  such  a  condition  and  one  where  the  parts 
have  been  drawn  up  into  the  abdomen.  To  a  less  extent  the  same  conditions  are 
present  when  a  woman  bears  down  before  the  cervix  has  retracted  above  the  head. 
The  frequency  of  procidentia  after  forceps  deliveries  and  breech  extractions  before 
complete  dilatation  is  thus  explained.  After  such  destruction  of  the  connective 
tissue  the  fat  disappears  from  the  pelvis,  and  this  should  also  be  considered  in  the 
study  of  the  causes  of  prolapse.  Women  who  have  tlieir  first  children  late  in  life 
are  much  more  predisposed  to  procidentia  than  young  primiparae,  because  their 
connective  tissue  is  not  so  elastic,  tearing,  rather  than  stretching. 

Labor  in  elderly  primiparae  is  often,  not  always,  characterized  by  delay  due 
to  rigid  soft  parts.     While  tiie  dangers  are  exaggerated  in  the  public  mind  I  have 


THE    ACCIDENTS    OF    LABOR 


741 


louiul  that  la('(M"ati()n.s  arc  more  frcciiK'iit  mid  cxlciiisivc,  faults  of  iiiccliaiiism  are 
commoner,  prolon^inji;  labor,  the  infant  mortality  is  hifi,lier,  and  the  maternal 
morhidily  also  increased.      (See  Sixain  for  literature.) 


Fig.  685. — Showixg  how  the   Head  Comes  Through  a  Properly  Prepared   Parttrient  Canal. 
Arrows   indicate   direction  of  the   tissues  retracting   above   the   advancing  head. 


Fig.  6S6. — .\uthor"s  Obstetric  Specula. 


742 


THE    PATHOLOGY    OF   LABOR 


Prognosis. — Perineal  and  vaginal  lacerations  are  not  serious  if  properly  treated. 
Infection  is  the  worst  danger.  Hemorrhage  may  be  fatal  if  large  veins  or  arteries 
are  involved.  In  placenta  prsevia  cervicovaginal  tears  are  often  fatal.  Scar  for- 
mation may  later  deform  and  displace  the  vagina  and  neighboring  hollow  organs. 
Incontinence  of  urine  may  be  thus  produced  from  scars  pulling  open  the  neck  of 
the  bladder,  also  strictura  recti.  The  uterus  may  be  dislocated  in  all  directions. 
In  one  case  I  saw  the  cervix  pulled  down  to  the  introitus.  Subsequent  labors  may 
be  rendered  so  difficult  l^y  these  deforming  and  obstructive  scars  that  even  cesarean 
section  may  be  required. 

Treatment. — By  the  employment  of  the  colpeurynter  to  dilate  rigid  vaginas, 


jr  Edge  of  levator  ani 
X  Retracted  levator  ani 


Fio.  687. — Repair  of  Laceration  at  Base  and  Side  of  Bladder. 
A  broad,  short  speculum  retracts  the  perineum,  a  pad  holds  the  cervix  out  of  the  way  and  absorbs  the  excess 
blood,  a  narrow  speculum  lifts  up  the  bladder.  Thus  exposed,  the  wound  is  visible,  but  not  comfortably  accessible. 
The  needle  passes  through  the  posterior  lip  of  the  wound  first,  then  across  the  base  of  the  bladder,  avoiding  the  ureters, 
and  out  through  the  upper  lip  of  the  wound,  the  point  striking  the  speculum  and  sliding  over  it  into  the  bite  of  the 
assistant's  artery  forceps.  If  it  is  possible  to  pick  up  the  torn  levator  ani  pillar  at  X  and  attach  it  to  the  periosteum 
or  obturator  fascia  at  F,  it  should  be  attempted.     There  are  large  veins  at  this  point. 


or  those  which  are  to  be  exposed  to  injury  from  rapid  stretching,  many  tears  may 
be  avoided.  If  the  laceration  of  the  anterior  and  lateral  walls  of  the  vagina  is 
unavoidable  and  the  levator  ani  is  endangered,  it  is  better  to  make  a  deep  incision 
into  this  muscle  in  its  median  portion,  than  to  allow  it  to  be  pulled  off  the 
ramus  pubis.  Tears  in  the  upper  third  of  the  vagina  require  no  treatment  unless 
they  bleed.  A  few  stitches  usually  will  stop  the  hemorrhage,  but  sometimes  the 
flow  is  so  profuse  that  one  cannot  see  the  wound.  Here  uterovaginal  tamponade  is 
indicated  instead  of  the  suture.  Next  day  an  attempt  at  repair  may  be  made,  or  the 
operation  postponed  for  six  months.  If  free  ])leeding  obstructs  the  view,  rendering 
the  operation  technically  difficult,  it  may  Ijc  possible  to  tampon  that  part  of  the 


THE    ACCIDENTS    OF    LABOR  743 

wound  from  which  tiic  licmorrhiisc  comes  wliilc  the  ot  hor  part  is  Ix-inp;  sutured,  or  the 
suture  nuiy  he  piissed  entirely  under  the  guidance  of  tiie  finger.  After  suturing,  it  is 
best  to  do  a  uterovaginal  tamponade  to  prevent  hematoma  formation  in  the  loose 
paravaginal  tissues.  Tears  around  the  base  of  tlie  bladder  require  accurate  repair 
— even  then  cystocele  may  not  always  be  prevented.  If  the  puborectal  portions  of 
tiie  levator  ani  are  torn  from  the  posteri(jr  surface  of  the  pubis,  this  fact  may  be 
discovered  by  opening  up  the  rent  widely  to  view.  I  have  tried  to  reunite  the 
muscle  to  the  obturator  fascia,  having  failed  to  attach  it  to  the  bone,  and  with  fair 
success.  A  broad  speculum,  very  good  light,  sharply  curved  needles,  and  several 
assistants  are  needed  for  good  repair  work  in  the  vagina. 


HEMATOMA  VULV^  ET  VAGINA 

Blood-vessels,  particularly  the  veins,  in  the  pelvis  may  burst  during  pregnancy, 
labor,  or  postpartum,  and  a  blood  tumor  or  "thrombus"  form  in  the  loose  connective 
tissue.  Hematomata  have  been  found  under  the  skin  of  the  vulva,  around  the 
vagina,  under  the  Ijroad  ligaments,  in  the  broad  ligaments,  and  they  show  a  tendency 
to  enlarge,  following  the  lines  of  cleavage  of  the  connective-tissue  layers  or  fasciae. 
If  below  the  deep  pelvic  fascia,  they  distend  the  perineum  and  dislocate  the  rectum 
and  anus,  forming  tumors  sometimes  as  large  as  a  cocoanut.  If  around  the  vagina, 
they  may  fill  up  the  pelvis,  forcing  the  vagina  to  the  side  and  closing  it,  causing 
obstruction  to  delivery  or  to  the  flow  of  the  lochia.  They  m.B.y  be  pedunculated  in 
the  vagina,  and  may  occur  in  a  septum  vaginae.  If  at  the  base  of  the  broad  liga- 
ments, they  may  extend  up  into  the  false  pelvis  under  Poupart's  ligament,  or, 
behind,  they  may  dissect  up  to  the  kidney  back  of  the  peritoneum.  In  the  case 
from  which  Fig.  688  was  taken  the  blood  tumor  was  so  extensive  that  the  woman 
nearly  died  of  anemia— the  vagina  was  closed,  the  vulva  displaced  do^^'nward,  and 
the  cavity  formed  by  the  blood  extended  up  out  of  the  pelvis  to  a  level  with  the 
anterior  superior  spine  of  the  ilium.  While  the  hematoma  begins  to  form  at  once, 
it  requires  a  few  hours  for  its  presence  to  become  manifest,  and  usually  within  ten 
hours  the  blood  mass  is  fully  developed. 

Etiology. — The  bursting  of  the  vessel  may  be  caused  by  injury — the  trauma- 
tism of  spontaneous  labor — or  by  the  forceps,  etc.  Pressure  necrosis  exi^lains  the 
cases  of  formation  of  hematoma  late  in  the  puerperium — on  the  third,  eleventh,  and 
twenty-first  days,  as  reported.     Varices  are  said  not  to  favor  hematomata. 

Rough  uterine  massage  in  the  treatment  of  postpartum  hemorrhage  may  cause 
small  hematomata  in  the  subperitoneal  connective  tissue  and  in  the  broad  liga- 
ments, but  perhaps  in  the  fatal  cases,  w^here  such  findings  were  made,  the  woman 
died  of  a  hemophilic  diathesis  and  the  latter  caused  the  blood  extravasations.  In 
one  of  my  cases,  during  the  treatment  of  placenta  praevia,  a  tumor  developed  in  the 
perivaginal  connective  tissue,  extending  from  the  vulva  to  the  uterus,  which  was 
taken  to  be  a  hematoma,  but  upon  cutting  into  it  with  the  expectation  of  turning 
out  a  clot,  none  was  found,  the  tissues  being  simpl}^  infiltrated  with  blood.  Hema- 
tomata are  rare,  about  1  to  4000  labors,  but  statistics  var}'.  In  an  experience 
comprising  the  pathologic  work  of  over  20,000  routine  cases,  only  five  cases  of  large 
hematomata  have  come  under  my  notice.  Small  hematomata  are  not  exceedingly 
rare,  and  their  formation  may  sometimes  be  observed  when  a  vein  is  pricked  while 
repairing  the  torn  perineum. 

Symptoms. — Intense  pain  is  the  most  prominent  symptom,  and  the  intelligent 
patient  will  describe  the  tearing  open  of  the  tissues  and  the  intolerable  pressure  on  the 
rectum  and  bladder.  Sometimes  the  skin  or  the  vagina  covering  the  tumor  bursts, 
and  the  patient  may  bleed  to  death.  If  the  hematoma  burrows  a  great  distance, 
signs  of  anemia  from  internal  hemorrhage  appear.  Small  extravasations,  as  a  rule, 
are  quickly  absorbed.     Larger  ones  usually  become  infected,  wT.th  abscess  forma- 


744 


THE    PATHOLOGY    OF    LABOR 


tion,  or  even  general  septicemia,  but  sometimes  they  open  spontaneously,  the  clots 
are  discharged,  and  the  cavity  closes  (rare).  Hematomata  which  complicate  rup- 
ture of  the  uterus  are  not  considered  here. 

Prognosis. — Nowadays  death  from  this  accident  is  rare,  but  formerly  the  mor- 
tality was  from  12  to  40  per  cent.  If  the  tumor  does  not  become  infected,  recovery 
is  the  rule.  If  it  extends  up  under  the  peritoneum  and  infection  of  the  immense 
blood-masses  takes  place,  peritonitis  is  the  usual  outcome.  It  is  wise  to  make  a 
guarded  prognosis  until  it  is  determined  how  far  the  hematoma  is  going  to  burrow, 
and  whether  or  not  infection  will  occur. 

Treatment. — If  the  hematoma  begins  to  form  during  labor,  its  course  must  at 
first  be  carefully  watched,  and  if  its  growth  is  rapid,  it  is  to  be  incised  and  packed. 


/ 


Fig.  688. — H/ematoma  Yvuvjb  et  Vaginae. 
From  a  photograph,  Mrs.  F.,  Mercy  Hospital. 


In  cases  where  delivery  of  the  child  may  be  accomplished  this  should  be  effected, 
and  then  the  whole  uterovaginal  canal  firmly  tamponed,  together  with  the  hematoma 
sac.  If  the  tumor  begins  to  form  before  the  placenta  is  delivered,  the  latter  is 
manually  removed,  and  then  the  tamponade  made,  as  in  the  last  instance.  If  the 
hematoma  is  found  after  labor,  at  first  expectancy  and  ice  applications  are  to  be 
practised,  but  if  the  hcnnorrhage  into  the  tissues  continues,  shown  by  increasing 
size  of  the  tumor  and  redoubled  pain  cries  of  the  woman,  the  sac  must  be  broadly 
opened,  the  clots  and  fluid  blood  turned  out,  bleeding  vessels,  if  found,  ligated,  and 
every  crevice  of  the  cavity  firmly  packed  with  sterile  or  mildly  antiseptic  (not 
styptic)  gauze.  Then  the  uterovaginal  canal  is  packed  and  a  firm  abdominal  binder 
applied.     To  procure  a  bloodless  field  while  operating  the  Momburg  belt  or  an 


THE    ACCIDENTS    OF    LAUOR  745 

aorta  comprossor  may  t)0  used,  this  only  in  critical  cases.  If  it  is  possible  to  wait 
twenty-four  to  forty-eifi;lit  hours  before  performing  this  operati(jn  to  allow  firm 
thrombosis  in  t  he  torn  vessels,  the  possibility  of  secondary  hemorrhage  at  the  opera- 
tion is  avoided.  Small  heniatomata  may  be  left  to  be  absorbed,  but  all  are  to  be 
opened  at  the  first  sign  of  inl'cction. 

LESIONS  OF  THE  CERVIX 

Every  labor  is  attended  by  more  or  less  injury  to  the  cervix,  since  even  a  normal 
uterus  cannot  stand  the  enormous  radial  dilatation  required  for  the  passage  of  the 
child.  Large  tears  of  the  cervix  result  from — (1)  Too  rapid  or  too  forceful  dilata- 
tion by  the  powers  of  labor  (precipitate  births)  or  by  the  accoucheur,  with  his 
ojK'rative  deliveries  before  the  os  is  completely  dilated;  (2)  from  disease  of  the  cervix, 
anatomic  rigidity,  old  primiparity,  healed  ulcers  and  scars  from  former  deliveries 
or  operations,  cancer,  syphilitic  and  gonorrheal  induration,  etc.;  (3)  too  large  child 
or  congenital  smallness  of  the  cervix.  Most  of  the  tears  are  of  the  first  class  and 
are  due  to  violence.  Every  case  of  accouchement  force  and  every  manual  or  instru- 
mental dilatation  of  the  cervix  is  attended  by  more  or  less  numerous  and  deep  lacer- 
ations. If  the  operation  is  performed  before  the  cervix  is  completely  effaced,  serious 
or  even  fatal  injuries  may  result. 

The  lesion  may  be  a  small  nick  in  the  mucosa,  or  a  deep  rent  extending  through 
the  cervix,  the  vaginal  vault,  the  parametrium,  even  to  the  brim  of  the  pelvis, 
and  up  under  the  peritoneum  of  the  broad  ligaments,  or  even  into  the  peritoneal 
cavity — with  all  grades  between.  The  large  rents  are  treated  under  the  subject  of 
Rupture  of  the  Uterus.  Lateral  or  bilateral  lacerations  are  most  commonly  found, 
but  radial  tears,  from  one  to  five  in  number,  may  be  observed,  and  they  occupy  any 
part  of  the  cervix.  Sometimes  a  portion  of  the  cervix  is  dragged  off  the  uterine 
body  at  the  vagino-uterine  junction,  or  the  whole  cervix  may  thus  be  amputated 
and  cast  off  as  a  ring  of  tissue.  The  circular  amputation  of  the  cervix  may  be  pro- 
duced by  trying  to  drag  a  colpeurynter  through  the  unprepared  cervix,  or  the 
uterus  may  force  the  head  down,  carrying  the  cervix  before  it.  The  resulting  scar 
nearly  always  closes  the  uterus.  The  anterior  lip  of  the  cervix  may  be  caught 
between  the  head  and  the  pubis  and  I)e  squeezed  off,  or  suffer  so  much  compression 
that  it  becomes  necrotic. 

Cervix  tears  are  usually  not  discovered  until  after  the  child  is  delivered,  when 
the  hemorrhage  begins.  Bleeding  is  not  constant.  Unless  a  large  branch  of  the 
uterine  artery  or  a  vein  is  torn  across,  there  is  none  of  any  moment.  In  placenta 
prsevia  cervix  tears  usually  bleed  furiously,  the  immensely  dilated  veins  being 
opened  by  even  a  superficial  lesion. 

Prognosis. — Small  tears  of  the  cervix,  unless  infected,  heal  without  troulile, 
but  larger  tears  always  leave  deforming  scars,  leading  to  ectropion,  catarrh,  and, 
some  say,  to  carcinoma.  Perforating  tears  are  often  fatal.  Chronic  metritis 
undoubtedly  follows  large  cervix  tears,  and,  since  they  are  always  associated  with 
injury  of  the  pelvic  connective  tissue,  descensus  uteri  often  results. 

Treatment. — In  spontaneous  deliveries  it  is  not  advisable  to  pass  the  finger 
into  the  uterus  in  search  of  injuries  unless  bleeding  or  other  indication  (for  example, 
collapse,  precipitate  birth)  demands  it.  ]\Iany  advocate  the  search  for  and  the 
immediate  repair  of  all  lesions  as  a  routine.  In  hospitals  with  good  technic  such  a 
course  might  be  followed,  but  in  the  home  it  is  generally  impracticable.  After 
forceps  and  other  operative  deliveries,  and  always  when  injury  is  suspected,  a 
complete  digital,  and,  if  need  be,  a  specular,  examination  is  to  be  made.  "Whether 
or  not  to  sew  up  the  tear  in  such  cases  depends  on  circumstances.  "Where  infection 
is  present  or  probable,  the  tear  is  not  sutured  unless  it  bleeds  and  packing  will  not 
stop  it.  If  the  operator  has  good  help,  the  lacerations  are  repaired  in  all  clean 
operative  cases,  whether  or  not  there  is  bleeding.     Under  unfavorable  operating- 


746 


THE    PATHOLOGY    OF   LABOR 


room  conditions  the  woman  is  safer  with  the  cervix  open  to  drain,  and  repair  may 
be  made  later.  Hirst  and  a  few  others  recommend  secondary  suture  on  the  fifth 
or  sixth  day  of  the  puerperium,  but  the  author  does  not  advise  it,  for  reasons  already 
given  under  Perineorrhaphy. 

Fig.  689  shows  a  typical  cervical  laceration  extending  to  the  fornix  vaginae, 


Fig.  689. — Sewing  a  Lacerated  Cehvix. 


Fio.  G90. — .Author's  Cervix  Forcep.s. 
Hold  tissues  securely  without  tearing  them,  and  present  no  points  to  puncture  rubber  gloves. 

the  result  of  a  forceps  delivery  through  a  narrow  os.  It  was  bleeding  moderately 
and  was  easily  sewed,  as  shown.  By  means  of  the  vulsellum  forceps  or  the  cervix 
forceps  shown  in  Fig.  690  the  two  lips  of  the  uterus  arc  drawn  down  to  the  vulva 
and  become  readily  accessible  for  suture.     (See  Postpartum  Hemorrhage.) 

When  bleeding  is  profuse,  it  is  not  so  easy  to  sew  the  cervix,  because  it  is 


THE    ACCIDENTS    OF    LABOK  747 

hidden  in  a  pool  of  blood.  A  l)ull('t  forceps  may  bo  clamped  on  the  base  of  the 
broad  ligament,  as  advised  by  Ilenkel  f(jr  temporary  hemostasis.  Another  plan  is 
to  pass  the  needle  from  the  inside  of  the  cervix  under  the  guidance  of  the  finger, 
and  tie  the  suture  inside  the  uterus.  The  balance  of  the  stitches  are  put  in  from 
the  outside  of  the  cervix,  the  most  important  being  the  uppermost  one,  near  the 
fornix  vagina^  since  it  is  intended  to  stop  the  hemorrhage  which  comes  from  the  large 
vessels  here.  Continued  suture  is  used  if  haste  is  demanded,  otherwise  interrupted 
No.  2  hardened  catgut.  Since  the  ureter  is  close  by,  the  needle  in  the  first  suture 
must  be  passed  in  a  direction  nearly  parallel  to  the  uterine  })ody.  The  others  are 
transverse  and  pass  to,  but  not  through,  the  mucosa.  They  may  be  drawn  fairly 
tight,  l)ecausc  the  cervix  rapidly  shrinks  postpartum.  The  j\I(jmburg  belt  has 
l)een  used  in  urgent  cases  to  stop  the  bleeding  until  the  wound  could  be  sutured. 
Should  infection  begin  in  the  puerperium,  the  stitches  are  to  be  at  once  removed 
and  drainage  provided,  because  otherwise  the  parametria  will  be  rapidly  involved, 
and  even  fatal  septicemia  result.     Douches  are  contraindicated. 


RUPTURA  UTERI 

This  fearful  accident  occurs  oftener  than  is  generally  believed,  and  few  emer- 
gencies in  all  medicine  require  so  much  of  what  makes  a  great  surgeon  as  docs  this 
one.  The  uterus  may  rupture  during  pregnancy  and  during  labor,  and  since  the 
latt(>r  is  more  common,  it  will  be  first  considered. 

During  Labor. — Etiology. — Ruptures  of  the  uterus  are  divided  into  two  classes 
— spontaneous  and  violent  or  traumatic.  Spontaneous  ruptures  are  those  which 
occur  as  the  result  of  the  natural  forces  of  labor,  or  because  the  muscle  of  the  uterus 
is  pathologically  altered,  so  that  it  bursts  from  the  ordinary  processes  of  labor  or 
gestation.  Violent  or  traumatic  ruptures  are  those  w'hich  result  from  injury,  either 
from  the  hand  or  instrument  of  the  attendant  or  by  external  agencies.  Often  the 
uterine  muscle  is  so  thinned  by  the  action  of  labor  that  it  bursts  with  onlj^  a  little 
traumatism.  The  causes  of  actual  rupture  may  be  divided  into  predisposing  and 
exciting.  Predisposing  causes  are,  first,  those  conditions  which  produce  a  weaken- 
ing of  the  uterine  wall,  as  fatty  or  hyaline  degeneration  of  the  muscle;  pressure 
necrosis  during  prolonged  labor;  scars  from  previous  operations  (cesarean  section, 
salpingectomy  with  excision  of  uterine  cornu,  curetage) ;  scars  from  previous  rup- 
ture, from  puerperal  septic  processes,  and  old  inflammations;  thinned  spots  from 
the  removal  of  adherent  placenta  in  previous  labors;  fibroids  and  other  neoplasms; 
adherent  uterus;  overdistention  of  part  of  uterus;  congenitally  undeveloped  uterus; 
pregnancy  in  a  horn;  interstitial  pregnancy;  gro^^'th  of  the  placenta  into  the 
uterine  musculature;  placenta  prsevia;  edema  of  the  lower  uterine  segment  the 
result  of  prolonged  lal)or ;  polyhy  dramnion .  The  second  group  of  predisposing  causes 
comprises  all  the  mechanical  factors  which  stop  the  advance  of  the  child  through 
the  birth-canal,  as  contracted  pelvis  of  all  kinds;  overgrown  fetus;  deformities  of  the 
child  which  increase  its  size,  especially  hydrocephalus;  malpresentations  (shoulder, 
face,  and  brow,  anterior  and  posterior  parietal  bone);  malpositions,  as  occipito- 
posteriors;  delayed  rotation  of  the  head;  obstruction  of  the  soft  parts,  as  tumors 
blocking  the  pelvis,  atresia  cervicis  or  vaginae,  rigid  perineum;  and  incarceration 
of  the  cervix  between  the  presenting  part  and  the  pelvic  brim.  Pendulous  abdo- 
men, by  putting  the  posterior  uterovaginal  wall  on  the  stretch,  creates  a  condition 
favorable  to  rupture,  the  resulting  lesion  being  called  kolpoporrhexis,  or  kolpor- 
rhexis.  Unless  the  natural  powers  can  overcome  these  obstructions  by  a  moderate 
amount  of  effort,  something  has  to  give  way,  and  the  weakest  point  or  the  most 
overstretched  point  is  the  site  of  rupture. 

Exciting  causes  of  the  rupture  are  the  contractions  of  the  uterus  and  mechanical 
insult  or  violence.     To  understand  the  mechanism  of  spontaneous  rupture  it  is 


748 


THE   PATHOLOGY   OF   LABOR 


necessary  to  refer  to  the  normal  mechanism  of  labor  and  the  formation  of  the  par- 
turient canal.  We  are  indebted  to  Michaelis,  Bandl,  and  Freund  for  the  foundation 
of  our  knowledge  of  this  subject.  Throughout  labor  the  fundus  of  the  uterus  con- 
tracts, while  the  isthmus  and  cervix  are  dilated  from  above  downward,  the  muscle 
being  differentiated  into  an  upper  zone  of  contracting,  and  a  lower  of  dilating, 
fibers.  The  fibers  of  the  isthmus  uteri  and  cervix  are  drawn  upward  into  the  body 
of  the  uterus,  and,  at  the  junction  of  the  contractile  with  the  dilating  portions,  is  a 
well-defined  ring  of  muscle  which  Bandl  called  the  contraction  ring.  The  sacro- 
uterine ligaments  fix  the  cervix  in  the  pelvis  behind,  the  bases  of  the  broad  ligaments 
fix  it  at  the  sides,  and  the  connective  tissue  at  the  base  of  the  bladder  anchors  it  in 


Fig.  G91. — Excessive  Thinning  of  Lower  Uterine  Segment. 
Arrows  indicate  direction  of  tension. 


Brow  Presentation. 


front,  all  of  which  connective  tissue  and  partly  muscular  support  prevent  too  great 
upward  retraction  of  the  cervix.  An  additional  and  important  factor  in  the  mechan- 
ism of  rupture  is  the  fixation  of  the  cervix  by  the  head,  squeezing  it  against  the  bony 
pelvis.  This  is  ]:)articularly  likely  to  hai:)pen  if  the  bag  of  waters  ruptures  before  the 
cervix  is  dilated  and  retracted  above  the  presenting  part.  The  fundus  uteri  is 
held  down  and  prevented  from  pulling  too  far  up  over  the  child,  and  away  from  the 
pelvis,  by  the  guy-rope-like  action  of  the  round  ligaments  (Fig.  169)  and  the  pres- 
sure of  the  abdominal  wall.  It  is  easy  to  see  that  if  the  child  may  not  advance 
along  the  birth-canal,  the  continued  action  of  the  uterus  will  result  in  the  contractile 
portion  having  forced  nearly  the  whole  child  down  into  the  dilating  portions,  the 
lower  uterine  segment  and  cervix,  and  itself  having  retracted  above  the  child  as 


THE   ACCIDENTS    OF    LABOR 


r49 


far  as  the  i-ound  li^aiiicnts  and  tlic  alHloiiiiiial  wall  would  permit.  Its  wall  may 
have  a  thickness  of  only  a  few  niillinielers,  while  the  fundus  is  4  cm.  thick.  Fig. 
691  shows  the  contlition.  Sometimes  the  cervix  is  more  or  less  fixetl  at  the  inlet 
and  cannot  wholly  retract  with  the  lower  uterine  segment,  and,  therefore,  the 
latter  is  drawn  out  in  tiie  length  and  may  tear  transversely  (Fig.  692).  Since  the 
dilatation  of  the  lower  uterine  segment  is  never  symmetric,  owing  to  the  obliquity 
of  the  uterus,  the  irregularity  of  the  body  contained  therein,  pendul(;us  abdomen, 
etc.,  some  i)orti()n  of  it  is  stretched  more  than  the  rest,  and  here  the  rui)ture  occurs. 
As  a  rule,  first  the  muscle-fibers  separate  and  tear,  then  the  mucous  memljrane 
gives  way,  and  finally  the  peritoneal  covering  of  the  uterus.  I  have  on  several 
occasions  felt  this  occurrence  under  my  hand.  If  the  cervix  has  already  been 
dilated  and  fully  taken  up  to  form  part  of  the  parturient  canal,  it  cannot  be  fixed 
below,  but  retracts  upward,  with  the  lower  uterine  segment,  and  the  full  force  of 
this  retraction  is  distributed  along  the  wall  of  the  parturient  canal  from  the  contrac- 


Contraction  ring 


Contraction  ring 


Fig.  602. — Inc.\rceratiox  of  the  Cervix  Between  Head  and  Pelvis.     Cervix  Swollen. 
Rupture  would  take  place  just  above  it.     Case  of  Mrs.  G. 


tion  ring  dovra  the  vagina  to  the  attachments  of  the  latter  onto  the  pelvic  floor. 
If  the  stretching  of  this  canal  is  too  great,  the  rupture  will  occur  at  its  weakest  spot, 
and  this  is  usually  the  posterior  fornix  of  the  vagina.  Indeed,  in  cases  of  shoulder 
presentation,  immense  hydrocephalus,  pendulous  abdomen,  where  the  presenting 
part  cannot  imprison  the  cervix  against  the  pelvis,  we  find  such  ruptures  of  the 
vagina  or  kolpoporrhexis  (Hugenlocrger)  (Fig.  693). 

Ruptures  in  the  lower  uterine  segment  are  usually  longitudinal  or  oblique; 
those  in  the  fornix  vaginae,  usually  transverse  or  even  completely  circular. 

Violent  or  traumatic  ruptures  have  no  special  mechanism,  but,  as  a  rule,  the 
fundus  is  already  dra^Mi  up,  and  the  lower  segment  and  vagina  thinned  out  as 
above  described  at  the  time  the  causative  injury  is  inflicted,  and  on  this  account 
the  shape  and  location  of  the  tear  are  very  similar  to  the  spontaneous  ones.  The 
forceps  blade  or  the  cranioclast  may  be  pushed  through  the  wall,  or  grasp  a  portion 
of  the  musculature  and  crush  it.     Traction  with  the  forceps  pulls  the  cersnx  do^^Ti, 


750 


THE    PATHOLOGY   OF   LABOR 


and  a  transverse  split  occurs  in  the  lower  uterine  segment,  already  stretched  in  the 
length  to  the  point  of  bursting.  The  hand  introduced  alongside  the  child  contained 
in  the  ad  maxima  distended,  lower  segment  may  cause  the  tear;  or  the  attempt  to 
turn  the  child  by  bringing  the  trunk  down  into  the  pelvis  alongside  the  head  puts 
too  great  a  strain  on  this  portion  of  the  uterus;  or  the  hand  pushes  the  uterus  up 
away  from  the  vagina,  and  the  rupture  occurs  at  the  junction  of  the  latter  with  the 
cervix,  or  finally  too  rapid  delivery  through  an  unprepared  cervix  simply  bursts  the 
narrow  canal.  Instrumental  injuries  usually  are  found  in  the  neighborhood  of 
the  fornix  vaginae  and  the  cervix;  the  others  usually  in  the  overdistended  lower 
uterine  segment,  and  it  is  evident  that  the  operator  only  completed  a  tear  that 
was  already  being  prepared  for  or  just  beginning. 

Frequency. — Freund,  from  the  collected  reports  of   17  authors,   found  one 
rupture  to  2114  cases,  but  the  individual  reports  varied  from  1  to  234  to  1  to  6100 


Contraction  ring 


Site  of  rupture   /        ^—  , 


Fig.  693. — Kolpoporrhexis. 
Mrs.  Y.   (Service  of  Chicago  Lying-in  Hospital  Dispensary.) 


cases.  These  statistics,  wath  few  exceptions,  came  from  hospitals,  and  since  the 
rupture  cases  go  to  the  hospitals,  the  figures  are  large. 

Multiparse  are  oftener  thus  injured  than  primiparae, — about  eight  times  as 
often, — and  the  danger  increases  with  the  number  of  children.  This  is  due  to  the 
structural  changes,  the  weakness  of  the  muscular  fibers,  the  scars  and  inflamma- 
tions, the  residues  from  previous  labors.  In  primipara?  the  perforating  cervix 
tears  are  commoner  than  the  true  uterine  ruptures.  The  years  of  greatest  fre- 
quency are  from  thirty  to  forty.  Women  with  loose  abdominal  walls  are  more 
endangorod,  and  fat  women  seem  to  be  especially  predisposed. 

Pathology. — Ruptures  are  dividerl  into  two  classes — the  complete,  where  the 
peritoneal  cavity  is  opened,  and  the  incomplete,  Avhcre  the  muscle  is  torn,  but  the 
peritoneum  remains  intact. 

Fig.  694  shows  an  incomplete  rupture  with  a  subperitoneal  hematoma,  and 
Fig.  695  the  same  case  after  the  thin  peritoneal  covering  of  the  blood  tumor  had 
given  way  because  of  the  restless  tossing  of  the  patient,  and  a  fatal  hemorrhage 
into  the  peritoneal  cavity  had  ensued.     Note  how  the  peritoneum  has  been  stripped 


THE    ACCIDENTS    OF    LABOR 


751 


off  the  utoriis.  In  violent  or  tnnunatic  ruptures  the  cervix  is  oftenest  split  in  the 
length,  or  at  least  the  rupture  is  usually  lon<2;itu(hnal;  in  spontaneous  rui)turcs  the 
tear  is  usually  more  or  less  ol)li(|ue  and  often  transverse,  while  it  may  he  L  or  V 
shaped.  The  anterior  uterine  wall  is  oftenest  involved,  then  the  sides,  the  left 
more  commonly,  and  least  frequently  the  posterior  wall.  Doul^le  tears,  one  on 
either  side  of  the  uterus,  are  on  record.  Rupture  of  the  vagina — kolpoporrhexis — 
is  rare,  and  oftenest  the  posterior  fornix  is  torn,  while  the  anterior  and  lateral  walls 
suffer  less.  According  to  Stseli<jtkin,  there  were  36  posterior,  24  anteri<^r,  8  lateral, 
and  8  completely  circular  tears  in  74  cases.  Involvement  of  the  bladder  is  a  very 
serious  complication,  with  87  per  cent,  mortality  (Klien),  but  is,  fortunately,  rare. 
The  edges  of  the  tear  are  suggillated  and  ragged.  If  the  broad  ligaments  are 
()l)ened  up,  the  veins  and  arteries  can  be  felt  traversing  the  connective-tissue  spaces, 
which  are  filled  with  blood,  and  sometimes  with  air  or  gases  of  decomposition 
(emphysema).  The  hemorrhage  comes  from  the  large  venous  plexuses,  from  the 
utcrme  arteries  and  its  large  branches,  especially  the  uterovaginal.     The  hematoma 


Subperitoneal  hematoma 


Edge  of  rupt 
uterus 


matoma  in  broad 
ligament 


Fig.  G94. — Diagram  of  Uterixe  RrpTfRE.     Broad  Lioamext  Unfolded  and  Distended  dy  Immense  Hematoma. 


may  burrow  in  the  connective  tissue,  far  away  from  the  site  of  rupture,  even  to 
the  kidneys.  If  the  tear  is  behind  the  broad  ligaments,  the  bleeding  may  be  small, 
but  if  it  is  through  the  bases  of  the  broad  ligaments  or  involvesthe  siteof  the  placenta, 
the  woman  may  die  in  a  few  minutes  from  the  sudden  immense  loss  of  l^lood.  In 
my  cases  the  loss  of  Ijlood  was  greatest  in  the  incomplete  ruptures,  while  the  shock 
was  most  evident  with  the  complete  ones.  Urine,  meconium,  lanugo,  vernix 
caseosa,  and  licpor  amnii  may  be  fomid  in  the  peritoneal  cavity. 

Usually,  at  the  height  of  a  pain,  the  thinned  portion  of  the  uterus  gives  way, 
but  sometimes  the  separation  of  the  fibers  is  gradual,  and  the  rupture  is  completed 
without  producing  alarming  symptoms  (latent  rupture).  Only  after  peritonitis 
sets  in  is  the  condition  recognized,  or,  indeed,  at  a  subsequent  labor,  when  the 
uterus  ruptures  again  at  the  site  of  the  previous  scar.  The  point  which  is  most 
subjected  to  the  strain  gives  way;  then  the  uterine  contractions  force  the  child 
through  the  weak  spot  thus  created.  After  the  child  is  expelled  through  this  new 
passage  the  uterus  contracts  down  beside  it  and  comes  to  rest.     Sometimes  the 


752 


THE    PATHOLOGY    OF   LABOR 


rent  is  enlarged  by  the  operative  delivery.     Intestines  and  omentum  may  protrude 
through  the  opening  into  the  vagina. 

Incomplete  ruptures  occur  under  the  same  circumstances,  and  from  the  same 
causes,  as  the  perforating  ones,  and  the  tear  may  involve  one  or  two  of  the  layers 
of  the  uterus.  That  is,  the  peritoneum  only  may  split,  and  may  give  rise  to  intra- 
peritoneal hemorrhage,  mild  or  fatal,  or  the  muscle  only  may  part,  the  mucous 
membrane  and  peritoneum  being  intact,  or  the  peritoneum  and  muscle  break, 
leaving  the  mucosa,  or  the  mucous  membrane  and  muscle  part,  leaving  the  serous 
membrane,  the  last  being  the  commonest  variety.  Hematoma  is  the  rule  in  such 
cases,  and  the  tear  is  always  located  at  a  spot  where  the  peritoneuni  is  loosely 
attached  to  the  uterus,  the  sides,  and  near  the  bladder.  Cervix  tears,  if  extensive, 
are  usually  of  this  type.  Bursting  of  a  varix  in  or  on  the  broad  ligament,  with  sub- 
peritoneal or  intraperitoneal  hemorrhage,  tearing  of  an  artery  in  the  broad  liga- 


Edge  of  rupture  of  ut 


ure  of  peritoneum 


Fig.  09.5. — Diagram  of  Uterine  Rupture.     Hematoma  Burst  During  the  To.ssing  About  op  the  Patient. 


ment,  have  })een  ol)Scrved  as  rare  causes  of  death.  Possibly  some  such  accidents 
occur,  but  are  not  discovered. 

Symptoms. — If  the  accoucheur  is  on  the  alert,  he  will  almost  always  be  able 
to  detect  a  threatening  rupture  of  the  uterus,  and  diagnose  early  a  dangerous 
thinning  of  the  lower  ut(!rine  segment.  In  contracted  pelves  and  all  cases  of 
mechanical  obstruction,  and  where  he  knows  that  the  uterine  wall  is  weakened,  the 
attendant  will  be  especially  watchful.  It  must  be  said,  however,  that  sometimes 
the  tear  will  occur  so  gradually  that  the  symptoms  will  hardly  attract  notice,  or  the 
tissues  will  suddenly  give  way  without  any  apparent  cause  and  without  any  warn- 
ing. This  may  occur  in  the  Ixsginning  of  labor,  with  few  pains  and  intact  membranes, 
or  even  during  pregnancy,  but  it  is  very  exceptional. 

Fortunately,  symptoms  are  usually  present.  The  parturient  is  restless,  toss- 
ing and  rolling  about  the  bed;  she  is  anxious  about  the  labor,  because  there  is  no 
progress  in  spite  of  her  strong  pains;   she  complains  of  constant  soreness  and  almost 


THE    ACCIDENTS    OF    LABOR 


753 


continual  pain  ovor  tlio  hyp()f>;asti-iuni,  and  unc()nK(;i()Usly  her  hands  support  tlie 
lower  uterine  segment  with  every  uterine  contraction;  the  face  is  reddened,  but 
the  alae  nasi  arc  gray;  the  mouth  and  tongue  are  dry  and  red;  she  complains  of  a 
desire  to  urinate  frequently,  and  bears  down  with  the  pain  in  a  helpless  sort  of  way, 
and  begs  for  relief  incessantly;  the  temperature  is  slightly  raised;  the  respiration 
is  panting;  the  pulse  is  fast  and  usually  of  high  tension.  If  the;  woman  has  syncopal 
attacks,  one  can  infer  that  slight  tearing  of  the  uterus  has  begun. 

The  Rupture. — Suddenly,  during  the  acme  of  a  pain,  or  while  the  woman  is 
tossing  from  one  side  to  the  other,  she  complains  of  a  sharp,  tearing  pain  in  the 
lower  belly,  and  may  exclaim  that  something  has  burst  within  her.  Now  the 
picture  rai")idly  changes  from  sthenic  to  asthenic.  As  a  result  of  the  shock  and 
internal  hemorrhage  the  face  pales,  the  lips  whiten  or  become  cyanotic,  the  features 
sink  in,  cold  sweat  appears  on  the  nose  and  forehead,  the  temperature  drops,  the 
pulse  becomes  small  and  running,  even  filiform,  and  the  respiration  sighing;    the 


Fig.  696. — Rupture  or  the  Uterus   (author's  specimen). 


pains  cease  and  the  patient  is  ominously  quiet  for  a  short  while.  The  woman  com- 
plains of  shortness  of  breath,  of  precordial  oppression,  of  a  feeling  of  impending 
death,  and  soon  becomes  restless  again.  Vomiting  begins,  but  usually  is  not  a 
prominent  symptom  until  later.  The  pains  almost  always  cease,  but  if  the  child 
has  not  been  expelled  into  the  abdominal  cavity,  they  may  continue,  though  weaker, 
and  they  may,  though  rarely,  suffice  to  deliver  the  child.  Hemorrhage  from  the 
genitals  now  appears,  but  is  usually  not  profuse.  The  fetal  movements  for  the 
first  few  minutes  are  very  violent,  while  the  child  dies,  then  cease,  a  phenomenon 
which  may  be  observed  with  special  distinctness  when  the  child  has  escaped  from  the 
rent  uterus  under  the  abdominal  wall.  If  the  child  is  delivered  and  the  rupture  un- 
treated, the  woman  may  die  from  primary  hemorrhage,  from  shock,  from  secondary 
hemorrhage  (a  hematoma  bursting),  from  peritonitis,  either  early  or  beginning  as  late 
as  the  twentieth  day,  or  she  may  recover  unaided  if  the  damage  is  not  great.  The  peri- 
toneal edges  of  the  tear  adhere,  and,  in  the  absence  of  infection,  the  wound  granulates. 
48 


754 


THE    PATHOLOGY    OF   LABOR 


A  few  cases  are  on  record  where  the  child,  expelled  through  the  rent  into  the 
peritoneal  cavity,  was  changed  into  a  lithopedion,  as  in  ectopic  gestation. 

Diagnosis. — (A)  Threatened  Rupture. — It  is  vitally  important  that  the  diagnosis 
of  dangerous  thinning  of  the  uterus  ])e  made  before  the  rupture  occurs,  because  if 
anj^hing  can  be  done  to  save  the  woman,  it  must  be  done  at  once.  The  findings 
on  examination  are — (1)  A  restless,  excited,  anxious  patient,  high  pulse  (90  to  110), 
irregular  respiration,  temperature  99.6°  to  100.4°  F.,  and,  if  infection  is  beginning, 
101°  to  103°  F.;  (2)  strong  uterine  contractions  without  'proportionate  advance  of  the 
'presenting  part;  (3)  the  uterus  hard  and  drawn  up  over  the  child,  which  lies  in  the 

dilated  lower  uterine  seg- 
ment (Fig.  697).  The  fun- 
dus is  thick  and  the  lower 
uterine  segment  soft;  it 
balloons  out  during  the 
pains,  allowing  the  fetal 
body  to  be  outlined  with 
startling  distinctness.  The 
latter  seems  to  lie  under 
the  skin.  This  finding  is 
possible  under  anesthesia 
— the  exquisite  tenderness 
prevents  it  otherwise;  (4) 
a  groove  is  visible  and  pal- 
pable, running  obliquely 
across  the  belly,  higher  on 
the  side  of  the  greatest 
stretching — ^the  contrac- 
tion ring  (Fig.  697).  It 
may  rise  as  high  as  the 
navel  or  higher,  and  the 
distance  from  the  pubis 
may  be  used  to  estimate 
the  degree  of  thinning  and 
stretching  of  the  lower 
uterine  segment;  (5)  the 
round  ligaments  are  in- 
serted high  on  the  uterus, 
are  hard  and  wiry,  and 
particularly  the  one  on  the 
side  which  is  going  to 
burst  may  be  tense  and 
taut,  like  a  violin  string 
(Fig.  697) ;  (6)  the  uterus 
is  oblique ;  (7)  the  bladder 
is  drawn  up  high;  (8)  a 
general  aljdorninal  tenderness  is  present,  but  the  lower  uterine  segment  is  so  sensi- 
tive that  the  woman  will  hardly  allow  it  to  be  touched;  (9)  internal  examination 
will  reveal  the  cervix,  either  imprisoned  in  the  pelvis  and  swollen,  l)lack  and  blue, 
or  drawn  up  out  of  the  pelvis  with  the  vagina  on  the  stretch,  taut  around  the  pre- 
senting part,  and  hot,  njddened,  and  dry. 

These  findings  on  the  direct  examination  will  enable  every  accoucheur  to  dis- 
cover the  danger  which  threatens  the  woman  in  time  to  institute  proper  treatment. 
Unfortunately,  in  the  latent  ruptures  they  may  be  absent  or  veiled. 

(B)  Actual  Rupture. — The  symptoms  of  the  actual  tearing  of  the  uterus  and 


Fio.   607. — Abdominal  FiNoiM-n   in    a   Case   of  THUEATKNto   iiupiuKA 

Uteri. 

Mrs.  S.,  V-para,  patient  from  whom  x-ray  in  Fig.  694  was  taken.     Note 

the  fundus;    the  ballooned  lower  uterine  segment;    the  contraction  ring;    the 

tense  round  ligaments.     A  full  bladder  may  present  a  picture  resembling  this. 


THE   ACCIDENTS    OF   LABOR  755 

of  the  shock  and  anciniii  which  follow  will  alinosi  alwa.\s  he  sufficient  to  make  the 
(lin>('t  (liaj;nosis,  l)Ut  an  examination  of  the  patient  must  Ik;  made  to  confirm  it. 
The  (iudinj^s  in  cases  of  i  upline  oi  the  uterus  vary,  of  course,  witli  tlie  time  in  lal)or 
when  it  occurs,  and  whethei-  or  not  tlie  child  is  in  the  uterus  or  in  the  l)ell>'  when  the 
examination  is  made.  Tliey  are:  (1)  A  collapsed  patient  with  all  the  signs  of 
anemia  and  of  shock;  (2)  uterine  action  stopped  or  very  weak;  (8)  external  hemor- 
rhage, mild  or  severe,  rarely  al)sent;  (4)  abdominally,  the  child  can  be  felt  with  sur- 
prising distinctness,  lying  right  under  the  belly-wall,  while  the  empty  uterus  is 
j)ushed  to  on(>  side,  or  behind,  where  it  is  not  palpable.  If  the  child  has  partly 
escaped,  tlu'  uterine  tumor  is  heart  shaped.  Dulness  in  the  flanks  from  free  blood 
is  very  rarely  determinable.  Tenderness  may  make  the  abdominal  examination 
nugatory;  (5)  externally  the  hematoma  may  Ije  felt,  or  emphysematous  crackling; 
(0)  internally,  the  ragged  rent  may  be  palpal)le,  and  intestines  or  omentum  may  fall 
into  the  hantl;  (7)  the  presenting  part  has  disappeared  from  the  inlet  or  lias  become 
freely  movable. 

The  author  makes  it  a  rule,  after  every  operative  delivery,  no  matter  how  hard 
or  how  easy,  whether  or  not  symptoms  are  present,  to  examine  the  uterus  with  the 
whole  hand  and  determine,  beyond  the  suspicion  of  a  doubt,  the  extent  and  location 
of  any  injury.     This  practice  cannot  be  too  strongly  recommended. 

Differential  Diagnosis. — As  a  rule,  during  labor,  little  difficulty  is  experienced,  but  some- 
times one  has  to  consider  abruptio  placenta',  placenta  prsevia,  and  extra-uterine  pregnancy  at  term. 
These  have  already  been  discussed  under  their  respective  headings.  Collapse  during  or  after  labor 
may  be  tlue  to  something  else,  but  rupture  of  the  uterus  is  first  to  be  thought  of. 

An  important  diagnosis  to  make  after  delivery  is  whether  the  rupture  is  complete  or  incom- 
l>lete,  since  the  principles  of  the  treatment  depend  on  this.  Abdominally,  little  can  be  found; 
in  rare  instances  a  hematoma  may  be  outlined.  Emphysema  is  not  distinctive,  nor  are  signs  of 
l)(>ritoneal  irritation.  Vaginally,  the  presence  of  intestines  or  omentum  is,  of  course,  conclusive, 
i)ut  not  the  discharge  of  peritoneal  fluid,  wliich  may  be  simulated  by  the  serum  squeezed  out  from 
a  blood-clot.  The  internal  examination  alone  can  be  relied  on  to  differentiate,  and  here  it  may  be 
necessary  to  use  the  hand  without  a  rubber  glove.  This  is  the  only  instance  where  I  have  had 
to  use  the  bare  hand.  The  fingers  gently  pass  through  the  uterine  portion  of  the  tear,  and  come 
into  a  sjiace  filled  with  soft  clot.  Strands  of  fibrous  tissue,  nerves,  and  sometimes  vessels  span  the 
space,  and  great  care  must  be  exercised  to  prevent  breaking  them.  I  once  felt  the  uterine  artery 
between  my  fingers  pulsating  ominously.  If  the  tear  is  complete,  the  fingers  pass  directh'  into 
the  peritoneal  cavity,  which  may  be  recognized  by — (1)  The  smooth,  slippery  surface  of  the  ad- 
jacent uterus  and  of  the  abdominal  wall;  (2)  the  presence  of  gut  and  omentum;  (3)  the  great  free- 
dom of  motion  for  the  fingers;  (4)  the  fingers  may  lift  up  the  abdominal  wall  from  the  inside;  (5) 
outlining  the  edges  of  the  wound.  To  recognize  the  thin,  veil-like  layer  of  peritoneum  over  an  in- 
complete rupture — (1)  Note  if  the  fingers  are  confined  to  a  ragged,  walled  cavity;  (2)  try  to  deter- 
mine the  upper  uterine  end  of  the  rupture,  and  find  if  the  peritoneum  has  been  stripped  off  the 
uterus  here;  (3)  bimanually,  determine  if  there  are  any  structures  between  the  hands;  (4)  try  to 
sliile  the  ([uc'stionable  layer  of  tissue  over  the  fingers,  or  depress  it  by  the  abdominal  hand  between 
the  two  i^arted  internal  fingers;  (5)  note  the  relation  of  the  gut  to  it.  In  the  last  instance  the 
peritoneum  may  be  so  thin  and  stripped  off  the  underlying  structures  so  extensively  that  the  gut 
appears  to  be  within  the  grasp  of  the  fingers,  uncovered.  Here  the  differential  diagnosis  is  not 
so  necessary,  because  in  such  cases  the  thin  veil  of  peritoneum  will  in  all  likelihood  slough  off,  so 
that  the  treatment  is  the  same  as  for  complete  tears. 

It  is  sometimes  necessary  to  decide  if  other  organs  beside  the  uterus — the  bladder,  the  rectum 
and  bowels,  the  omentum — are  involved.  If  there  is  the  least  suspicion  of  such  an  injury,  the 
case  is  to  be  treated  as  if  it  really  were  so.  The  bladder  may  be  examined  with  a  cystoscope.  I 
discovered  one  injury  in  this  way.  The  rectum  may  be  explored,  but  if  any  injury  higher  up  is 
suspected,  the  belly  should  be  opened. 

Prognosis. — This  is  grave  in  all  cases,  but,  fortunately,  the  improvement  of  the 
modern  obstetric  practice,  with  asepsis  and  early  recognition  and  operative  treat- 
ment of  the  accident,  has  effected  a  substantial  reduction  of  the  previous  high  mor- 
tality. Incomplete  ruptures  are  a  little  less  dangerous  than  complete  ones,  but  the 
l)rognosis  depends  on  so  many  conditions — the  site,  the  extent  and  method  of  in- 
fliction of  the  injury,  the  presence  of  infection,  the  enviromnent  of  the  patient 
(hospital  or  home),  the  kind  of  treatment,  etc. — that  figures  are  practically  useless. 
Of  the  author's  10  cases  of  complete  rupture,  8  died  of  shock  or  sepsis;  of  14  cases  of 
incomplete  tear,  3  died — 2  from  hemorrhage  and  1  from  peritonitis.  C'holmogarof, 
in  1894,  found  mortalities  given  by  different  clinics  from  21  to  65  per  cent.,  depend- 


756  THE    PATHOLOGY    OF   LABOR 

ing  on  no  particular  line  of  treatment,  and  Koblanck  showed  73  per  cent,  and  78  per 
cent.,  Braun,  63  per  cent.,  that  for  incomplete  tears  being  25  per  cent.  For  the 
child,  the  outlook  is  still  worse.  Unless  the  delivery  can  be  completed  at  once,  the 
child  is  surely  lost.  When  the  rupture  occurs  at  the  end  of  the  second  stage,  the 
child  may  come  out  alive.  If  it  is  forced  out  into  the  belly,  it  usually  dies  in  a  few 
minutes,  but  three  cases  are  on  record  where  a  hasty  abdominal  section  rescued  it. 

If  the  mother  survives  the  hemorrhage  and  shock,  her  life  depends  on  the 
presence  or  absence  of  infection.  Peritonitis  is  the  rule  because  the  cases  are 
usually  in  the  hands  of  midwives  or  unclean  attendants.  Even  if  she  recovers  from 
this  labor  she  is  threatened  by  a  worse  recurrence  of  the  accident  in  her  next  one. 
Perfect  health  is  never  restored;  the  uterus  remains  large  (chronic  metritis),  the 
laceration  scars  distort  and  displace  it,  and  the  pelvis  is  permanently  the  seat  of 
venous  congestion. 

Treatment. — Prevention  of  rupture  of  the  uterus  is  one  of  the  regular  duties  of 
the  accoucheur,  and  forms  part  of  the  "watchful  expectancy"  so  often  spoken  of  in 
the  treatment  of  labor  cases.  If  a  diagnosis  of  ruptura  uteri  imminens  is  made,  the 
indication  is  to  empty  the  uterus  as  quickly  as  possible,  and,  further,  this  must  be 
done  with  the  least  possible  increase  of  the  intra-uterine  tension,  i.  e.,  with  no  further 
stretching  of  the  already  overstretched  lower  uterine  segment,  cervix,  and  vagina. 
If  the  cervix  is  imprisoned  in  the  pelvis,  it  must  first  be  pushed  up,  because  traction 
on  it  from  below  would  stretch  it  still  further  in  the  length  and  cause  the  transverse 
tear  which  was  impending.  If  all  the  conditions  for  forceps  are  fulfilled,  this  is  the 
operation  of  choice,  but  it  may  not  be  forced,  since  the  dragging  down  of  the  child 
ma}'  pull  the  thinned  cervix  apart.  Cranioclasis,  followed  by  cleidotomy  and  evis- 
ceration, is  preferable  and  more  humane.  It  is  criminal  to  attempt  version  in  these 
cases.  In  breech  presentations  the  after-coming  head  must  be  carefully  led  through 
the  endangered  portion  of  the  parturient  canal.  In  shoulder  presentations  embry- 
otomy, i.  e.,  evisceration  and  rachiotomy,  is  the  method  of  election.  Since  the  child 
is  nearly  always  dead  or  dying,  the  accoucheur  should  have  no  compunctions  about 
this  operation,  especially  when  version  carries  so  terrible  a  risk  for  the  mother.  In 
cases  where  the  uterus  has  only  just  begun  to  show  evidences  of  thinning  out,  an 
expert  accoucheur  may,  exceptionally,  under  deep  anesthesia  and  in  ideal  surround- 
ings, make  a  gentle  trial  of  version  in  the  hope  of  saving  the  infant.  Under  other 
circumstances  the  mother  is  safest  with  embryotomy.  Cesarean  section  should 
always  be  considered  when  the  child  is  alive,  but  the  conditions  favorable  to  the 
mother,  too,  must  be  present.  Cesarean  section  must  always  be  done  in  high  de- 
grees of  pelvic  contraction  or  obstruction  of  the  soft  parts.  Pubiotomy  rarely  comes 
into  the  discussion  of  these  cases.     Vaginal  hysterotomy  occasionally  does. 

To  prevent  a  rupture  while  preparing  for  these  operations  the  patient  should 
be  instructed  to  lie  quiet  and  not  to  bear  down.  The  uterus  may  be  supported 
by  a  binder,  but  the  best  remedy  is  a  deep  ether  narcosis  to  paralyze  the  uterus 
until  aid  is  at  hand.  Under  no  circiwistcmces  may  a  woman  threatened  with  rupture 
of  the  uterus  be  transported  to  a  hospital.  I  have  known  the  tear  to  occur  on  the 
way  from  the  jolting  over  bad  roads. 

Treatment  after  Rupture. — If  the  woman  is  in  a  well-equipped  maternity  when 
the  rupture  occurs,  an  attempt  should  be  made  to  save  the  child,  either  by  a  quick 
delivery  from  below  or  by  abdominal  section.  Extreme  shock  and  collapse  may 
forbid  the  rapid  emptying  of  the  uterus  which  might  precipitate  the  fatal  end.  It 
is  not  advisable  to  transport  a  parturient  to  a  hospital  after  rupture,  but  this  may 
be  necessary,  if  the  child  has  escaped  into  the  peritoneal  cavity,  because  then  the 
proper  treatment  is  laparotomy,  which  cannot  always  be  done  at  home.  During 
the  transport  the  abdomen  is  to  be  supported  by  a  well-padded  l:)inder  and  steadied 
by  the  hands  of  a  medical  attendant  if  the  jolting  of  the  ambulance  is  excessive. 
When  it  is  necessary  to  treat  the  case  at  home,  the  child  must  be  delivered  through 


THE    ACCIDENTS    OK    LAUOIi  757 

tlic  iKiliiral  passages,  even  lli()Uj:;li  there  is  real  (lanf;<'r  of  making  the  rent  larger  and 
of  rupturing'  important  vessels. 

Mucli  difference  will  be  found  in  the  treatment  of  ruptured  uteres  between  that 
of  the  specialist  in  his  well-equipped  maternity  and  the  general  practitioner  without 
such  advantages.  The  following  methods  have  })een  in  use:  (1)  Extract  the  fetus 
through  the  vagina;  rei)laee  intestines;  mori)hin,  ergot,  ice-bag  on  alxlomen; 
(2)  extract  the  fetus  through  the  vagina,  replace  intestines,  drain  (not  tight  packing) 
tiie  rent  and  the  peritoneal  cavity  with  gauze  or  rubljer  tube;  ergot,  ice-bag,  mor- 
phin;  (3)  the  same,  then  sew  up  the  rent  from  below  and  drain  part  of  the  tear  with 
gauze;  ergot,  ic(»-l)ag,  etc.;  (4)  delivery  from  Ix'low,  followed  })y  vaginal  extirpation 
of  the  uterus;  (5)  laparotomy,  remove  fetus  and  placenta,  sew  up  rent,  and  drain 
from  below;  (G)  the  same,  but  with  amputation  of  the  uterus  or  total  extirpation, 
with  vaginal  drainage. 

The  first  four  methods  are  applicable  when  the  child  may  \)G  delivered  per 
vaginam,  and  where  the  rupture  is  discovered  only  after  deliver}'.  If  it  is  not 
]X)ssible  or  safe  to  deliver  the  child  from  ])elow,  laparotomy  must  be  done,  the 
child  and  the  placenta  removed,  and  the  uterus  and  hollow  organs  dealt  with  ac- 
cording to  conditions.  If  the  case  is  clean,  the  rent  in  the  uterus  may  be  repaired, 
and  drainage  through  the  vagina  with  gauze  secured;  if  it  is  septic  or  presumably  so, 
extirpation  or  amputation  of  the  uterus  is  to  be  performed,  with  drainage  of  the 
\-)d\\s  from  below.  If  the  hemorrhage  is  profuse  and  not  easil}^  controlled  by  clamps 
and  suture,  the  uterus  had  best  be  removed.  Whether  to  extirpate  or  only  to  ampu- 
tate tlepends  on  the  extent  and  location  of  the  injury  and  the  condition  of  the  par- 
turient, amputation  lieing  (luicker  than  total  extirpation. 

After  delivery,  when  the  question  arises  whether  to  open  the  belly  or  treat 
the  case  per  vaginam,  these  things  must  be  considered:  (1)  The  statistics;  (2) 
the  environment  of  the  patient;  (3)  her  condition  as  regards  infection  and  bleed- 
ing; (4)  the  skill  of  the  operator.  Statistics,  as  usual,  are  unreliable  guides, 
Klien  finding  that  44  jier  cent,  recovered  with  laparotomj',  while  only  39  per  cent, 
with  drainage,  and  Kolaczek  finding  that  only  25  per  cent,  recovered  after  lapa- 
rotomy, w^hile  39  per  cent,  recovered  with  drainage.  In  poor  surroundings  drain- 
age is  better  than  celiotomy,  and  since  it  is  dangerous  to  transport  these  patients, 
the  argument  for  drainage  is  stronger.  In  cases  of  infection  it  is  hard  to  de- 
cide, but  the  majority  of  authorities  seem  to  be  on  the  side  of  extirpation  of  the 
uterus,  with  most  thorough  drainage  below.  Vaginal  extirpation  should  show 
the  ])est  results  here.  In  the  milder  cases  hemorrhage  may  be  controlled  by  light 
tamponing  of  the  rent,  but  if  severe,  the  belly  must  be  opened.  When  injury  to 
adjacent  viscera  is  suspected,  immediate  laparotomy  is  demanded.  In  the  hands  of 
the  general  practitioner  drainage  is  the  operation  of  choice,  while  in  the  equipped 
maternity  more  radical  measures  may  be  attempted.  Scipiades,  of  Budapest,  in 
1910,  basing  his  judgment  on  an  experience  of  97  cases,  says  drainage  is  best  even  in 
hospitals.  J\Iy  own  experience  in  hospital,  dispensary,  and  consultation  practice 
has  convinced  me  that  drainage  of  the  peritoneum  and  the  tear  is  the  best  general 
treatment,  and  that  laparotomy  is  to  be  done  to  meet  special  indications.  In 
clean  cases  part  of  the  rupture  should  be  united  by  suture.  This  is  accomplished 
by  exposing  the  wound  with  very  broad  specula,  and  pulling  down  its  edges  with  the 
cervix  forceps  (Figs.  689  and  690) .  In  one  case,  in  1898,  in  order  to  bring  the  deepest 
portions  of  the  rent  wdthin  reach,  I  detached  the  bladder  from  the  cervix  in  a  manner 
similar  to  that  of  the  vaginal  cesarean  section.  After  the  tear  is  nearly  all  sewed 
the  space  above  is  drained  with  a  few  strips  of  gauze  or  a  soft-rubber  tube,  as 
thick  as  the  finger. 

I  have  not  jet  had  an  opportunity  to  use  the  IMomburg  belt  in  a  case  of  rupture 
of  the  uterus,  but  can  appreciate  that  it  might  be  valuable  to  arrest  hemorrhage 
while  the  rent  is  being  examined  and  repaired. 


758  THE    PATHOLOGY    OF    LABOR 

Incomplete  ruptures  are  best  treated  by  light  packing.  If  the  rent  is  packed  too 
tightly,  the  thin  peritoneum  may  be  burst  through,  or  may  split  over  the  tampon 
during  the  transport  from  table  to  bed,  or  during  the  restless  tossing  of  the  partu- 
rient. If  the  peritoneum  is  lifted  off  its  attachments  for  a  great  extent,  especially 
in  multiple  ruptures;  if  there  is  a  suspicion  of  infection;  if  the  hemorrhage  is  ob- 
stinate; if  the  wound  is  complicated — the  case  is  to  be  treated  like  a  complete 
rupture.  It  may  be  possible  to  reach  the  field  of  an  incomplete  rupture  by  an 
incision  similar  to  that  made  for  ligating  the  internal  iliac  artery. 

After-treatment. — Ergot  and  hydrastis  will  help  to  keep  the  uterus  contracted. 
A  firm  abdominal  binder  should  be  applied,  though  if  it  is  needed  for  counterpressure 
to  aid  a  tampon  in  stopping  hemorrhage  not  much  may  be  expected.  I  got  good 
results  in  one  case  by  sitting  by  the  woman's  side  and  holding  the  uterus  clown 
against  the  tampon  for  two  hours.  The  gauze  is  removed  on  the  third  or  fourth 
day,  and  a  smaller  strip  inserted  or  a  tube  substituted.  It  is  wise  not  to  let  the 
wound  close  too  rapidly.  If  signs  of  infection  appear,  a  vaginal  examination  is 
required  to  determine  the  presence  of  an  exudate. 

Since  the  site  of  a  healed  rupture  of  the  uterus  is  not  strong,  the  muscular  fibers 
near  it  being  usually  atrophied  and  the  scar  friable,  it  is  best  to  instruct  the  patient 
that  in  a  subsequent  pregnancy  she  should  spend  the  last  four  weeks  in  a  maternity. 
As  soon  as  labor  declares  itself  cesarean  section  should  be  performed.  If  this  advice 
is  unheeded,  the  accoucheur  should,  when  called  during  labor,  terminate  the  case 
with  forceps  as  soon  as  the  conditions  are  present.  Induced  labor  is  shghtly  less 
dangerous  than  labor  at  term,  but  if  pelvic  obstruction  is  to  be  overcome,  it  is  not, 
and  the  abdominal  delivery  at  term  is  imperative.  The  induction  of  abortion  for 
this  indication  alone  is  not  allowable. 


RUPTURE  OF  THE  UTERUS  DURING  PREGNANCY 

This  is  one  of  the  rarest  accidents  of  pregnancy,  if  one  excludes  perforation  of  the  uterus  by 
criminal  abortionists.  Baisch,  in  1903,  collected  78  cases.  A  healthy  uterus  will  tear  only  under 
the  most  violent  indirect  injury;  but  if  the  muscle  is  diseased,  it  may  give  way  during  the  natural 
growth  of  pregnancy,  or  during  one  of  the  contractions  of  the  uterus,  or  from  the  shock  of  a  fall, 
a  cough,  etc.  Ruptures  of  the  uterus  during  pregnancy  are  to  be  divided,  as  in  labor,  into  spon- 
taneous and  traumatic.  The  latter  group  must  be  further  divided  into  those  due  to  direct  injury 
applied  to  the  uterus,  and  those  occurring  indirectly,  as  from  a  fall  or  straining  of  any  kind.  Simple 
spontaneous  rupture  may  occur  from  yielding  of  the  scar  of  a  previous  cesarean  section,  or  from 
previous  rupture,  injury,  or  from  gynecologic  operations  (fibroid,  curetage,  etc.);  thinning  of  the 
uterine  wall  from  manual  removal  of  the  placenta,  especially  if  repeated;  hypoplastic  uteri;  mal- 
formed uteri,  as  single  or  double  horned;  interstitial  pregnancy;  actual  disease  of  the  wall,  car- 
cinoma, hydatid  mole,  fatty  and  hyaline  degeneration,  previous  infection,  and  small-cell  infiltra- 
tion; growth  of  placental  vilh  into  the  uterine  wall;  abruptio  placentte  (the  uterus  may  burst 
over  the  retroplaccntal  hematoma);  displaced  and  adherent  uterus;  in  short,  the  same  factors 
which  predispose  to  rupture  during  labor. 

E.xamples  of  direct  traumatism  are:  Puncture  of  the  uterus  by  sounds,  curets,  or  other  imple- 
ments, u.sed  in  operations  or  to  produce  abortion,  by  bullet,  the  horn  of  a  steer,  etc.  Indirect 
traumatism  is  often  the  cause,  but  often  a  disease  of  the  uterus  preexists,  because  the  normal  organ 
can  withstand  much  insult  without  injury,  as  witness  the  case  of  Hofmcier,  where  the  woman  fell 
from  a  fourth-story  window  without  rupture,  and  the  one  where  a  drunken  man  jumped  upon  the 
prostrate  woman's  abdomen  without  causing  abortion. 

Clinical  Course— Uiim-.h  found  .31  cases  of  rupture  during  the  first  five  months  of  gestation, 
and  in  thf>se  the  uterine  wall  was  diseascfl.  In  the  later  ruptures  scar  tissue  was  usually  found. 
The  symptoms  resemble  those  of  rujjlurcd  extra-uterine  pregnancy,  but  the  shock  is  usually  more 
marked,  f:specially  when  ext(!rnal  violence  is  the  causative  agent.  Pain  in  the  abdomen  is  the  rule, 
and  labor  pains  may  occur — this  wlieii  rujjture  is  incomplete.  These  contractions  complete  the 
tear  and  expel  the  child  out  of  thr;  uterus,  after  which  they  subside.  When  the  peritonitis  begins, 
pain  rccomrnenc<!S,  but  usually  the  patient  complains  of  a  t(>nder  body  in  the  abdomen  from  the 
start.  Vomiting,  hiccup,  and  other  signs  of  peritoneal  irritation  are  usually  present,  together  with 
signs  of  internal  hemorrhage. 

In  Leopold's  and  Henrotin's  cases  gestation  continued,  with  the  child  among  the  bowels,  the 
cord  is.suing  from  the  hole  in  the  uterus,  but  these  are  exceptional,  the  rule  being  that  the  child 
dies,  becomes  infect(>fl,  and  peritonitis  closes  the  scene.  It  is  possible  that  a  lithopedion  may  re- 
sult. The  hemorrhage  may  be  internal,  external,  or  both;  sometimes  the  child  tampons  the  rent, 
and  there  is  no  hemorrhage  at  all,  so  that  a  diagnosis  cannot  be  made  until  the  belly  is  opened. 


THE    ACCIDENTS    OF   LABOR  759 

Ilcmatoiuiita  urc  nirc,  b(H':iuso  the  tears  iirc  iisuully  fundal.  T{uj)turo  m;iy  sometimes  oceur  in 
the  interior  or  posterior  wall,  jiiid  also,  hut  rarely,  in  the  lower  part,  of  the  uterus.  While  the 
l.ihor  pains  are  t'orcinf:;  the  child  out  Ihrounh  the  tear,  a  ba^  of  waters  may  form  over  tlu;  os — the 
child  may  he  even  delivere(l  throufz;h  the  vagina  before  the  fundal  tear  is  completed. 

Instrumental  jjcrforations,  if  done  aseptically  and  not  lar^e,  hrin^  on  abortion  and  may  heal 
unnoticed;  if  done,  as  usual,  without  asepsis,  they  cause  decomposition  of  the  uterine  contents 
and  i)erit()nitis.      (See  Septic  Abortion.) 

DUiynosis. — This  is  almost  always  very  dillicult,  but  since  most  of  the  conditions  which 


Fig.  698. — Traum.vtic  Rupture  of  Fundus  Uteri  in  Ninth  Month  of  Pregn.vncy. 

simulate  the  accident  require  laparotomy  anyway,  it  is  not  absolutely  essential.  To  be  considered 
here  are  torsion  of  a  tumor  near  the  uterus,  rupture  of  the  liver,  gall-bladder,  or  spleen,  ileus,  rup- 
turetl  ectopic  gestation,  abriiptio  placenta^  and  placenta  pra?via. 

The  treatment  is  laparotomy  as  soon  as  the  diagnosis  is  made  or  becomes  even  only  probable. 


INVERSION  OF  THE  UTERUS 

Fig.  099  shows  a  complete  inversion  or  turning  inside  out  of  the  uterus,  together  with  pro- 
lai)se,  i.  e.,  prolapsus  uteri  inversi.  Lesser  degrees  occur,  and  only  the  placental  site  may  be  de- 
pressed, as  in  Fig.  708,  p.  772 — the  so-called  atony  of  the  placental  site.  All  grades  between 
thes(>  two  extremes  are  obscrv(Hl,  and  are  called  incomplete  or  partial  inversions,  the  most  com- 
mon of  which  are  those  in  which  the  fundus  comes  to  lie  in  the  vagina  just  within  the  introitus, 
and  feels  like  a  soft,  large,  globular,  fibroid  polj'p.  The  placenta  may  still  be  attached,  or  only 
partially  adherent.  If  the  inversion  occurs  after  the  third  stage,  the  naked  uterus  lies  in  the 
vagina  or  may  be  expelled  outside,  in  which  case  the  open  sinuses  and  tubal  ostia  are  visible. 
In  the  "inversion  funnel"  from  the  abdominal  side  the  tubes,  ovai'ies,  the  round  and  broad 
ligaments,  sometimes  the  gut  and  omentum,  may  be  seen. 

Eliologij. — In  one  of  the  author's  cases,  during  the  removal  of  the  placenta,  the  uterus  was 
felt  to  contract,  the  contraction  ring  opened  outward,  a  condition  shown  in  Fig.  700  appearing  for 
a  few  mom(>nts.  The  view  that  an  inversion  could  be  thus  produced  by  contraction  of  the  fundus, 
with  relaxation  of  the  lower  portions  of  the  uterus,  was  held  by  Kokitansky,  Duncan,  and  others, 
but  Schauta  strongly  asserted  the  contrarj- — that  it  was  atony  of  the  uterus  which  caused  the 
accident.  While  atony  of  the  organ  may  cause  the  majority, I  am  convinced  that  the  view  of  Ro- 
kitansky  is  correct  in  some  cases.  An  atonic  uterus  may  become  inverted  by  a  sudden  action  of 
the  abdominal  muscles,  increasing  intra-abdominal  pressure,  such  as  bearing  down  to  express  the 
placenta,  turning  in  bed,  sitting  up,  coughing,  raising  the  hips  to  allow  a  clean  sheet  to  be  placed. 
Inversion  from  such  causes  is  called  ■•<ponl(i)ico>is.  Violent  inversion  may  be  due  to  traction  on  the 
luubilical  cord  in  the  effort  to  remove  the  ]ilacenta  (24  of  47  cases  of  Yogel),  traction  on  part  of  the 
placenta  or  on  the  membranes,  and  too  powerfid  Crede  expression  of  the  placenta.  Spontaneous 
inversion  may  result  from  pulling  on  the  too  short  cord  liy  the  child  during  natural  delivery.  While 
many  cases  are  reported  as  spontaneous,  probably  most  of  them  are  the  result  of  errors  of  art. 


760 


THE    PATHOLOGY    OF   LABOR 


Inversion  of  the  uterus  is  rare  in  hospitals.  Braun,  in  250,000  labors,  did  not  see  one,  and  in 
Dublin  only  one  was  observed  in  190,000  consecutive  labors.  Most  of  the  cases  occur  in  private 
practice,  but  the  accident  is  exceedingly  rare.  It  may  occur  in  abortion  as  early  as  the  fourth 
month,  Holmes  having  \vxd  a  case  at  the  fifth  month,  and  it  may  appear  on  the  second,  sixth,  even 
the  fifteenth,  day  after  delivery. 

Symptoms. — As  a  rule,  the  inversion  is  gradual,  beginning  as  a  little  depression,  and  then 
suddenly  the  fundus  drops  into  the  vagina  (Fig.  701).  If  traction  on  the  cord  has  been  made, 
the  movement  is  more  abrupt.  The  patient  utters  a  sharp  cry  and  bears  down,  the  latter  having 
a  tendency  to  increase  the  prolapse.  Shock  is  almost  always  present,  certainly  if  the  uterus  turned 
inside  out  suddenly,  and  is  due  to  the  stretching  of  the  peritoneum  and  the  nerves  of  the  broad 
ligaments,  perhaps  also  from  the  reduction  in  intra-abdominal  tension  and  consequent  downward 


External  os 


External  os 


Fio.  699. — Invbrsio  I^rKRi  Totalis  (adapted  from  Tandler). 


displacement  of  the  fliafihragm,  the  heart,  etc.  Profuse  hemorrhage  is  the  rule,  because  the  pla- 
centa has  almost  always  been  cither  partly  or  completely  detached,  but  it  may  be  absent  if  the 
organ  is  still  adherent  to  tlic  inverted  uterus.  .Shock  is  disproportionate  to  blood  loss.  If  the 
uterus  contracts,  especially  if  the  cervix  snuj)s  together  Mroiind  llic  extruded  fundus,  the  bleeding 
may  be  .slight,  but  this  is  the  exception.  In  rare  instances  both  colla])Ke  and  severe  bleeding  are 
absent,  and  the  condition  is  discovered  only  at  a  subse(}uent  (examination.  If  the  woman  does  not 
die  from  shock  or  hemorrhage,  the  inverted  fundus  may  slough  off,  resulting  in  death  or  recovery; 
it  may  be  infected,  resulting  in  septicopyemia,  or  it  may  undergo  involution  and  come  under  late 
treatment,  or  it  may,  spcintaneously,  and  without  explainable  cause,  b(^  reinverted.  Such  cures 
have  been  observed  a  few  liours  after  tlic  occurrence  and  as  late  as  five  and  eight  years  (Meigs  and 
Baudelocque). 

Ileus,  from  incarceration  of  tlic  gut  in  the  inversion  funnel,  has  been  observed.     In  the 


THE   ACCIDENTS    OF   LAHOR 


761 


chronic  casos  the  fundus  in  the  vagina  alrophics  and  becomes  covered  with  a  dry,  sliKhtly  liornified 
epithelium,  and  is  often  the  seat  of  erosions  and  ulcers.  Menorrhagia,  leukorrhea,  and  irregular 
blecdinji  are  often  (•om|)lained  of,  with  dragging  pains  in  the  hack  and  a  feeling  of  bearing  down,  but, 
remarkably,  one  or  all  of  these  symptoms  may  be  wanting. 

Diagnosis.  If  only  the  attendant  would  bear  this  accident  in  minri,  there  need  be  no  difli- 
culty  in  making  the  diagnosis  on  the  direct  examination.  A  large,  roundish  tumor  in  tlie  vagiriii, 
with  absence  of  tiic  fundus  uteri  from  its  proi)er  i)lace,  in  the  presence  of  sliock  and  liemorrliage, 
will  clear  up  the  situation  at  once.  It  may  be  possible  to  feel  tlie  inversion  funnel  from  the  abdo- 
men after  the  bladder  is  emptied.  In  the  dilTerential  diagnosis  fibroid  polj'p,  adherent  placenta, 
and  total  atony  of  the  uterus  are  to  be  considci'cd, 
and  a  careful  bimanual  examination  will  easily  dccich! 
between  them.  Tlie  inverted  fundus  has  been  torn 
otT  under  the  notion  that  it  was  the  i)lacenta  alone; 
it  has  been  cut  ofT  as  a  tumor,  and  tlie  whole  uterus 
has  been  pulled  out  as  a  second  twin!  If  the  fundus 
is  prolapseil,  the  bright-red,  rough,  bleeding  endo- 
metrium, or  the  placenta,  cannot  fail  to  tell  what 
has  hajipened.  In  debating  the  causes  of  postpartum 
shock  inversio  uteri  must  be  considered  with  rupture 
of  the  uterus,  liemorrliage,  etc. 

Prognosis. — This  is  better  now  than  formerly, 
by  graci-  of  asepsis  and  better  obstetric  practice  in 
general.  Crosse,  in  lS4;i,  found  that  SO  of  109  re- 
ported cases  died;  Vogel,  in  1900,  reported  only  22 
per  cent,  mortality.  Even  some  of  the  cases  where 
the  uterus  has  been  torn  olT  recover  if  infection  is 
absent.  Reposition  improves  the  outlook.  It  may 
be  possil)!e  even  after  twent}^  years. 

Treatment. — Although  inversion  of  the  uterus 
is  rare,  the  accoucheur's  routine  technic  in  handling 
hibor  cases  should  comjjrise  means  for  its  prevention. 
Traction  on  the  cord  must  be  avoided,  and,  while 
drawing  the  membranes  off  the  uterine  wall,  the  out- 
side hand  must  lie  on  the  fundus  and  assure  its  contraction.  Atony  of  the  uterus  postpartum  is 
to  be  rectified  as  soon  as  possible.  In  turning  the  newly  delivered  woman  from  side  to  side,  or 
when  she  raises  her  hips  for  the  removal  of  soiled  bed-clothes,  the  bed-pan,  the  rubber  pad,  etc., 
the  attendant  must  lay  a  hand  on  the  uterus  and  be  sure  that  it  is  firmly  contracted.  During  the 
manual  removal  of  the  placenta  the  first  indications  of  inversion  are  to  be  corrected. 

What  to  do  in  acute  cases  requires  deliberation,  because  if  the  attempt  is  made  to  put  the 
utinnis  back  while  the  woman  is  in  deep  shock,  the  delicate  balance  will  be  turned  against  her. 
Here  it  is  better  to  replace  the  fundus  in  the  vagina,  pack  the  latter  firmly,  and  let  the  parturient 
rally.     If  bleeding  is  going  on,  however,  it  may  be  necessary  to  risk  the  added  shock  in  order  to 


Fig.  700. — Diagram  to  Show  How  a  Uterus  tax 
Invert  Itself  by  Contraction. 


Fig.  701. — Diagrams  to  Show  how  an  Atonic  Uterus  mat  be  Ina'erted. 
Arrows  show  placental  site. 


Stop  it.  Ether  is  the  anesthetic  of  choice,  but  sometimes  only  a  little  encouragement  is  required 
to  enable  the  woman  to  stand  the  operation.  The  shoulders  should  be  raised  a  little  to  avoid  air 
embolism.  It  is  best  to  remove  the  placenta  cleanly,  before  reposition  is  attempted,  but  if  the 
case  seems  favorable,  the  removal  of  the  placenta  may  be  done  after  the  uterus  is  returned.  If  the 
attendant  feels  that  the  surroundings  and  his  assistance  do  not  justify  his  interference,  the  external 
portion  of  the  mass  may  be  returncfl  to  the  vagina  and  the  latter  packed,  to  await  the  arrival  of 
help  or  during  transportation  of  the  ]iatient  to  a  maternity.  Spontaneous  reinversion  may  thus 
occur.     It  may  be  wise  to  thus  tampon  until  the  woman  has  recovered  from  the  shock. 


762 


THE    PATHOLOGY    OF   LABOR 


The  tochnic  of  the  operation  in  acute  cases  is  simple  (Fig.  702).  While  the  whole  mass  Hes 
in  the  grasp  of  the  hand,  the  fingers  spread  out  the  constricting  portion  of  the  uterus,  and  the  palm 
pushes  up  on  the  inverted  funtkis — all  this  in  the  direction  of  the  axis  of  the  pelvis,  well  forward, 
to  avoid  the  sacrum.  The  mancruver  may  be  aided  by  the  outside  hand  dilating  the  funnel.  It 
may  be  best  to  push  up  one  side  of  the  uterus  first, — a  sort  of  taxis, — replacing  first  the  part  which 
came  down  last.  Great  care  is  to  be  exercised  to  avoid  puncturing  the  soft  atonic  uterine  wall. 
It  occurs  surprisingly  easily.  Deep  anesthesia  must  be  induced  if  there  is  a  tendency  to  spasm  of 
the  constricting  portion,  and  the  operation  may  be  neither  prolonged  nor  forced.  It  is  better  then 
to  pack  the  vagina  lightly  with  gauze,  suri'ounding  a  colpeurynter,  which  latter  is  then  filled  with 
sterile  water.  Treatment  with  the  colpeurynter  is  very  successful,  but  sometimes  several — as  high 
as  20 — applications  may  be  needed.  The  colpeurynter  is  left  from  twelve  to  thirty  hours,  and  the 
foot  of  the  bed  is  elevated.  Gentleness,  asepsis,  and  patience  are  the  watchwords.  After  reposi- 
tion it  is  wise  in  all  cases  to  tampon  the  uterovaginal  tract.  While  the  colpeurynter  is  most  suc- 
cessful in  the  early  cases,  it  should  always  be  tried  before  resorting  to  operative  measures,  even  for 
verj'  chronic  inversions.     In  the  last  class  it  may  be  necessary  to  employ  the  knife,  and  then  Kiist- 


FiG.  702. — Diagram  Showing  Method  of  Replacing  Inverted  Uterus. 
After  the  whole  hand,  firasping  tlic  utiiiuc  liody,  has  replaced  same  in  vagina,  the  constricting  cervical  ring  is 


spread  by  means  of  the  finger.s  and  thuinl) 
by  arrows.     The  outside  hand  aids  to  dihi 


I  he  palm  of   the  hand  forces  up  the  fundus  in  the  directions  indicated 
liiiinel. 


ner's  operation  or  one  of  its  modifications  may  be  used.  Hirst  advises  splitting  the  cervix  pos- 
teriorly, .since  this  forms  the  constricting  ring  in  old  cases,  and  then  to  replace  the  uterus,  or  if  this 
is  impossible,  to  prolong  the  cut  onto  the  posterior  wall  of  the  uterus,  all  the  incisions  to  be  re- 
paired after  reposition.  If  the  incision  on  the  posterior  wall  of  the  uterus  is  long,  it  may  be  neces- 
sary to  pull  the  replaced  and  retroverted  uterus  down  through  an  opening  in  the  culdesac  for 
suture.  Failing  this  operation,  vaginal  extirpation  of  tlie  uterus  may  be  required.  In  acute  cases 
such  operations  are  almost  never  needed,  sepsis,  gangrene,  or  intractable  bleeding  giving  the  few 
rare  indications.  When  extirpation  is  done  it  is  best  to  split  the  fundus  to  avoid  injury  to  struc- 
tures which  may  have  fallen  into  the  funnel,  and  to  obtain  easier  access  to  the  broad  ligaments. 


Literature 

De  Lee:  "  Ruptura  Uteri,"  Amer.  Jour.  Obatct.,  1903,  No.  .3;  ibid.:  Amer.  .Tour.  Obstet.,  1906,  vol.  1,  No.  6.  Gives  com- 
plete literature. — Dickinson:  Amer.  .Jour.  Obstet.,  July,  1910. — "Hematoma,"  Arch.  f.  Gyn.,  1910,  vol.  xcii,  p. 
29.5,  H.  2,  and  Ilill:  New  York  Med.  Jour,  and  Phila.  Med.  Jour.,  April  22,  I'M!).  Gives  complete  literature 
up  to  date. — Kolnczek:  Inaug.  Di.ss.,  1903,  Breslau. — Lobensline:  Amor.  Jour.  Obstet.,  November,  1909.— 
Peterson:  "Inversion  of  the  Uterus,"  Amer.  Gyn.,  June,  1903. — Rouvier:  "Kolporrhexis,"  Amer.  Jour.  Obstet., 
July,  1912,  p.  116. — Spain:  "  Labor  in  Elderly  Primipara;,"  Amer.  Jour.  Obstet.,  March,  1912.  Literature. — 
Thorn:  "521  Inverisions,"  Voikmann's  Samml.  klin.  Vortriige,  1911,  No.  229.  Literature. — Vogel:  "Inver- 
sion," Zeitschr.  f.  Gob.  u.  Gyn.,  1900,  vol.  xlii,  p.  490. 


CHAPTER  LX 

INJURIES  TO  THE  BLADDER,  RECTUM,  ETC. 

THE  BLADDER 
During  labor  the  bladder  is  dI•a^vn  up  with  the  unlolding  lower  uterine  segment, 
antl,  when  overfilled,  forms  a  rounded  tumor  above  the  })ul)is,  extending  sometimes 
even  above  the  navel.  It  may  be  mistaken  for  the  dilated  lower  uterine  segment 
and  contraction  ring.  The  full  bladder  may  prevent  delivery  by  weakening  uterine 
action,  by  making  it  too  ])ainful  or  impossible  for  the  woman  to  bear  doAAm,  and,  if 
it  is  filled  before  the  head  has  entered  the  pelvis,  by  preventing  engagement.  Cathe- 
terization will  make  the  diagnosis  and  cure.  Tumors  of  the  bladder  have  caused 
dystocia,  as  also  have  vesical  calculi.  The  head  may  crush  them  against  the  bone  and 
break  them,  or  the  vaginovesical  wall  may  be  rubbed  through,  causing  fistula.  Such 
ol)st  ructions  should  be  pushed  up  out  of  the  pelvis  with  the  patient  in  the  knee- 
chest  i)osition,  and  if  this  is  not  possible,  removed  per  vaginam.  Varices  of  the 
1  )ladder  may  rupture  during  pregnancy  and  labor.  A  kidney  may  be  displaced  and  be- 
come adherent  over  the  inlet,  causing  dystocia.  Horseshoe  kidney  has  thus  been  ob- 
served, but  it  need  not  give  trouble.  Cystocele  may  come  down  before  the  ad- 
vancing head  and  delay  delivery.  It  has  been  punctured  for  the  bag  of  waters,  and 
torn  off  as  a  tumor.  The  cystocele  is  not  so  much  to  be  feared  as  the  abruption  of 
the  base  of  the  bladder  from  its  pubic  attachments.  The  duplication  of  the  con- 
nective-tissue strands  which  radiate  from  the  neck  and  anterior  wall  of  the  bladder 
to  the  pubis  and  ligamentum  arcuatum — the  so-called  pubovesical  ligaments — are 
stretched,  separated,  and  torn,  allowing  a  descensus  of  the  bladder.  In  addition 
the  fibers  between  the  bladder  and  vagina  and  those  in  the  base  of  the  broad  liga- 
ments which  support  the  bladder  are  also  disrupted,  all  of  which  causes  cystocele 
and  prolapsus  vesicae.  Unfortunately,  little  can  be  done  during  labor  to  prevent 
this  downward  dislocation  of  the  lower  half  of  the  bladder.  The  protruding  organ 
may  be  gentl}^  pushed  back  above  the  advancing  head,  and  in  a  few  cases  I  have  done 
episiotomy  to  deflect  the  head  from  the  posterior  surface  of  the  pubis  and  thus  re- 
lieve the  crowding  here.  For  this  purpose  the  operation  has  not  been  often  enough 
performed. 

FISTULAS 

Fistulas  are  false  passages  between  adjacent  hollow  organs,  and  in  the  pelvis 
are  almost  always  due  to  labor,  but  cancer,  etc.,  may  ulcerate,  leaving  such  defects, 
while  foreign  bodies,  such  as  pessaries  or  objects  introduced  for  purposes  of  mastur- 
bation, sometimes  do  the  same.  Fistulas  due  to  labor  are  getting  rarer  every  year 
by  grace  of  the  better  practice  of  obstetrics.  In  my  student  days  such  operations 
were  not  uncommon — now  they  are  curiosities. 

Pressure  necrosis  of  the  bladder  results  from  prolonged  compression  betAveen 
the  head  and  the  pelvis.  This  was  discussed  under  Contracted  Pelvis.  Usually 
the  vaginovesical  septum  is  caught  betAveen  the  two  hard  objects,  and  as  the  result 
of  the  prolonged  arterial  anemia,  the  area  under  the  compression  necroses  and  is 
cast  off  as  a  slough  in  the  first  Aveek  of  the  pucrperium,  causing  incontinence  of 
urine.  If  the  cervix  is  not  dilated,  but  caught  in  the  zone  of  compression,  the  re- 
sulting fistula  will  be  cervicovesical,  perhaps  utero vesical,  or  ureterocervicovesico- 
vaginal.     All  sorts  of  combinations  occur  (Fig.  703).     "Without  doubt  bacteria 

763 


764 


THE    PATHOLOGY    OF   LABOR 


aid  in  causing  the  necrosis.  In  their  absence  the  tissues  tolerate  much  more  pres- 
sure. Fistulas  are  caused  also  by  direct  traumatism,  an  instrument  being  punched 
through  the  bladder  or  cutting  the  ureter,  or  from  a  wound  of  the  uterus  extending 
into  the  bladder  or  involving  the  ureter.  Forceps,  the  sharp  hook,  or  the  cranioclast 
has  thus  torn  great  gashes,  and  sharp  spiculae  of  bone  in  the  operation  of  crani- 
otom}'  have  cut  deeply  into  the  soft  parts.  Posteriorly,  the  cervix  may  be  caught 
between  the  head  and  the  promontory,  or  the  rectum  may  be  compromised.  In  the 
former  case  adhesion  of  the  uterus  to  the  promontory  may  result,  or,  if  the  tissue 
necroses,  perforation  and  peritonitis,  in  the  latter  case,  rectovaginal  fistula,  which 
is  rare. 

The  prevention  of  fistulas  has  already  been  considered.     Knowing  the  causa- 
tion, and  by  observing  that  the  portions  of  the  parturient  canal  below  the  point  of 


Cervicoperitoneal, 
usually  abscess 


Rectovaginal 


Vesicocervical 

Ureterovaginal 
Vesicovaginal 


Urethrovaginal 


Vaginoperineal 


RectoprTinoal 


Fio.  703. — Sites  of  Fistulas. 


compression  are  becoming  swollen,  the  suspicion  of  danger  is  grounded.  Palpation 
of  the  thin  portion  and  bloody  urine  confirm  it. 

Immediate  delivery  as  soon  as  danger  is  recognized  is  the  treatment,  but  the 
delivery  itself  must  be  a  protective  one.  After  delivery  the  bladder  is  catheterizecl, 
and  the  fact  that  there  is  no  perforation  established;  then,  if  the  possibility  of  too 
long  compression  and  the  fear  of  a  fistula  by  necrosis  are  entertained,  the  woman 
must  be  instructed  to  urinate  regularly  every  four  hours,  or  the  bladder  must  be 
emptied  so  often,  with  a  view  to  avoid  further  danger  of  sloughing.  Hexamethy- 
lentetramin,  in  5-grain  doses,  is  administered  four  times  a  day  as  a  prophylactic. 

Infection  often  accompanies  such  injury,  which  is  unfortunate,  because  the 
scars  which  result  from  the  ulceration  radiate  to  the  sides  of  the  pelvis,  even  to  the 
bone,  and,  by  contracting,  pull  open  the  fistula  and  prevent  its  closing,  also  render- 


I XJ TRIES  TO  THE  BLADDER,  RECTUM,  ETC.  7G5 

ing  (lifTicult  tlio  operations  for  euro.  If  slouKhinK  of  the  compressed  area  ensues, 
the  aclnunistration  of  urinary  antiseptics  should  be  kept  up,  but  bladder  irrigations 
are  unnecessary,  since  there  is  free  drainage.  The  development  of  eczema  from  the 
continuous  (Iril)bling  of  urine  is  ])revented  by  proper  nursing.  A  thick  salve  con- 
taining carbonate  of  zinc,  zinc  oxid,  and  vaselin  is  useful.  Later  a  urinal  may  be 
worn.  Small  fistulas,  esi)ecially  of  the  traumatic  variety, — that  is,  those  perfora- 
tions not  attended  with  extensive  necrosis  and  radiating  scars, — often  heal  spon- 
taneously. Operation  is  not  to  be  performed  until  the  parts  are  thoroughly  healed 
and  dcvascularized,  that  is,  a])out  four  months  postpartum.  Suture  at  this  time, 
I  have  found,  gives  the  l)est  results.  Although  i)roperly  belonging  here,  the  opera- 
tions for  the  repair  of  fistulas  may  not  be  discussed  because  of  the  lack  of  space. 

If  a  woman  whose  fistula  has  been  successfully  repaired  becomes  pregnant  again, 
abortion  may  not  be  induced,  ])ut  the  advisability  of  cesarean  section  at  term  should 
be  debatcMl  with  the  family.  The  healing  of  fistulas  is  so  precarious  that  this  opera- 
tion should  be  performed,  certainly  if  the  original  fistula  was  a  complicated  one. 
Only  too  often  the  trauma  of  the  labor  reopens  the  old  wound  and  a  new  operation 
may  not  be  at  once  successful. 

INJURIES  TO  THE  RECTUM 

Rectovaginal  fistulas  the  result  of  compression  necrosis  and  direct  injury  by 
instruments  or  spicules  of  bone  have  been  referred  to,  as  also  have  been  those  cases 
where  the  rectovaginal  septum  gives  way  .over  the  advancing  presenting  part,  head, 
arm,  or  breech,  and  the  latter  appears  at  the  anus.  Splitting  of  the  mucous  mem- 
brane of  the  rectum  or  of  the  anus  is  not  rare,  and  results  in  fissures  which  may  cause 
painful  defecation,  bleeding,  even  local  infections.  Injury  to  the  rectum  may  be 
produced  by  Ritgen's  and  Olshausen's  manoeuvers  for  delivery  of  the  head.  "With- 
out doubt  much  of  the  pain  of  delivery  is  due  to  stretching  and  dislocation  of  the 
rectum  and  of  the  fourth  sacral  nerve,  which  supplies  the  levator  ani.  The  rectum 
may  be  implicated  in  rupture  of  the  uterus. 

THE  PELVIC  JOINTS  AND  BONES 

Softening  and  relaxation  of  the  pelvic  joints  have  already  been  discussed,  and 
the  value  of  this  factor  in  the  mechanism  and  treatment  of  labor  pointed  out. 

Rupture  of  the  pelvic  joints  during  labor,  while  rare,  is  not  so  uncommon  as  is 
generally  believed.  I  have  treated  8  cases  and  have  learned  of  3  others.  In  1898 
I  pul)lished  2  cases;   in  1901,  2  more,  and  gave  the  literature  to  date  (Kaj^ser). 

Rupture  of  the  symphysis  pubis  is  most  often  found,  but  sometimes  the  sacro- 
iliac joints  are  involved,  either  alone  or  with  the  former.  Traumatism  causes  rup- 
ture of  the  joint,  but  since  it  requires  the  enormous  force  of  from  400  to  2600  pounds 
to  disrui)t  the  pelvic  girdle,  some  inherent  weakness  of  the  joint  must  preexist. 
Softening  and  relaxation  of  the  capsules,  caries,  rachitis,  osteomalacia,  chronic 
rheumatism,  trauma  during  pregnancy,  congenital  weakness  of  the  ligaments,  have 
all  been  found  in  such  cases  when  even  the  distention  of  the  pelvis  during  sponta- 
neouslabor  may  cause  the  jointto  give  way.  Contracted  pelvis,  especially  the  justo- 
minor  and  funnel  varieties,  predispose,  because  the  expansile  force  acts  in  the 
narrow  transverse  diameter.  A  large  child  or  especially  broad  shoulders  may  act 
in  the  same  way.  In  three-fourths  of  the  cases  the  joint  is  sprung  during  operative 
delivery,  and  in  my  collection  the  forceps  caused  67  per  cent.,  and  the  others,  the 
after-coming  head,  the  shoulders,  and  the  vectis  (Boddaert).  In  one  case  the 
rupture  occurred  postpartum  while  the  woman  got  out  of  bed,  but  probably  the 
separation  had  been  started  by  the  delivery  and  was  thus  completed.  Improperly 
directed  forceps  traction,  as  by  pulling  upward  too  soon  or  by  pulling  upward  with 
the  patient  on  a  low  bed,  in  both  cases  the  head  acting  as  a  wedge  between  the  rami, 


766  THE    PATHOLOGY    OF   LABOR 

or  using  too  great  force,  will  produce  the  rupture,  perhaps  even  in  the  absence  of 
pathologic  softening.     These  facts  are  important  from  a  medicolegal  point  of  view. 

Sympto7ns. — The  patient  may  have  complained  of  pains  in  the  pubis  and  sacro- 
iliac joints,  with  difficulty  of  locomotion  for  several  weeks.  During  spontaneous 
labor  the  rupture  may  be  discovered  at  the  moment  it  occurs,  being  heard  as  a  dull 
cracldng,  or  the  woman  says  something  has  burst.  Usually  the  operator  feels  and 
hears  the  joint  open  during  the  operative  delivery,  and  notes  that  the  obstruction  to 
the  progress  of  the  child  has  suddenly  disappeared.  Later  the  patient  complains 
of  intense  pain  over  the  affected  joint  and  radiating  down  the  thighs,  and  cannot 
move  the  legs,  which  lie  everted  and  abducted.  It  is  a  sort  of  pseudoparalysis,  and 
doubtless  has  often  been  mistaken  for  acute  paraplegia  due  to  injury  of  the  nerves  in 
the  pelvis  or  an  acute  infectious  myelitis.  Overstretching  of  the  joints  without 
actual  rupture  sometimes  occurs  in  difficult  forceps  cases,  and  makes  the  woman 
bechridden  for  months.  Bladder  and  rectal  symptoms  are  absent  unless  the  viscera 
are  injured  at  the  same  time,  which  is  not  rare. 

When  spontaneous  cure  results,  fibrous  union  takes  place  between  the  ends  of 
the  bones,  but  excessive  play  at  the  joint  may  render  the  patient  invalid  for  years. 
In  general  the  results  correspond  with  those  after  symphysiotomy.  If  the  vagina 
communicates  with  the  wound,  suppuration  is  the  rule.  Sometimes  infection  of 
the  joint  occurs  through  the  blood  or  by  contiguity,  especially  if  infection  of  the 
parturient  canal  exists.  In  pubic  arthritis  complicating  general  sepsis  it  is  hard  to 
decide  if  the  joint  was  primarily  or  secondarily  involved.  Chills  and  high  fever 
betoken  the  advent  of  infection  to  the  joint;  pus  forms  rapidly,  burrows  far,  and 
makes  a  big  abscess  unless  evacuated  early,  and  may  even  cause  fatal  pyemia. 

The  diagnosis  is  usually  easy  if  the  condition  is  at  all  considered.  The  history 
of  difficult  delivery,  the  position  of  the  patient  in  bed,  the  pain  and  tenderness  of  the 
pul^is,  tlie  palpation  of  a  groove  over  the  joint,  with  movability  of  the  pubes  on  each 
other,  enable  one  to  make  the  diagnosis  on  the  direct  examination.  In  the  differen- 
tial diagnosis  paraplegia  must  first  be  excluded,  which  is  done  by  finding  the  reflexes 
normal,  the  individual  muscle  groups  functionating,  and  normal  sensation. 

Later,  after  fever  has  developed,  in  their  order  must  be  considered  acute  sepsis, 
pelvic  inflammations  and  pressure  on  the  nerves  by  the  pelvic  exudates,  acute  toxic 
neuritis,  myelitis,  cystitis,  or  even  only  full  bladder  and  hysteria.  When  an  abscess 
has  formed  around  the  joint,  one  must  determine  if  the  suppuration  is  primary  or 
secondary — that  is,  part  of  a  general  infection,  the  latter  mainly  for  the  prognosis. 
Even  recognized  early,  this  accident  is  very  dangerous,  although  often  recovery  and 
later  restoration  of  function  occurs,  the  latter  requiring  from  three  to  eight  weeks, 
like  symphysiotomy.  Injuries  to  adjacent  viscera,  primary  hemorrhage,  shock,  and 
later  sepsis,  bring  the  mortality  of  reported  cases  up  to  35  per  cent.  Infection  of 
the  joint  is  serious,  and  very  serious  if  more  than  one  is  involved,  because  the  ab- 
scesses burrow  far  and  wide.  Permanent  wide  separation  of  the  ends  of  the  pubis 
may  require  a  bone  operation,  wiring  or  nailing,  to  restore  function.  The  treatment 
is  the  same  as  after  symphysiotomy  (q.  v.). 

Loosening  of  the  sacrum  from  the  innominates  may  result  from  labor,  and, 
without  doubt,  explains  many  of  the  cases  of  backache  after  normal  as  well  as 
operative  deliver}^  Pain  and  tenderness  over  the  joints,  abnormal  mobility,  the 
two  latter  determinable  best  by  intrapelvic  exploration,  the  pelvic  organs  being 
free  of  disease,  will  nuik(;  the  diagnosis.     The  treatment  is  along  orthopedic  lines. 

Injury  to  the  Coccyx. — During  delivery  the  coccyx  is  forced  backward  an  inch 
or  more,  this  excursion  of  the  bone  being  permitted  by  a  healthy  sacrococcygeal 
joint.  If  the  joint  is  ankylotic,  the  bone  itself  may  be  fractured,  or  the  joint  may 
l>reak  open,  a  chronic  arthritis  resulting.  Dislocations  of  the  bone  onto  the  an- 
terior or  posterior  surface  of  the  sacrum  occur,  and  also  a  pericoccygeal  cellulitis, 
which  is  chronic  and  very  painful.     Without  doubt  many,  if  not  most,  of  the  cases 


INJURIKS   Tf)    THE    BLADDER,    RECTUM,    ETC.  707 

of  so-f'allo(l  cof'cy<>;()(lynia  are  rcrcrablc  to  the  al)Ovo  conditions.  After  injur}'  to 
tlic  bone  th(>  ends  may  unite  at  a  right  angle,  or  such  (U;forinity  may  occur  at  the 
joint,  though  oftener,  because  the  bone  is  moved  so  frecjuently  (walking,  defecation, 
sitting),  a  ])seudarthrosis  is  formed. 

Even  while  the  woman  is  in  bed  there  are  symptoms  referable!  to  i\w  injury,  as 
pain  in  defecation,  and  tenderness,  but  usually  the  first  sitting-up  attracts  th(!  at- 
tention of  the  accoucheur.  Inability  to  sit  with  comfort,  the  patient  often  resting 
her  body  on  either  trochanter,  pain  radiating  up  the  back  and  down  the  thighs, 
difficulty  of  locomotion  ])ecause  of  pain,  painful  defecation,  and  intense  nervous- 
ness— often  a  real  neurasthenia — are  the  main  symptoms.  The  diagnosis  is  easy, 
since  the  history  will  draw  attention  to  the  location  of  the  trouble,  and  an  exami- 
nation with  the  finger  in  the  rectum  and  the  thumb  over  the  coccyx  will  show 
dislocation  of  the  bone,  fracture  (crepitus),  or  excessive  tenderness  in  or  around  the 
joints  (Fig.  704). 

Spontaneous  recovery  is  the  rule,  but  sometimes  it  requires  many  months. 


Fig.  704. — Palpating  the  Coccyx  with  a  Finger  in  the  Rectum. 

Trealmcnl-  Local  applications  give  very  little  relief.  In  cases  of  cellulitis  a  gentle  massage, 
after  the  acutcness  has  subsided,  will  help.  For  fracture  and  dislocations  a  period  of  at  least  six 
months  should  be  allowed  for  spontaneous  cure,  and  then,  in  the  absence  of  improvement,  the  bone 


bone.  This  is  bared  and  lifted  up  with  a  bullet  forceps.  With  a  sharp  knife  it  is  detached  from 
the  coccygeus  on  each  side  and  the  lower  fibers  of  the  sacrosciatic  ligament,  taking  care  to  avoid 
tearing  the  fascia  on  its  anterior  surface.  The  joint  is  severed  last,  or,  if  the  fracture  had  not  united, 
the  distal  portion  of  the  bone  is  excised  and  the  proximal  portion  smoothed  with  the  bone  forceps. 
The  whole  coccyx  had  best  be  removed.  The  rectum  is  attached  to  the  end  of  the  sacrum  by  a 
few  firm  strands  of  connective  tissue;  care  is  required  to  prevent  tearing  this  organ.  Hemorrhage 
is  stopped  by  packing  with  hot  iodoform  gauze  for  a  few  minutes.  Then  the  two  edges  of  the 
coccygeus  muscle  are  united  in  the  median  line  by  interrupted  catgut  sutures;  next  the  fascia 
which  was  over  the  bone  and  three  or  four  deep  silkworm-cut  sutiuTs  close  the  skin.  Accurate 
coaptation  of  the  edges  of  the  skin  should  be  obtained,  and  the  wound  painted  with  collodion. 
The  patient  should  keep  the  side  jxisition  for  three  days.  On  the  fifth  day  castor  oil  is  given.  It 
is  highly  important  that  feces  and  urine  do  not  contaminate  the  w^ound,  and  the  patient  should  sit 
up  straight  or  bend  forward  when  the  bowels  move. 

Olhcr  Injuries. — As  the  result  of  overpowerful  bearing-down  efforts  the  woman  may  fracture 
her  sternum  or  dislocate  one  or  more  ribs  upon  it.  The  severe  straining  may  rupture  the  vesicles 
of  the  lung  and  give  rise  to  emphysema  of  the  neck,  chest,  even  of  the  entire  body.  Kosmak,  in 
1907,  collected  77  cases  in  the  literature  since  1791.  Primipara?  are  usually  affected.  Tenderness 
and  dyspnea  are  prominent ;  the  prognosis  is  good,  the  swelling  disappearing  in  a  few  days  without 
treatment. 

Literature 

De  Lee:   "Ruptura  Symphysis  Pubis,"  Amer.  Jour.  Obstet.,  1001,  vol.  xliii. — Derraigne:  L'Obstetrique,  Februarj-,  1910. 
— Kayser:  Arch.  f.  Gyn.,  1903,  vol.  Ixx,  p.  50. — Kosmak:  Bulletin  of  Xew  York  Lying-in  Hospital,  March,  1907. 


CHAPTER  LXI 
POSTPARTUM  HEMORRHAGE 

Strictly  speaking,  postpartum  hemorrhage  means  bleeding  after  labor,  that 
is,  after  the  placenta  is  delivered,  but  for  purpose  of  study  it  is  best  to  consider  under 
this  heading  all  hemorrhages  occurring  from  the  time  the  child  is  delivered  until 
the  puerperium  is  completed.  Those  which  occur  after  the  first  twenty-four  hours 
are  called  late  hemorrhages,  and  will  be  considered  separately.  At  present  we  are 
concerned  only  with  those  attending  the  delivery  of  the  placenta  and  immediately 
thereafter. 

The  reproductive  function  is  the  only  one  normally  attended  by  hemorrhage, 
and  nature,  bj^  wise  provision,  fortifies  the  woman  against  the  inevitable  loss,  and 
even  overprovides,  so  that  she  may  survive  a  drain  that  would  prove  fatal  in  a  non- 
pregnant female  or  a  male.  During  pregnancy  the  total  quantity  of  blood  is  in- 
creased, and  the  fibrin  is  also  greater  in  amount,  these  changes  beginning  after  the 
fifth  month.  There  is  a  slight  leukocytosis  which  becomes  marked  (16,000)  during 
labor.  In  healthy  gravidse  these  are  the  changes,  while  in  a  sickly  or  anemic  woman, 
pregnancy  may  induce  a  condition  of  chloranemia.  The  point  has  a  strong  clinical 
bearing. 

In  healthy  gravidas  a  loss  of  blood  up  to  one  pint  (500  gm.)  is  usually  borne 
without  any  symptoms,  and  it  is  generally  believed  that  the  woman  has  gained  about 
this  amount  during  pregnancy.  The  average  loss  during  labor  is  about  300  gm.^ — 8 
to  10  ounces.  It  is  best  to  consider  a  loss  above  a  pint  as  pathologic.  Bloodless 
labors  are  very  rare,  and  are  usually  found  where  the  fetus  has  been  dead  a  long  time 
and  firm  thrombosis  has  occurred  in  the  placental  site.  Leukemics  also  are  said  to 
have  bloodless  labors,  which  is  fortunate,  if  generally  true,  because  leukemics 
stand  bleeding  badly.  Before  the  expulsion  of  the  placenta  the  oozing  should 
be  very  slight,  if  any,  and  after  it  the  puerpera  should  not  lose  over  3  ounces  of 
fresh  blood  in  the  first  two  hours.  Inclosed  in  the  placenta  will  be  found  the  bulk 
of  the  blood.  If  the  blood  gushes  from  the  genitals  or  oozes  steadily  in  larger 
amounts  than  here  indicated,  the  case  is  pathologic. 

ETIOLOGY 

During  the  separation  and  expulsion  of  the  placenta  hemorrhage  is  prevented 
by  the  retraction  and  contraction  of  the  uterine  muscle  and  by  thrombosis  of  the 
uterine  sinuses.  The  more  important  factor  in  securing  hemostasis  is  the  uterine 
action,  since  thrombosis  may  be  absent  and  no  hemorrhage  occur;  and,  conversely, 
thrombosis  alone,  unaided  by  the  contraction  and  retraction  of  the  uterus,  will  not 
check  a  hemorrhage. 

The  sinuses  in  th(!  uterine  wall  are  simply  blood-spaces,  lying  between  the  mus- 
cular lamellae  and  muscle-bundles,  and  lined  with  a  single  layer  of  endothelium. 
As  the  uterus  empties  the  muscular  lamellae'  become  superimposed,  the  muscle- 
bundles  crowd  closer  together,  theseveral  layerssliding  over  each  other.  As  a  result, 
the  blood  sinuses  are  bent  and  twisted  on  themselves,  the  muscle  effectually  choking 
off  the  current  of  ])\()()d  that  flowed  through  them.  There  is  even  some  influence  on 
the  larger  vessels  at  the  sides  of  the  uterus  after  they  enter  its  wall.  The  retraction 
of  the  uterine  muscle  does  the  actual  work  in  this  operation.  The  regularly  re- 
curring uterine  contractions  aid  and  support  the  permanent  retraction. 

768 


POSTPARTUM    HEMORRHAGE 


769 


Postpartum  li('iiu)rrlia<i;(',  therefore,  will  bo  most  often  found  to  be  due  to  some 
anoiiKily  of  this  i)hysi()h)j;i('  mechanism,  and  such  an(Mnalies  are  usually  due  to 
weakni'ss  or  abnormal  contraction  and  retraction  of  the  uterus.  In  practice  we 
find  two  additional  factors — lacerations  of  the  parturient  canal  and  disease  of  the 
blood  or  blood-vessels. 

(A)  LdccrdtioNs  of  tiie  <>;<'nital  tract  ]:»lay  a  much  HK)re  important  role  in  the 
production  of  hemorrhage  postpartum  than  is  generally  believed.  Many  hemor- 
rhages called  atonic  are  due  to  tears  in  the  genitalia. 

Lacerations  of  the  clitoris  and  of  the  bulbi  may  give  rise  to  even  fatal  hemor- 
rhage, as  may  also  a  ruptured  varix  of  the  vulva  or  vagina,  though  both  are  rare. 
Perineal  tears  seldom  bleed  enough  to  require  immediate  suture,  and  vaginal  tears 


Koliio] 


Pu-sterior  vaginal  tear  or 
La 


Tear  in  contraction  ring.    Dan- 
gerous in  placenta  praevia 

Rupture  of  cervix 


Usual  cervical  tear 
—  Clitoris  tear 

Lateral  vaginal  tear 


L'sual  perineal  tear,  second 
degree 


Fig.  70.5. — Diagram  of  Tears  of  PARTrRiExx  C.\n"al. 


are  also  rarely  attended  l^y  much  hemorrhage.  They  may,  however,  require  suture 
or  packing,  and  when  they  do,  packing  is  the  best  method,  because  the  field  is  so 
inundated  with  blood  that  it  is  impossible  to  see  where  to  place  the  sutures. 
High  vaginal  tears,  extending  into  the  fornices,  may  lay  open  the  bases  of  the 
broad  ligaments  and  may  ])leed  furiously.  They  are  usually  coml^ined  with 
cervix  tears. 

A  laceration  of  the  cervix  extending  into  the  broad  ligament  may  not  bleed  if 
the  tearing  is  gradual  and  not  forced.  Such  findings  are  occasionally  made  after 
spontaneous  labors  or  dilatation  with  one  of  the  crushing  dilators  (the  Bossi,  de 
Seigneux)  or  the  hands  (Bonnaire,  Harris).  Usually,  however,  a  deep  cervical  tear 
gives  rise  to  serious  hemorrhage.  Deep  cervical  tears  are  most  likelj'  to  occur  if  a 
rapid  delivery  is  made  before  the  cervix  is  completely  effaced  or  shortened,  that  is, 
49 


770  THE    PATHOLOGY    OF   LABOR 

draA\'ii  up  into  the  body  of  the  uterus.  Even  after  the  cervix  is  completely  dilated 
a  laceration  of  the  upper  fibers  maj^  result  if  the  extraction  of  the  child  is  forced 
during  a  spasmodic  contraction  of  the  lower  uterus  and  upper  cervix.  Sometimes 
the  head  passes  through  the  cervix  and  the  contraction  ring  closes  down  around  the 
neck  of  the  child.  Forcing  the  delivery  in  such  a  case  may  cause  the  shoulders  to 
tear  the  edge  of  the  contraction  ring.  In  the  last  three  varieties  of  cervical  lacera- 
tion the  tear  is  more  likely  to  be  a  longitudinal  split  of  the  cervical  wall,  usually 
lateral,  extending  more  or  less  deeply  into  the  broad  ligament,  and  indicating  that 
if  it  Avent  much  further  it  would  have  to  be  called  a  rupture  of  the  uterus,  incomplete 
or  complete,  depending  on  whether  or  not  the  peritoneal  cavity  was  opened.  With- 
out doubt  many  cases  of  so-called  postpartum  hemorrhage  are  in  reality  ruptures  of 
the  uterus,  as  likewise  are  many  cases  of  "shock"  after  labor.  A  rupture  of  the 
uterus  occurring  during  an  operation  or  spontaneously  gives  rise  to  internal  and 
external  hemorrhage,  and  such  cases  are  not  to  be  considered  in  this  chapter. 

When  the  cervix  is  torn  after  complete  effacement,  but  before  complete  dilata- 
tion, few  large  blood-vessels  are  opened  unless  the  tear  extends  into  the  bases  of  the 
broad  ligament. 

Special  emphasis  must  be  placed  on  the  lacerations  of  the  cervix  and  lower 
uterine  segment  occurring  in  placenta  prsevia.  It  is  usually  thought  that  the  fre- 
quency of  postpartum  hemorrhage  in  placenta  prsevia  cases  is  due  to  uterine  atony, 
while  as  a  matter  of  fact  atony  is  rare,  there  being  often  too  strong  uterine  action. 
The  branches  of  the  uterine  artery  supplying  the  lower  uterine  segment  are  given 
off  above  the  contraction  ring,  and  therefore,  are  somewhat  compressed  by 
the  contracting  uterus  before  entering  the  relaxed  lower  uterine  segment. 
While  one  would  expect  a  placental  site,  located  out  of  the  active  contracting  zone, 
to  permit  free  oozing,  this  is,  to  a  large  extent,  prevented  by  the  peculiar  situation  of 
the  blood-supply.  Hemorrhage,  therefore,  is  due  to  some  other  cause,  and  this 
will  usually  be  found  to  be  a  laceration.  The  extreme  vascularization  of  the  lower 
uterine  segment  and  cervix,  due  to  the  placental  implantation,  permits  every  tear 
to  bleed  profusely.  Since  the  veins  and  sinuses  are  situated  close  to  the  surface,  a 
laceration  one-eighth  inch  deep  may  cause  uncontrollable  hemorrhage  and  may  be 
discovered  only  at  the  autopsy. 

(B)  Insufficient  retraction  and  contraction  of  the  uterus,  or  anomalies  of  the 
same,  cause  few  of  the  fatal  postpartum  hemorrhages.  They  may  be  associated 
with  any  of  the  lacerations  previously  described,  and  when  the  tear  is  situated  in  the 
lower  uterine  segment,  the  absence  of  a  firm  restraining  action  of  the  uterus  is 
apparent. 

It  is  not  feasible  to  try  to  separate  anomalies  of  retraction  from  those  of  con- 
traction. Normallj'-,  the  two  functions  cooperate,  and  in  practice  we  find  that  where 
the  uterus  does  not  contract  well,  it  does  not  retract  well.  We  will  call  a  uterus 
atonic  when  the  contraction  and  retraction  of  its  muscles  are  insufficient  or  irregular, 
though  etiologically  and  strictly  other  terms  should  be  used.  "Uterine  atony" 
is  a  favorite  term  for  these  conditions,  but  it  does  not  always  apply  to  the  case. 

The  causes  of  atonic  hemorrhages  are  general  and  local.  Generally  weak 
women — those  of  excessive  cultivation,  who  often  have  poorly  developed  genitalia 
and  generally  poor  innervation — have  slow  labors  and  a  greater  tendency  to  atony 
in  the  third  stage.  Exhaustion  from  prolonged  labor,  especially  if  the  parturient 
takes  no  food,  may  lead  to  atony.  In  some  families  a  tendency  to  postpartum 
hemorrhage  is  transmitted.  This  is  an  entirely  different  condition  from  hemophilia, 
which  is  to  be  considered  later.  Some  women  have  atony  of  the  uterus  in  successive 
labors.  This  may  be  due  to  a  persistence  of  a  local  cause.  Blonds  and  red-haired 
women,  in  the  author's  experience,  are  likely  to  have  hemorrhage  postpartum,  but 
how  much  is  dependent  on  the  constitution  of  the  blood  it  is  impossible  to  say.  Myo- 
carditis, valvular  disease,  and  pulmonary  affections  are  said  to  favor  atonia  uteri, 


POSTPARTUM    HEMORRHAGE 


771 


'.->->--'  ■ 


■'■'m'- 


'■^M- 


Uterine 
wall 


U^^^ 


y^KT-,, 


'm^-.- 


•«f  ■'-'VV,-*''/ 


-'\-^.r 


C-ji-'''*a<  Placenta 


"^i^' 


Fia.  706. — Placenta  Accreta  (from  Schauta  anJ  Ilii.schinann). 

but  the  writer  has  had  Httle  trouble  with  it  in  such  eases.     Chronic  nephritis  has 
been  given  as  a  cause  of  atony,  a  hyahne  degeneration  of  the  uterine  muscle  and 
disease    of    the   blood-vessels   being    directly 
active. 

The  use  of  chloroform  during  labor  un- 
doubtedly increases  the  tendency  to  hemor- 
rhage, though  this  action  is  not  constant. 

Of  local  causes  there  are  many:  Overdis- 
tention  of  the  uterus  by  twins — polyhydram- 
nion;  a  large  or  diseased  fetus,  or  an  accumu- 
lation of  blood  (abruptio  placentae).  The  elon- 
gated muscle-fibers  need  time  to  accommodate 
themselves  to  the  rapidly  diminishing  uterine 
cavity,  so  that  sudden  emptying  of  such  a  dis- 
tended uterus  nearly  always  predisposes  to 
hemorrhage.  Abnormal  shape  of  the  uterus, 
bihorned  uteri,  uterus  arcuatus,  septus,  etc.; 
distortion  of  the  uterus  l^y  adhesions  (rarely) ; 
distortion  by  tumors,  as  fibroids  (commonly); 
old  scars  in  the  uterus,  after  cesarean  section, 
or  ruptures — all  these  interfere  with  the  con- 
traction and  retraction  of  the  organ  and  allow 

the  sinuses  to  remain  open,   and  from  these  

more  or  less  profuse  hemorrhage  occurs.  ^^^  707.-tubal  Corner  placenta,  with 

Metritis  is  given  b}^  J.  Veit  as  a  cause  of       imperfect  separation  and  hemorrhage. 
atony.     Lal:)hardt  found  an  anatomic  basis  for 

such  hemorrhages  in  an  increase  of  the  uterine  fibrous  tissue  around  the  blood- 
vessels.    This  may  have   preexisted  or   have  developed  during  pregnancy,  and 


772 


THE    PATHOLOGY    OF   LABOR 


explains  the  frequenc}^  of  hemorrhage  in  old  multiparse,  in  cases  of  subinvolution, 
and  after  puerperal  infection. 

Endometritis  is  a  cause,  since  retention  of  pieces  or  all  the  placenta  is  favored. 
A  piece  of  placenta,  a  placenta  succenturiata,  or  what  acts  the  same  way,  a  thick 
layer  of  decidua  with  clots  deposited  on  it,  prevents  proper  retraction  of  the  uterus 
and  the  latter  fills  with  blood.  Abnormal  adherence  of  the  placenta  to  the  uterine 
wall,  with  partial  separation, — "placenta  accreta"  (Fig.  706), — causes  the  worst 
hemorrhages.  In  such  cases  the  villi  burrow  into  the  uterine  muscle — there  is  no 
decidua  serotina.  Retained  membranes,  sometimes  mixed  with  a  clot,  or  a  large 
hard  clot  itself,  may  act  like  pieces  of  placenta.  They  cause  persistent  oozing  after 
labor,  which  may  be  enough  to  demand  interference.  If  the  primary  hemorrhage 
ceases,  the  foreign  body  may  dissolve  and  come  away  in  the  lochia,  which  are  profuse 


Placental  site 


Fio.  708. — Atony  op  Placental  Site. 
Its  spongy  nature  is  shown  and  the  ease  of  perforation  is  made  plain. 


and  fetid,  or  it  may  ])C  discharged  en  masse,  more  or  less  decomposed,  or  there  may 
be  repeated  hemorrhages  which  require  interference,  or  a  placental  polyp  forms. 
Tubal  corner  placentae  (Fig.  707)  separate  poorly  l^ecause  of  the  bad  uterine  action. 
Atony  of  the  placental  site  (Fig.  708)  is  more  frequent  than  is  generally  thought.  It 
may  be  the  beginning  of  inversion. 

Irregular  action  of  the  uterus  itself,  the  formation  of  contraction  rings  (see  p. 
574,  Strictura  Uteri),  the  best  known  of  which  is  the  "hour-glass  contraction" 
(Fig.  709),  an  exhausted  uterus,  one  displaced  by  a  full  bladder  or  rectum — all  these 
may  be  attended  by  l:)leeding.     The  full  bladder  as  a  cause  must  be  emphasized. 

Improper  conduct  of  labor,  too  rapid  delivery  of  the  child,  which  is  dragged  out 
of  the  uterus  without  allowing  time  for  the  latter  to  adapt  its  walls  to  its  diminishing 
contents;  too  much  massage  of  the  fundus  in  the  third  stage,  with  premature 
attempts  to  expel  the  placenta  by  Crede  expression,  traction  on  the  cord,  giving 


POSTPARTUM    HE.MOHKIIAGE  773 

er^ot  too  soon — all  thoso  disturl)  llic  normal  meciianisni  of  the  third  sin^c  by  jiro- 
duciiig  anomalous  uterine  acticMi,  l)n'akin<^  tiie  rctroplaccntal  hematoma,  separat- 
ing the  pUvcenta  partially,  bruising  the  uterus,  and  cnishiiia;  the  placenta,  which 
favors  retention  of  pieces  of  it,  and  all  cause  bleeding. 

(C)  Abnormal  blood  states  or  diseases  of  the  })lood-vessels  may  cause  seven;  and 
even  fatal  p()sti)artum  hemorrhage.  Ilemojjhilia  is  rare,  and  while  it  usually 
causes  severe  hemorrhage,  death  seldom  results.  Ahlfeld  n'ported  a  fatal  case; 
the  author  has  had  two  fatal,  and  two  other  severe,  hemophilic  bleedings;  Wells 
reports  one.  Scurvy,  Werlhoff's  disease,  syphilis,  certain  chronic  anemias  and 
toxemias,  and  sepsis  may  all  lead  to  profuse  hemorrliages.  Without  doubt  such 
hemophilic  tendencies  may  develop  during  pregnancy.  They  may  be  of  a  toxemic 
nature.  Lack  of  thrombokinase  explains  the  actual  bleeding,  but  it  may  not  be 
jH)ssihle  to  explain  the  absence  of  the  ferment. 

SYMPTOMS 

General.- — The  symjitoms  are  those  of  loss  of  blood,  and  varj^  in  intensity  with 
th(>  rapidity  of  the  flow,  the  amount,  the  condition  of  the  patient,  and  idiosyncrasy. 
A  sudden  large  loss  is  attended  by  shock,  which,  being  overcome,  the  patient  rapidly 
improves.  A  slow  but  long-continued  hemorrhage  is  more  often  fatal.  Previous 
rejioated  hemorrhages,  as  from  placenta  prsevia,  exhaust  the  blood-making  organs, 
so  that  even  a  small  loss  in  labor  is  Ijadl}'  borne.  Chloranemics,  leukemics,  sufferers 
from  malarial  and  certain  cachexias,  diabetics,  and  typhoids  are  bad  subjects. 

The  symptoms  of  hemorrhage  in  the  usual  order  of  their  appearance  are: 
Faintness,  dizziness,  air-hunger,  yawning,  nausea,  restlessness,  thirst,  precordial 
anxiety,  smothering  fear  of  impending  dissolution,  vomiting,  fainting,  collapse, 
convulsive  twitchings,  and,  as  death  nears,  involuntary  bowel  movements  and 
coma.  These  symptoms  in  a  person  already  anemic  come  on  sooner  and  more 
pronouncedly.  Examination  will  show  the  face  pallid,  the  lips  bluish  white,  the 
nose  and  forehead  cold,  and  sometimes  covered  with  sweat,  the  eyes  sunken,  the 
conjunctivae  pearly,  respiration  rapid  and  shallow,  the  pulse  small  and  fast,  filiform, 
and  finally  gone  from  the  w^rist.  Sometimes  the  pulse  holds  up  well  for  a  while, 
then  suddenly  disappears.  These  cases  give  a  false  sense  of  security,  because  the 
pulse  is  slow.  By  determining  the  fullness  of  the  vessel  an  error  of  judgment  may 
be  avoided. 

It  is  astonishing  how  much  blood  a  woman  can  lose  and  survive.  Ahlfeld  confined  several 
thousand  women  on  a  bed  with  a  hole  through  the  center,  underneath  which  was  placed  a  glass 
graduated  pail.  He  found  that  in  a  normal  labor  the  loss  of  blood  would  average  43.5  c.c;  that 
pathologic  labors  show  an  average  of  677  c.c,  the  average  blood-loss  of  all  labors  being  .505  c.c. 
Ahlfeld,  therefore,  concludes  that  a  loss  up  to  800  c.c.  is  normal,  and  that  a  healthj'  woman  of 
average  weight  may  safely  lose  a  liter,  which  is  a  little  more  than  a  quart.  Ahlfeld  found  that  the 
first  sym])toms  following  loss  of  one  liter  were  pallor  and  rapid  pulse;  as  the  flow  continued  up  to 
U)Q{)  or  ISOO  c.c,  the  surface  of  the  patient  grew  cold,  sweat  appeared,  and  thirst,  dyspnea,  ya\\-n- 
ing,  dizziness,  and  faintn(\ss  were  to  be  noted.  OccasionaUi/,  dcnth  occurred  with  a  losf!  of  less  tJtan 
two  liters.  In  6000  labors  there  were  14  hemorrhages  over  2.500  c.c.  (.5  pints),  one  of  which  was 
over  .3000  c.c.  All  the  patients  recovered.  A  loss  of  3S00  to  4000  c.c  (a  gallon)  is  considered 
absolutely  fatal.  No  doubt  the  danger  to  life  of  severe  blood-loss  postpartum  appears  greater 
than  it  really  is,  but  since  one  cannot  prcchct  the  woman's  ability  to  withstand  bleechng,  it  is 
prudent  to  take  alarm  at  small  hemorrhages  and  quickly  institute  means  to  check  them.  Ahlfeld's 
cases  were  hardj'  peasant  women.  Our  highly  bred  American  women  would  show  more  serious 
results  and  many  would  die  from  such  extreme  losses  of  blood. 

Local. — The  bleeding  may  be  internal  or  external  or  both.  If  the  cervix  is 
occluded  by  a  clot,  membranes,  or  the  placenta,  or  if  the  vulva  is  held  closed  by  ap- 
position of  the  thighs,  an  enormous  amount  of  blood  may  be  dammed  back,  distending 
the  vagina  and  the  uterus.  When  the  hand  is  l^orne  on  the  belly  or  the  uterus,  blood 
gushes  out.  Sometimes  there  is  a  terrific  rush  of  blood  follo^^^ng  the  child,  and  it 
may  be  fatal  in  a  few  minutes.  Only  a  man  who  has  seen  one  would  believe  such  a 
flooding  could  occur.     Usually  there  is  a  steady  oozing  or  more  copious  flow,  neces- 


774 


THE    PATHOLOGY   OF   LABOR 


sitating  frequent  changing  of  the  sheets.  A  wise  accoucheur  will  make  note  of  the 
number  of  changes.  Sometimes  the  flow  is  interrupted,  the  uterus  filling  and  empty- 
ing several  times,  or  there  may  be  one  gush  and  that  be  all,  the  uterus  having  ob- 
tained a  firm  grasp  of  itself.  The  first  blood  is  thick  and  deep  red;  later  it  grows 
paler,  and  it  appears  to  me  it  has  lost  its  clotting  power.  Sometimes  the  blood  is 
dark,  like  port  wine,  and  the  clots  are  black,  or  it  seems  to  be  lake-colored — trans- 
lucent; this  an  evidence  of  hemolysis. 

The  local  findings  vary  with  the  cause  of  the  hemorrhage.  If  from  laceration, 
the  uterus  is  usually  hard,  but  sometimes  it  fills  up  with  blood  and  becomes  atonic. 
In  real  atonia  uteri  it  is  difficult  to  locate  the  flabby  fundus;  the  whole  abdomen 
feels  boggy.  If  the  placenta  is  incarcerated,  the  uterus  is  firm  and  globular,  but 
balloons  out  between  pains,  and  each  contraction  is  attended  by  a  gush  of  blood  from 
the  vagina  (Fig.  709). 

DIAGNOSIS 

Ideal  obstetrics  demands  that  no  woman  should  lose  enough  blood  to  give  rise 
to  sj'mptoms  of  anemia.  If  such  are  present,  the  accoucheur  must  quickly  deter- 
mine their  cause,  and  shock,  rupture  of  the 
uterus,  inversion,  rupture  of  an  abdominal  vis- 
cus,  pulmonary  embolism,  and  uremic  collapse 
are  to  be  considered.  When  the  amount  of 
blood  known  to  have  been  lost  is  small  and  the 
uterus  is  well  contracted,  probably  some  other 
cause  is  acting,  but  the  idiosyncrasy  of  the 
patient  must  be  remembered.  Almost  always 
the  question  to  decide  is  the  source  of  the 
bleeding.  Broadly  speaking,  a  bleeding  with 
a  hard  uterus  comes  from  laceration,  and  when 
the  organ  is  large,  boggy,  or  even  too  soft  to 
outline,  atony  is  the  cause.  The  history  of  the 
labor  will  give  valuable  data;  if  the  uterine  ac- 
tion was  torpid  in  the  first  two  stages,  inertia 
may  be  expected  in  the  third.  (See  Etiology.) 
After  forceps  or  other  operations,  lacera- 
tions are  to  be  looked  for,  and  they  will  be  found 
in  the  operative  field.  Before  the  placenta  is 
out  it  may  be  impossible  to  decide  between 
atony  and  injury.  As  a  rule,  diagnosis  and 
treatment  go  together,  and  this  is  the  usual 
procedure :  A  brisk  massage  is  given  the  uterus, 
and  at  the  same  time  the  vulva  and  introitus 
are  sponged  free  of  blood  and  inspected  carefully  for  tears.  If  firm  contrac- 
tion of  the  uterus  ensues,  the  hemorrhage  ceasing,  atony  was  probably  the 
cause,  and  nothing  further  is  done.  If  not,  the  placenta  is  removed.  Now 
if  the  bleeding  continues  with  a  hard  uterus,  laceration  is  probably  the  cause. 
A  vaginal  examination  will  settle  the  doubt.  "W-nosity  of  the  blood  is  no  criter- 
ion of  atony.  Concealed  hemorrhage  may  be  due  to  a  tear  as  well  as  atony, 
and  the  blood  may  not  appear  for  from  five  to  fifteen  minutes  after  delivery.  It 
is  ofttimes  necessary  to  decide  whether  or  not  a  piece  of  placenta  or  a  clot  is  still 
in  the  uterus.  In  the  first  place,  a  careful  inspection  of  the  pacenta  should  invari- 
ably be  made  immediately  after  its  delivery,  while  it  and  the  accoucheur's  hands 
are  still  aseptic,  because  it  may  be  necessary  to  at  once  enter  the  uterus.  If  the 
placenta  is  too  much  torn  to  guarantee  certainty  that  nothing  has  been  retained, 
and  bleeding  continues,  it  is  best  to  revise  the  uterus  with  the  hand.     A  large 


Fig.    709. — Hour-glass    Contraction 
PRISONS  Placenta. 


Im- 


POSTPAinUM    HK.MORUHAGE  775 

elastic,  ^lohular  uterus,  issuinp;  occasional  ^i^f^J'^'i^  'jf  1'1o(k],  almost  always  has 
sonu'thiuf;-  inside  it.  If  a  clot  is  seen  or  felt  in  the  vagina,  prohahl}'  another  lies 
in  the  uterine  cavity.  If  the  attendant  notes  the  discharge  of  blcjod-serum  from  the 
vagina,  he  may  be  sure  that  there  is  a  clot  in  the  parturient  canal. 

Incarceration  of  the  placenta  is  diagnosed  from — (1)  The  large  globular  uterus, 
whose  contractions  are  irregular  as  to  time,  strength,  and  location;  (2)  the  inter- 
mittent gushes  of  blood;  (3)  the  cord  advances  and  recedes  when  pressure  is  made  on 
the  fundus;  (4)  the  vein  in  the  umbilical  cord  becomes  tense  when  the  uterus  is 
compressed;  (5)  internal  examination  discloses  the  tight  contraction  ring  with  the 
placenta  above  (Fig.  709). 

PROGNOSIS 

Nowadays  few  women  die  from  postpartum  hemorrhage.  In  over  15,000  con- 
secutive cases  in  the  Chicago  Lying-in  Hospital  Dispensary  service  not  one  woman 
di(Hl  from  it,  l)ut  there  were  six  or  more  who  came  verj'  near  death.  Statistics  are 
hard  to  get.  In  the  United  States  al)out  750  deaths  from  jDuerperal  hemorrhage  are 
annually  recorded.  DUhrssen  said  that  in  Germany  a  woman  dies  every  day  from 
postpartum  hemorrhage.  In  general,  it  may  be  said  that  severe  hemorrhage  occurs 
in  about  2  per  cent,  of  labors,  but  that  a  death  in  experienced  hands  is  rare — prol> 
ably  not  oftener  than  once  in  5000  deliveries.  Cases  of  true  atony  are  rare,  and 
often  fatal,  but  not  more  often  fatal  than  cervix  tears  in  placenta  previa.  Simple 
cervix  tears  offer  a  better  prognosis  than  atony,  especially  if  the  latter  is  due  to 
disease  of  the  uterine  structure.  Tears  of  the  clitoris  and  of  varices  in  the  vagina 
may  be  fatal  unless  recognized  early. 

In  individual  cases  the  expressed  prognosis  as  to  life  will  depend  on  the  phy- 
sician's examination  and  his  estimate  of  the  proportion  of  the  woman's  blood  that 
is  lost.  The  pulse,  while  a  good  one,  is  not  always  a  reliable  guide.  I  have  felt  a 
fairly  good  sloir  pulse  with  a  serious  hemorrhage.  It  seems  as-  if  the  arteries  can 
keep  their  grasp  on  the  circulation  up  to  a  certain  point,  which,  being  passed,  they 
lose  their  grip  and  collapse  occurs.  The  quality  of  the  pulse-beat  gives  more  infor- 
mation than  its  rapidity.  Hurried  respiration,  extreme  dyspnea,  and  air-hunger 
are  very  ominous,  but  not  necessarily  fatal,  s^nnptoms.  Extreme  restlessness  and 
repeated  vomiting  indicate  a  very  serious  condition. 

At  the  beginning  it  is  impossible  to  foretell  how  dangerous  a  certain  bleeding 
will  become.  Slight  oozing  may  baffle  the  accoucheur  entirely,  while  a  furious 
cascade  of  blood  may  suddenly  cease.  It  is  advisalDle  to  stop  all  hemorrhages  as 
soon  as  possible,  because  the  constitution  of  the  patient  is  an  unknown  quantity. 

There  are  remote  dangers  in  these  cases.  Thrombosis  and  embolism  are  com- 
moner after  severe  losses,  and  sepsis,  too,  the  latter  because  the  resisting  power  of 
the  woman  has  been  lowered,  and,  secondly,  because  the  accoucheur,  in  his  haste, 
has  forgotten  the  principles  of  asepsis.  Hemorrhage  into  the  retina  and  edema 
with  blindness,  chronic  diarrhea,  gastric  ulcer,  and  permanent  debilitation  of  the 
blood  and  neurasthenia  have  been  noted  as  sequels.  Even  in  cases  where  the 
blood-loss  did  not  exceed  800  gm.  the  patients  made  slower  recoveries,  lactation 
was  interfered  with,  subinvolution  was  commoner — altogether  the  convalescence 
was  not  so  satisfactory  as  in  those  women  where  the  bleeding  was  strictly  limited. 


TREATMENT 

Prevention  should  begin  during  pregnancy,  and  the  patient's  family  and  per- 
sonal history  will  be  the  guide.  If  such  a  history,  which  should  be  a  part  of  the 
routine  examination  when  the  accoucheur's  services  are  engaged,  should  discover 
any  of  the  causes  of  postpartum  hemorrhage  mentioned  under  Etiology,  appropriate 
treatment  during  gestation  may  prevent  trouble,  at  least,  the  warning  will  have 


776 


THE    PATHOLOGY    OF   LABOR 


been  sounded  in  time  to  have  everything  in  readiness  for  instant  use  if  necessary. 
Thus  valuable  time  is  saved.  Forewarned  is  forearmed.  During  labor  the  possi- 
bility of  postpartum  hemorrhage  must  be  borne  in  mind,  particularly  when  the  ac- 
tion of  the  uterus  is  sluggish,  and  in  cases  of  overdistention,  twins,  polyhydramnion, 
etc.     By  supporting  the  parturient  with  food,  rest,  and  help  at  the  proper  time 


Fig.  710. — Author's  Packing  Forceps. 
It  is  11. 1  inches  long  and  rounded  end  is  VJ  inch  across. 

much  can  be  done.  Too  early  operative  interference  causes  lacerations  and  hemor- 
rhage. In  delivery  the  uterus  must  be  slowly  emptied,  and  especially  must  the 
rules  of  the  conduct  of  the  third  stage  be  closely  observed. 

Preparations. — Every  obstetric  kit  should  contain  the  apparatus  for  coping 
with  this  comphcation:  (1)  Instruments  for  the  repair  of  lacerations  (Fig.  664); 
(2)  for  douching  the  uterus,  douche-can  or  bag,  with  tube  and  nozzle ;   (3)  for  packing 


Fig.  711. — Author's  Portable  Douche-can. 
This  is  of  Ijrass,  nickel  plated,  with  all  corners  rounded.     Brass  union  for  tube. 


the  uterus,  uterine  packing  forceps  (Fig.  710)  and  specially  prepared  gauze;  (4) 
for  the  treatment  of  anemia,  salt  solution  apparatus,  or  a  sterile  douche-bag  or  can 
^Fig.  711),  a  salt  solution  needle  (Fig.  712),  hypodermic  syringe  with  stimulants, 
aseptic  ergot,  camphorated  oil,  ether,  adrenalin,  etc.  Forearmed  is  forewarned. 
(For  instructions  regarding  the  preparation  of  gauze  sec  Appendix.) 

Treatment  of  Hemorrhage  During  the  Third  Stage. — When  a  severe  bleeding 


POSTPARTUM    HEMORRHAGE 


777 


follows  th(^  (Iclivcrv  of  the  child,  Ihe  first  move  is  to  grasp  the  uterus  and  massage 

it  vifiorously.     As  a  rule,  as  soon  as  the  uterus  contraots  tlic  licmorrhagc  ceases.     At 


Fia.  712. — Needle  for  Hypodek.mcjclysis  (actual  size). 


Fig.  713. — Manual  Re.moval  of  Placenta.     Hand,  Cone  Shaped,  Going  Through  Contraction  Ring. 
For  artistic  effect  the  rubber  gloves  are  not  shown. 


the  same  time  the  attendant  inspects  the  genitals  to  find  the  laceration  that  may  be 
bleeding.  If  the  uterus  contracts  and  the  hemorrhage  continues,  an  internal  ex- 
amination should  be  made  to  see  if  there  is  a  cervix  tear.     Should  the  bleeding  con- 


/  / O  THE    PATHOLOGY    OF    LABOR 

tinue,  it  is  necessary  to  remove  the  placenta  whether  or  not  a  tear  is  found.  Mas- 
sage the  womb  vigorously,  and  in  the  moment  of  contraction  perform  Crede  expres- 
sion. This  manoeuver  may  stop  the  flow;  if  not,  it  will  be  needful  to  remove  the 
placenta  manually.  Before  attempting  the  Crede  one  must  empty  the  bladder  by 
catheter  and  luring  the  uterus  to  the  median  line.  Squeeze  only  when  the  organ  is 
contracting  and  hard.     It  is  useless  and  verj^  dangerous  to  squeeze  a  soft  uterus. 


Fig.  714. — Manual  Removal  of  Placenta.     Separating  it  from  Uterus. 


Manual  Removal  of  Placenta. — Havinp  flccidod  that  it  is  necessary  to  remove  the  pla- 
centa manually,  the  patient  is  brought  across  the  bed,  with  the  buttocks  well  over  its  edge;  the 
as.sistant,  either  a  physician,  a  nurse,  or,  if  absolutely  necessary,  the  husband  or  a  courageous 
neighbor,  holds  the  legs  in  the  lithotomy  position,  and  the  accoucheur  sees  that  his  instruments, 
basins  with  antiseptic  solutions,  gauze  for  packing  the  uterus,  and  a  hot  douche  are  all  prepared  and 
within  easy  reach.  If  the  accoucheur  has  his  obstetric  technic  well  developed,  and  his  assistants 
and,  most  important  of  all,  his  client  (Me,  ])r(jperly  trained,  it  is  i)ossible  to  be  so  prepared  for  labor 
ca.ses  that  a  change  from  the  bed  to  1  he  kitchen-table  may  be  made  in  a  minute.  Usually,  however, 
the  exigencies  of  the  case  will  force  the  physician  to  operate  with  the  patient  across  the  bed,  but 
whenever  it  is  possible  one  should  do  these  things  on  a  table.  This  is  one  of  the  most  dangerous 
operations  in  obstetric  practice,  because  of  the  likelihood  of  infec^tion  of  the  naked  placental  site. 


POSTPARTUM   HEMORRHAGE  /  <  \) 

Its  mortality  is  placod  l)y  Riiiiun  iit  10  per  cont.     It  is,  therefore,  l)est  to  make  another  attempt  to 
remove  the  plaeenta  by  Credo  expression  after  tl>e  woman  is  deeply  nareotizr-d. 


Fia.  71o.- 


-Section  through  Uterfs  and  Placenta  (Still  Attached),  Showing  Large  Venous  Sinuses  at  Pla- 
cental Site  and  how  Easily  Finger  may  Perforate  Wall  (Barbour). 


A  eareful  disinfection  of  the  external  genitals  and  the  lower  vagina  should  now  be  made.  Xo 
hemorrhage  is  so  tlangerous  that  such  preparations  may  be  neglected.  The  danger  of  sepsis  would 
thusreplaeiMhat  of  liemorrhage.  Tlie  parts  have  already  been 
clipped  or  shaveil,  and  they  have  been  well  washed  with  anti- 
sept  ic  solut  ions  during  the  delivery.  Before  inserting  the  hand 
th(^  externals  should  again  be  liberally  sponged  with  1  :  1500 
bichlorid  and  then  with  1  per  cent,  lysol  solution.  The  vagina 
should  be  well  flushed  out  with  1  per  cent,  lysol  solution,  using 
large  cotton  or  gauze  sponges.  The  use  of  rubber  gloves  can- 
not be  too  warmly  recommended  for  obstetric  practice,  and, 
especially  for  this  dangerous  operation  of  invading  the  uterine 
cavity,  they  arc  almost  indispensable.  The  gloves  should  be 
long,  should  fit  well,  and  they  sliould  b(>  drawn  on  dry,  over 
sterile  hands.  A  sterile  towel  is  laid  on  the  abdomen,  and  the 
hand  put  into  the  vagina,  avoiding  the  anus  and  perineum. 
The  left  hand  is  usually  found  to  be  most  adapted  for  internal 
work.  The  fingers  spread  out  in  the  cervix  so  that  the  mem- 
branes and  cord  fall  into  their  grasp,  then  the  tips  of  the  fin- 
gers are  brought  together  to  form  a  cone  for  passage  of  the 
contraction  ring  (Fig.  713).  It  is  seldom  necessarj-  to  use  force 
in  passing  this  point.  If  ergot  has  been  administered  or  if  tlie 
contraction  ring  has  closcxl  down,  it  may  be  necessary  to  press 
the  fingers  firmly  through  the  constriction.  Profound  anes- 
thesia aids  much.  The  fingers  seek  tlie  edge  of  the  placenta, 
and  the  hand  on  the  belly  forces  the  uterus  down  over  the  inside 
fingers  (Fig.  714).  With  a  gentle  combined  movement  the  pla- 
centa is  separated  from  its  bed.  It  is  usually  very  easy  to 
separate  the  organ;  but  if  it  is  pathologically  adherent,  tough 
strands  will  have  to  be  sawn  through  by  the  fingers  supported 
by  the  outside  hand.  A  warning  not  to  bore  into  or  through 
the  uterus  must  be  given,  i^ecause  this  is  sometimes  surprisingly 
easy  (Fig.  71.")).  After  the  placenta  has  been  cleanh'  separated 
the  two  hantls  give  the  uterus  a  brisk  massage,  and  a  contrac- 
tion will  expel  the  hand  containing  the  placenta.  It  is  better 
to  let  the  uterus  expel  the  hand  with  the  placenta  than  to  drag 
the  latter  out.  After  washing  the  blood  off  the  hand,  and  again 
sponging  the  parts  with  antiseptic  solution,  the  liand  is  once 
more  insei'ted,  and  the  whole  interior  of  the  uterus  carefully  in- 
spected. One  must  be  absolutely  certain  that  the  uterus  is 
perfectly  empty.  Care  should  be  taken  to  remove  all  the 
meml:)ranes  and  thickened  decidua.  Tlic  rubber  gloves  arc  so 
slippery  that  shreds  of  decidua  cannot  be  grasped.  One  misses 
the  sharp  finger-nail  in  such  cases.  The  author  uses  a  piece  of 
gauze  for  the  purpose  of  cleaning  off  the  decidua  and  mem- 
branes, as  in  Fig.  716.  One  may  now  give  a  hot  0.5  per  cent, 
lysol  intra-uterine  douche,  which  usually  causes  firm  contrac- 
tion and  retraction.     A  hvpodermic  of  ergonc,  ergotole,  or 

aseptic  ergot  is  also  administered.         '  Fig.  71G.— Hand  Armed  with  Gauze 

'^    fc  ■^-     ■  11^  ii  1  i.  -f       •  FOR   W  iPiNG  Piece    of   Placenta 

it  It  IS  mipossible    to  remove    the    placenta,  or  it    pieces  Off  the  Placental  Site  OR  Re- 

of  cotyledons  or  shreds  of  membrane  are  unavoidablj'  left  moving  Att.\.ched  Membranes. 


780 


THE    PATHOLOGY   OF   LABOR 


adherent  on  the  uterine  wall,  a  firm  uterovaginal  tamponade  is  made  and  the  gauze  removed  in 
forty-eight  hours.     ]\Iissing  portions  often  come  away  with  the  gauze. 

Treatment  after  the  Placenta  is  Out. — In  all  labor  cases,  as  soon  as  the  placenta 
has  been  delivered,  inspect  it  carefully  before  throwing  it  in  the  drainage-jar.  This 
is  done  at  once,  because  if  a  piece  of  it  is  missing,  one  may  adopt  appropriate  meas- 
ures, and  will  not  be  surprised  by  a  hemorrhage  after  the  patient  has  been  prepared 


Fig.  717. — Compression  of  Aorta. 
This  method  may  be  used  in  cesarean  section  also. 

for  Ijed,  or,  indeed,  after  the  physician  is  ready  to  leave  the  house.     If  convinced 
that  a  piece  of  the  placenta  has  been  retained,  it  must  be  removed. 

If  the  membranes  are  missing  or  incomplete,  should  you  enter  the  uterus  for 
their  removal?  Opinions  of  authorities  differ.  In  maternity  hospital  practice, 
with  the  protection  of  sterile  rubljor  gloves  and  an  aseptic  confinement  room,  the 
author  removes  such  retained  membranes.  If  only  a  third  or  a  half  of  the  mem- 
branes is  left,  providing  there  is  no  hemorrhage,  the  removal  of  the  missing  portion 
may  be  trusted  to  nature.     In  private  practice,  under  usual  conditions,  it  is  safer 


POSTPARTUM   HEMORRHAGE 


781 


to  trust  tlie  expulsion  of  the  iiicinlirancs  to  tlic  uterus.  I'^rgot  and  hydrastis  are 
given  for  two  weeks,  and  usually  the  uterus  gets  rid  of  the  membranes  in  the  first 
eight  days.     Sapremie  fever  is  not  rare,  hut  usuall}'  subsides  safely. 

Routine. — In  all  eases  of  i)()sti)artuni  hemorrhage  a  brisk  uterine  massage  is  the 
first  action.  Uterine  contraction  has  a  deterrent  effect  even  on  the  flow  from  cervical 
laceration.  The  first  motions  should  be  slow  and  even,  but  unless  the  uterus  re- 
sponds ]M-()mptly,  they  should  be  rapid,  and  spread  all  over  the  fundus  and  also  at 
the  sides,  near  the  tubes  and  ovaries.  Another  method,  recommended  by  Kunipf, 
is  compression  vibratory  massage.     The  uterus  is  grasped  by  the  right  hand,  pressed 


Fig.  718. — Bim.\nual  Compressiox  of  the  Uterus  ix  Anteflexion. 


down  into  the  inlet;  the  arm  is  held  rigid,  and  then  a  rapid  vibratory  massage  is 
administered,  the  excursions  of  the  muscles  being  very  small.  If  the  other  hand 
happens  to  be  in  the  uterus,  a  combined  massage  may  be  thus  given.  If  a  mechanical 
vibrator  is  available,  it  may  be  used.  As  an  aid  to  uterine  massage  the  accoucheur 
mav  irritate  the  sjTnpathetic  ganglia  around  the  bifurcation  of  the  aorta.  The 
hand  verj'  gently  rubs  over  this  region,  and  uterine  contractions  often  result. 
If  the  hemorrhage  is  very  profuse,  threatening  the  woman's  life,  the  same- hand 
compresses  the  aorta  firmly  against  the  spine  (Fig.  717),  as  recommended  by 
Baudelocque  in  179G.     This  will  check  the  flow  until  the  uterus  has  obtained  control 


782 


THE    PATHOLOGY    OF   LABOR 


of  itself,  or  until  the  attendant  can  prepare  the  patient,  his  instruments,  gauze, 
etc.,  for  effective  hemostasis. 

Second,  ergot,  a  dram  of  the  fiuidextract,  is  administered  by  mouth,  and  in 
urgent  cases  a  hypodermic  of  the  same  is  given.  The  best  place  to  inject  is  deeply 
into  the  outer  muscles  of  the  thigh,  and  an  aseptic  ergot,  coming  in  little  glass  bulbs, 
is  employed.  In  no  instance  should  the  accoucheur  wait  for  the  action  of  the  drug, 
which  may  be  absent,  or  at  least  delayed  five  to  thirty  minutes,  during  which  time 


1 


Fig.  719. — Packing  the  Uterus  with  the  Hands  Alone. 
The  thumb  pushes  up  the  gauze  for  the  fingers  to  pack. 

the  woman  may  die.    Experience  has  proved  that  it  is  not  wise  to  give  ergot  until 
the  placenta  has  left  the  contracting  portion  of  the  uterus. 

The  next  procedure  (third)  is  the  hot  uterine  douche.  The  douche-bag  should 
be  prepared  in  every  labor,  and  should  be  hung  near  the  bed,  properly  protected 
against  contamination.  The  patient  is  brought  across  the  bed  with  the  hips  well 
over  the  edge;  the  parts  are  sterilized,  and  everything  is  arranged  as  for  rnanual  re- 
moval of  the  placenta;  one  hand  is  inserted  into,  the  uterus,  and,  aided  by  the  outside 
hand,  all  clots,  membranes,  and  shreds  gently  wiped  out,  after  which  the  douche 
nozzle  is  introduced  into  the  uterus  and  one  (luart  of  hot  (120°  F.)  0.5  per  cent,  lysol 


I'OS'ri'AUTrM    HKMOUUIIAOE 


783 


solution  iillowcd  to  flow  through.  All  air  should  he  cvacuatod  from  the  douclic-tube 
Ix'forc  its  insertion.  The  danger  of  air-eniholisni  is  emphasized  hy  most  authors. 
Experiments  on  horses  and  (lo{;s  have  shown  that  inunense  quantities  of  air  can  be 
inje('t(>d  into  theii'  veins,  with  the  production  of  only  mild  and  transient  symptoms. 
In  the  hiunaii,  h()we\'ei-,  clinical  exjicrience  furnishes  many  examples  of  severe  eol- 
la{)se  and  death  from  the  admission  of  air  to  the  veins. 

.'"^ome  authors  advise  cold  or  even  iced  Avater  instead  of  hot  for  the  douche. 
The  hot  water  is  better  because  it  is  easier  to  obtain  than  sterile  cold  water;  it 
does  not  shock  an  alreatly  weakened  woman,  and  it  is  just  as  efficient.  Sterile 
vinciiar  and  lemon-juice  have  becMi  added  to  the  douche  or  used  alone.  In  the  great 
majority  of  cases  the  above  treatment  will  suffice  to  stoj)  the  hemorrhage  com- 


FiG.  720. — Packixg  Uterus  with  Long  Forceps. 
Hand  as  a  directing  speculum;    assistant  outside  steadies  fundus. 


pletely.  If  it  does  not,  one  has  to  do  with  an  extensive  laceration  or  a  bad  case  of 
atony  of  the  uterus.  The  laceration,  of  course,  will  have  been  discovered  wdien  the 
hand  was  inserted  either  for  removal  of  the  placenta  or  preliminary  to  the  douche. 
Treatment  of  lacerations  naturally  occurs  at  this  point,  but  we  will  leave  the  dis- 
cussion until  later.  Should  the  diagnosis  of  severe  inertia  be  made,  one  has  to 
adopt  other  measures.  Time  is  an  element  in  such  cases.  Give  the  uterus  a  little 
time  and  it  will  contract,  but  one  must  not  allow  the  bleeding  to  continue  all  the 
while.  To  stop  the  hemorrhage  and  to  give  the  uterus  this  opportunity  (fourth) 
compress  the  uterus  between  the  two  hands,  as  in  Fig.  718.  The  cervix  is  grasped  by 
the  whole  hand  and  folded  together,  while  the  outside  hand  forces  the  uterus  down 
firmly  against  the  pubis  and  inside  hand.     One  may  feel  the  uterus  gradually  as- 


784 


THE    PATHOLOGY    OF   LABOR 


suming  its  normal  shape  and  consistence,  and  when,  after  ten  or  fifteen  minutes, 
the  pressure  is  relaxed,  the  physician  finds  that  the  flow  has  ceased,  he  may  remove 
his  hands.  Should  the  flow  continue  in  spite  of  this  manoeuver,  or  should  it  recom- 
mence after  he  has  removed  his  hands,  no  further  time  and  blood  should  be  wasted, 
but  the  uterovaginal  tract  should  be  packed  (fifth). 

Uterine  Tamponade. — One  may  tampon  the  uterus  with  gauze,  using  the  hands  alone,  or 
with  the  single  aid  of  the  uterine  packing  forceps,  or  by  sight,  having  drawn  the  uterus  down  with 


Fig.  721. — Packing  Uterus — Instrumental. 
Two  cervix  forceps  pull  the  uterus  down  and  straighten  it.     The  as.sistant's  hand  should  control  the  fundus  to  make 

sure  that  the  gauze  enters  it. 


the  vulsellum  forceps  and  spread  the  genitals  by  specula.  The  kind  of  gauze  is  very  important 
and  the  author  recommends  that  described  in  the  Appendix. 

Most  often  it  will  be  necessary  to  operate  with  insufficient  help,  and  then  the  second  method 
is  employed  (Hg.  720).  The  operator  i)uts  tlie  left  hand  into  the  vagina,  the  fingers  inside  the 
uterus  as  hisrh  as  possible. 

With  long  uterine  packing  forceps  the  end  of  the  strip  is  carried  up  to  the  top  of  the  uterus, 
taking  care  that  the  tip  of  the  forceps  does  not  catch  on  the  contraction  ring  or  in  a  fold  of  the  re- 
laxed uterine  wall.  A  sterile  towel  is  laid  on  the  belly,  and  with  his  right  hand  the  operator  de- 
termines that  the  tip  of  the  forceps  carrving  the  gauze  is  really  in  the  highest  point  of  the  uterus. 
The  gauze  is  then  evenly  packed  into  the  uterine  cavity,  from  side  to  side,  and  from  above  down- 


POSTPAUTITM    HEMORRHAGE 


785 


ward.  An  ii.ssi.stant  stfadics  the  fundus,  or  the  oiu'rator  from  tirno  to  tirno  assurfs  him.sflf  that 
llic  utorus  is  hcin^  evenly  filled.  The  inside  hand  acts  as  a  f^rooved  cliannel  alon^  whieh  the  gauze 
and  foreeps  find  easy  direction.  The  first  part  must  be  most  firmly  placed.  When  tlie  uterus  is 
full,  the  forceps  are  laid  temporarily  in  the  basin;  two  finK<'rs  of  the  left  hand  are  placed  against 
the  tanii)()ii;  the  right  liand  grasps  the  uterus  through  the  sterile  towel,  and  the  fingers  force  the 
gau/e  upward  more  firmly  into  liie  fundus,  thus  leaving  room  in  the  cervix  for  more  gauze.  Tliis 
maiueuver  must  be  perfoiined  carefully  and  gentlj',  and  one  nuist  leave  a  vent  for  the  escaju-'of  air, 
otherwise  (here  is  danger  of  air-embolism.  It  is  well  to  have  the  trunk  a  littl(>  liigher  than  the 
pelvis.  The  muse  holds  the  gauze  jar  near  tlie  vulva,  exactly  as  in  the  illustration  (Fig.  720).  In 
the  ab.seiice  of  a  nurse  or  other  jierson  to  hold  the  jar  of  gauze  it  may  be  held  Ijetween  the  accou- 
ch(>ur's  knees,  as  he  sits  before  the  patient,  with  his  heels  caught  on  a  rung  of  the  chair. 

The  writer,  in  several  ca.ses  of  great  urgency,  applied  the  gauze  successfully  with  the  hands, 
the  left  hand  forcing  the  strip  up  into  the  uterus  as  it  was  fed  into  it  by  the  right  hand  (Fig.  710). 


Fig.  722. — A  Uterus  Correctly  Plugged. 


If  the  operator  prefers  the  third  method,  a  table,  good  hght,  and  several  assistants  are  re- 
quired. A  broad  speculum  retracts  the  perineum;  one  cervix  forceps  is  placed  on  the  anterior  lip 
of  the  cervix,  and,  if  necessary,  one  on  the  posterior  lip,  the  operator  holding  one,  the  assistant,  the 
other.  The  right  hand,  armed  with  the  long  forceps,  inserts  the  gauze,  while  the  hand  outside 
controls  the  fundus  uteri  and  guards  against  false  movements  (Fig.  721). 

In  all  cases,  after  the  uterus  is  Jlnnltj  plugged,  the  vagina  is  firmly  tamponed  with  the  re- 
maining portion  of  the  strip.  Diihrssen  advised  tamponing  the  vagina  with  cotton,  which  is  better 
in  some  respects,  but  gives  more  pain  and  trouble  in  removal. 

In  all  but  a  very  few  cases  packing  will  stop  the  bleeding.  Chrobak,  Ahlfeld, 
Bumm,  von  Braun,  report  10  failures  in  120  cases,  but  an  exact  study  of  the  his- 
tories shows  that  too  much  was  expected  of  the  operation.  The  author  has  plugged 
the  uterus  over  a  hundred  times  for  conditions  not  due  to  lacerations.  Only  twice 
was  it  necessary  to  replace  the  pack  with  a  second  one.  In  two  cases  of  laceration 
of  the  cervix  with  hemophilic  diathesis  the  women  died  of  hemorrhage.  In  two 
50 


786 


THE    PATHOLOGY    OF   LABOR 


cases  of  atony  of  the  uterus  with  hemophiUc  diathesis  it  was  necessary  to  repack 
with  gelatinized  gauze. 

Without  doubt  most  of  the  reported  failures  are  due  to  poor  technic :  the  gauze 
is  not  put  in  correctly.  Fig.  722  shows  the  parturient  canal  correctly  packed ;  Fig. 
723,  a  case  where  the  operator  has  failed  to  grasp  the  situation.  If  the  first  tampon 
is  unsuccessful,  it  should  be  removed  and  another  inserted  more  snugly.  If  ab- 
solutely sterile  and  non-toxic  gelatin  (Merck)  is  at  hand,  the  gauze  should  be  well 
saturated  wdth  it  before  being  applied.  In  emergency,  2  ounces  of  French  gelatin 
are  melted  into  about  24  ounces  of  boiling  water  and  boiled  violently  over  a  hot  fire, 
with  constant  stirring,  for  twenty  to  thirty  minutes.  It  is  poured  over  the  gauze 
shortly  before  the  operation.     Another  resource  is  to  sew  the  cervix  together  over 


Fig.  723. — A  Uterus  Incorrectly  Plugged. 

the  uterine  plug.  (See  Fig.  725.)  In  obstinate  cases  it  may  be  necessary  to  ex- 
tirpate the  uterus,  but  few  are  the  reported  recoveries.  After  the  tamponade  ergot 
is  given  as  usual,  and  the  hand  should  guard  the  uterus,  massaging  it  lightly,  or 
rubbing  the  aorta  gently,  if  there  be  any  tendency  to  further  atony,  for  several 
hours.  A  tight  abdominal  binder  is  recommended  by  some,  but  the  author  has  not 
seen  any  real  indication  for  it.  It  is  better  to  force  the  uterus  down  from  the  out- 
side, while  the  balled  fist  exerts  counterpressure  from  the  perineum. 

The  gauze  is  removed  in  twenty-four  to  thirty-six  hours,  and  must  be  with- 
drawn very  slowly,  twenty  to  thirty  minutes  being  consumed  in  the  operation.  One 
must  be  prepared  to  pack  again;  but  the  author  has  never  found  it  necessary  in 
cases  of  atony.     (For  further  details  and  history  of  uterovaginal  tamponade  the 


POSTPARTUM    HEMORUHAGE 


787 


n^adcr  is  rcrcrrcil  to  my  article  in  tlic  Amci'icaii  .Journal  of  Ohstetrics,  1903,  Vf)l. 
xlvii,  No.  4.) 

To  sum  up  bricliy  tlu-  treatment  of  atonic  jjostpartum  hemorrhage:  I'irst,  if 
the  placenta  is  in  the  uterus,  massage;  failing  this,  expression  of  the  placenta; 
failing  this,  manual  removal.  Second,  after  placenta  is  out,  massage,  ergot,  hot 
uterine  douclie  witli  cleansing  of  uterine  cavity,  compression  of  the  uterus  in  ante- 
flexion;   failing  all  these,  uterine  tamponade. 

Many  otlirr  methods  have  boon  prnposod,  and  ooca.sionally  thoy  will  prove  u.seful.  Com- 
l)ro.ssioii  of  the  ahdoniinal  aorta  may  be  employed  as  a  temporary  expedient  until  one  can  prepare 
for  more  jjormanent  measures.  Packinjj;  the  vagina  with  a  ball  of  gauze,  a  towel,  or  anythinp; 
sterile  that  is  near  at  hand,  and  pressing  the  uterus  against  this  from  the  outside,  may  limit  the 


Fig.  724. — Momburg's  Tocrxiqcet.     Drawn  kro.m  Life. 
T^'o  or  three  turns  are  laid  and  drawn  tightly  enough  to  cause  the  disappearance  of  the  femoral  pulse. 


flow  until  the  accoucheur  can  procure  a  hot  douche  or  gauze  for  packing.  Squeezing  a  sponge  with 
vinegar  or  lemon-juice  in  the  uterus  has  already  been  mentioned.     These  fluids  must  be  sterile. 

Fritsch  recommendcfl  pulling  the  fundus  forward  over  the  pubis  and  filling  up  the  space  be- 
tween it  and  the  promontory  with  towels,  after  which  one  was  to  put  on  a  very  tight  abdominal 
binder.  The  uterus  has  been  folded  together  from  the  side,  twisted  on  its  axis,  turned  inside  out, 
ligated,  etc.  Chlorid  of  iron  and  Monsell's  solution  have  been  injected,  and  even  packed  in  the 
uterus  on  gauze.  This  is  unqualifiedly  condemned,  because  harmful  and  unnecessary.  The  gauze 
used  for  i)acking  might  be  saturated  with  sterile  and  non-toxic  gelatin,  or  with  sterile  blood  from 
the  husband  or  relative,  the  idea  being  to  supply  the  missing  thrombokinase.  Suprarenin  is 
powerless  to  cause  uterine  contractions  unless  injected  directly  into  the  uterine  muscle,  as  pro- 
posed b}'  Xeu.  At  the  operation  of  cesarean  .section  I  have  seen  strong  contraction  of  the  uterus 
follow,  at  once,  the  intramuscular  injection  of  1  c.c.  1  :  10,000  adrenalin.  This  is  now  put  up  in 
sealed  bulbs.  Pituitrin,  10  drops  hypodermically,  repeated  if  required,  has  been  found  efficacious 
in  atony  of  the  uterus  (Foges).     Given  by  douche  or  on  packing,  both  drugs  are  useless. 

Parsenow  recommended  pulling  the  cervix  down  to  the  vulva  with  vulsellum  forceps,  thus 


/88  THE    PATHOLOGY    OF   LABOR 

stretching;  and  kinking  the  uterine  vessels,  and  Henkel  advised  placing  a  bullet  forceps  temporarily 
on  the  uterine  vessels  at  the  sides  of  the  uterus  through  the  lateral  fornices.  Henkel's  mana?uver 
is  not  entirel}'  safe,  and  has  been  seldom  used,  but  Parsenow's  is  safe  and  may  control  the  bleeding 
more  or  less  until  the  uterus  maj'  be  packed. 

jNIomburg  proposed  circular  constriction  of  the  waist  with  a  rubber  tube,  to  cut  off  the  circu- 
lation in  the  lower  half  of  the  body,  which  he  had  used  successfully  in  surgery.  Fig.  724  shows  the 
belt  applied.  By  constricting  the  aorta  hemorrhage  is  stopped,  and  the  sudden  anemization  of 
the  uterus  stimulates  it  to  strong  contraction.  Sigwart  reports  24  successful  cases,  and  because  of 
its  apparent  safety  even  recommends  the  procedure  for  mid  wives.  In  the  Revue  de  Chii'urgie  for 
INIay,  1910,  a  death  from  heart  paralysis  on  the  removal  of  the  belt  is  reported,  and  reference  made 
to  gangrene  of  the  thigh,  intestinal  and  pulmonary  hemorrhage,  and  a  possible  death  noted  by 
deBovis.  Buck  reports  a  case  of  gangrene  of  the  intestine,  and  Pagenstecher  one  of  ischemic 
paralysis  of  the  distal  end  of  the  spinal  cord.  Latest  experience  with  the  belt  shows  that  it  may  not 
be  used  in  cases  of  disease  of  the  heart,  blood-vessels,  kidneys,  or  intestines,  nor  in  Basedow's. 


Fig.  72.5. — Uterus  Being  Clo.sed  Over  a  Plug. 

The  first  lialf  of  the  wound  on  both  sitle.s  is  closed  with  continuous  catgut,  the  middle  part  with  silkworm-gut  sutures, 

which  are  removed  in  twenty-four  to  thirty-six  hours. 

In  severe  anemia  it  is  dangerous  unl(\ss  the  limbs  are  tied  with  an  Esmarch  before  application  of 
the  constriction.  The  C!onstrictor  is  applied  with  the  body  slanting,  to  allow  the  intestines  to 
gravitate  toward  the  diaphragm.  As  soon  as  possible  after  the  bleeding  has  been  definitively 
stopped  it  is  removed.  Before  removing  the  belt  salt  solution  is  to  be  given  hypodermically. 
The  Esmarch  bandages  should  bo  removed  one  at  a  time,  leaving  an  interval  of  ten  minutes,  and 
the  limbs  should  bo  kept  elevated  until  the  volume  of  blood  is  such  that  the  heart  will  not  "pump 
empty."  To  substitute  the  belt,  Rissmann  invented  an  aortic  clamp  similar  to  the  tonsil  com- 
j)ressor. 


TREATMENT  OF  LACERATIONS 
When  a  tear  of  the  parturient  canal  has  ])een  discovered,  the  treatment  of  the 
case  must  l)e  modified  somewhat.     If  you  compress  a  chtoris,  vulvar  or  lower  vaginal 
tear  for  a  few  minutes,  very  often  the  bleeding  will  cease  and  the  regular  conduct  of 


POSTPAiniM    lIK.NKMaiHAGE  789 

tlic  third  stiver  will  not  need  to  he  altered.  If  compression  docs  not  suffice,  a  few 
sutures  will  iilwuN's  do  so. 

Higher  vaginal  tears  and  cervi.x  tears,  especially  in  placenta  pry.'via,  may  cause 
most  serious  hemorrhage.  It  is  important  to  get  rid  of  the  placenta  at  once  and 
get  contraction  and  retraction  of  the  uterus.  This  part  of  the  treatment  is  the 
same  as  for  atony.  If  the  bleeding  continues,  two  courses  are  open — one,  utero- 
vaginal tamponade,  the  other,  suture  of  the  laceration.  One  may  comljine  the  two 
jjrocedures.  ^Vitllout  doubt  the  best  way  to  stop  hemorrhage  from  a  laceration  is 
to  sew  up  the  tear,  but  it  may  be  impossible  to  do  this  because  of  lack  of  proper 
pre))arations,  of  assistants,  light,  or  skill.  Then,  too,  sometimes  the  bleeding  is  so 
l^rofuse  that  you  cannot  sec  where  to  place  the  stitches,  the  whole  field  being  a  lake 
of  l)lood.  It  may  also  be  inadvisable  to  sew  up  the  tear  because  of  sepsis,  or  be- 
cause the  facilities  are  not  at  hand  for  aseptic  w'ork.  It  may  thus  be  safer  to  leave 
the  wound  open  for  drainage.  In  such  cases  the  tampon  will  be  indicated,  but  it  is 
not  so  certain  a  remedy  as  in  atony  of  the  uterus. 

When  jilugging  a  uterus  and  tear,  the  operator  must  be  careful  not  to  enlarge 
the  latter  by  pushing  in  too  much  gauze,  and  the  whole  parturient  canal  must  always 
l^e  snugly  and  smoothly  filled,  never  the  vagina  alone. 

Lacerations  are  sewed  as  shown  in  Fig.  689,  and  Fig.  687,  p.  742.  Free,  perhaps 
torrential,  l)leeding  may  render  such  operations  difficult,  and  I  have  found  the  follow- 
ing measures  useful,  to  enable  me  to  see  the  field.  Compression  of  the  aorta  (now, 
perhaps,  Momburg  tourniquet) ;  traction  on  the  lips  of  the  cervix  with  cervix  for- 
ceps; packing  one  side  of  the  cervix  tear  while  the  other  is  sutured;  compression  of 
the  l)leeding  surface  with  a  large  w^ad  of  dry  cotton  or  the  hand  for  twenty  minutes; 
FLnikel's  method  of  clamping  the  bases  of  the  broad  ligament  with  Ijullet  forceps; 
filling  the  uterus  tight  full  of  gauze,  and  sewing  the  cervix  together  over  the  plug 
(Fig.  725).     Occasionally  a  spurting  vessel  may  be  clamped  and  iigated. 

After-treatment. — All  danger  is  not  past  when  the  hemorrhage  has  been  stopped. 
The  patient  may  die  from  the  loss  of  blood.  Unless  one  has  plent}'  of  medical 
assistants,  this  part  of  the  treatment  will  have  to  be  left  until  the  accoucheur  has 
stopped  the  active  hemorrhage.  Tliis  is  the  advantage  of  doing  obstetrics  in  a 
maternity — while  stopping  the  loss  of  blood  an  interne  may  be  filling  the  patient's 
blood-vessels  with  salt  solution  or  blood  transfusion  may  be  done. 

During  ol)stetric  operations  in  general,  and  the  treatment  of  hemorrhage  in 
particular,  the  patient  should  be  kept  covered  and  warm.  After  a  hemorrhage  has 
been  checked  the  patient  should  be  warmly  covered  in  bed  and  surrounded  by  hot- 
water  bottles.  If  she  is  in  much  shock,  the  foot  of  the  bed  should  be  elevated  at 
least  two  feet,  and  a  hypodermic  injection  of  camphorated  oil  given.  To  tide  the 
patient  over  a  fainting  spell  give  a  hypodermic  of  aromatic  spirits  of  ammonia,  and 
let  her  sniff  some  smelling  salts.  While  doing  these  things  saline  solution  for  sub- 
cutaneous administration  should  be  prepared.  Sterile  salt  in  2-dram  vials  should  be 
carried  in  the  obstetric  satchel.  A  douche-bag,  a  bath-thermometer,  and  salt  solu- 
tion needle  should  be  boiled.  Two  drams  of  sterile  salt  are  placed  in  the  bag;  the 
end  of  the  tube,  armed  with  the  needle,  is  also  put  in  the  bag;  then  one  quart  of 
boiling  water  is  poured  on  the  salt.  The  mouth  of  the  bag  is  stopped  with  a  large 
wad  of  sterile  cotton,  and  the  bag  is  held  under  the  cold-water  tap  or  in  a  dish-pan 
of  cold  water  mitil  the  thermometer  registers  115°  F.  (Fig.  726). 

The  skin  under  the  breasts  is  painted  with  tincture  of  iodin,  and  the  needle, 
Avith  the  solution  flowing,  is  put  in  below  the  mammary  gland.  The  accoucheur 
seeks  to  direct  the  needle  into  the  connective  tissue  under  the  glandular  portion  of 
the  breast.  The  bag  is  noAv  raised  4  feet.  As  much  as  32  ounces  may  run  under  the 
skin.  It  is  advisable  to  lower  the  bag  occasionally  to  prevent  overstretching  and 
too  rapid  opening  up  of  the  lymph-spaces.  If  the  case  is  critical,  the  other  side, 
as  well  as  the  two  flanks,  may  be  injected.     In  one  patient  I  injected  116  ounces  of 


790 


THE    PATHOLOGY   OF   LABOR 


saline  solution  in  one  sitting,  using  the  4  points  named.  The  patient  recovered. 
This  patient  also  absorbed  2  quarts  from  the  rectum.  Such  immense  quantities  are 
rarely  needed.  Shall  you  inject  the  salt  solution  while  the  hemorrhage  is  still  going 
on?  Yes,  subcutaneously,  not  intravenously.  The  blood  lost  then  will  not  be  pure, 
but  mixed  with  salt  solution,  and  it  is  not  so  precious.  By  the  time  a  quart  has 
been  absorbed  the  accoucheur  must  have  the  hemorrhage  in  his  control,  or  the 

patient  will  have  died.  Some  authors  ad- 
vise against  the  use  of  saline  solution  until 
after  the  flow  has  ceased.  I  think  their  ob- 
jections are  theoretic.  Without  doubt  salt 
solution  has  saved  many  lives. 

The  writer  has  never  seen  fit  to  bandage 
the  limbs — so-called  autotransfusion.  The 
position  of  the  body,  with  the  foot  of  the  bed 
elevated,  aided  by  saline  solution,  is  suf- 
ficient. 

Per  rectum,  salt  solution,  with  perhaps 
three  ounces  of  coffee,  is  quickly  absorbed, 
and  a  quart  may  be  administered  every  three 
hours.  It  is  not  wise  to  administer  it  per 
rectum  until  the  hemorrhage  has  been  per- 
manently stopped,  because  if  any  local  treat- 
ment is  to  be  carried  out,  the  discharge  from 
the  bowel  may  infect  the  field,  the  hands,  in- 
struments, gauze,  etc.,  so  that  sepsis  may  be 
the  direct  result.  One  of  the  most  unwel- 
come incidents  in  any  obstetric  operation  is 
a  flow  of  liquid  feces  from  the  anus,  and  the 
writer  is  certain  that  this  has  caused  infection 
and  death  many  times. 

Lower  transfused  human  blood  in  1666, 
but  although  the  operation  has  been  attempted  many  times  since,  success  has  not 
been  obtained  until  recently,  when  the  technic  of  artery  to  vein  suture  has  been 
perfected.  Lespinasse  gives  the  literature  to  date.  From  my  experience  with 
transfusion  in  hemophilic  new-born  infants  I  would  say  that  in  desperate  cases  of 
postpartum  hemorrhage  the  woman's  empty  vessels  should  be  filled  with  blood 
from  her  husband  or  near  relative,  if  healthy,  of  course. 


Fig. 


r20. — Cooling  the  Prepared  Saline  Solu- 
tion Under  the  Cold-water  Tap. 


Fk;.   727.— The   Bicrnheim  Cannula  (actual  size). 


The  radial  artery  is  joined  to  the  me(Han  basiHc  vein  by  means  of  the  old  method  of  Payer  or 
a  Crile  eannula,  or  by  means  of  direct  anastomosis  with  magnesium  rings,  and  the  blood  allowed 
to  flow  from  the  donor  to  the  recipient  until  the  latter  shows  some  color  in  the  ears  and  face,  or  the 
former  begins  to  evince  signs  of  anemia.  Recently  I'^lsbeig  and  Curtis  and  David  recommended 
apparatus  which  is  more  practif'al  for  one  not,  skilled  in  blood-vessel  surgery  (Fig.  727). 

By  mouth,  the  patient  may  have  wine,  hot  coffee,  water,  or  a  hot  oyster-stew. 
If  the  patient  vomits,  she  usually  feels  relieved,  after  which  liquids  may  again  be 
given,  using  care  not  to  overload  the  stomach. 


POSTPARTUM    HEMORRHAGE  791 

During  the  first  week  nourislinicnt  iimst  he  <;i\'cii  IVccly.  The  bed  is  lowered  in 
two  or  tiiree  days  or  sooner,  depeudiiifi;  on  tiie  condition  (jf  the  patient.  It  is 
lowered  a  few  inches  at  a  time  to  avoid  syncope.  Not  seldom,  after  severe  hemor- 
rhages, the  puerpera  will  have  a  rise  of  temperature  to  102°  F.  within  the  first 
twenty-four  liours.  This  is  reaction  fever,  and  will  go  down  without  treatment. 
But  occasionally  sei)sis  follows  in  th(>  wake  of  a  severe  loss,  first,  because  the  resis- 
tance of  the  patient  is  so  much  lowered  tliat  infection  finds  easy  access,  and, 
second,  because,  in  the  excitement  and  unprc^paredness  attending  most  of  such  cases, 
the  rules  of  asepsis  are  forgotten  or  are  impossible  of  being  carried  out  in  detail. 
Sepsis  under  these  conditions  is  likely  to  follow  a  severe  course. 

The  milk  secretion  is  diminished,  Ahlfeld's  statistics  to  the  contrary'  notwith- 
standing. Ahlfeld  had  strong  peasant  women  to  deal  with.  The  high-strung 
American  mother  cannot  stand  the  drain  of  lactation  after  severe  loss  of  blood. 
My  experience  has  been  unequivocal  on  this  point,  and  I  notice  that  von  Braun 
warns  against  forcing  the  niu'sing  of  the  infant  on  neurasthenic  women.  One  may 
permit  a  partial  breast-feeding  until  the  woman  has  completely  recovered  from  the 
exhaustion  of  the  hemorrhage.  Some  women  recover  very  slowly  from  the  spanemia 
and  require  blood-tonics  for  long  periods.  The  best  treatment  the  writer  knows  for 
such  cases  of  severe  hemorrhage  is  living  at  the  seashore,  and  the  woman  should  be 
sent  there  as  soon  as  she  can  bear  the  journey. 


LATE  PUERPERAL  HEMORRHAGES 

Even  after  delivery  the  woman  is  not  safe  from  the  dangers  of  bleeding,  since 
such  may  occur  as  late  as  the  fifth  week  postpartum.  A  hemorrhage  which  begins 
after  the  first  day  after  labor  is  called  late,  though  some  authors  distinguish  between 
those  which  occur  in  the  early  puerperium  and  those  of  the  late  puerperium.  Some- 
times, without  apparent  cause,  the  puerpera  begins  to  flow,  and  the  amount  of 
blood  lost  may  be  so  great  that  a  serious  anemia  or  even  death  results. 

Etiology. — Among  the  commonest  causes  rnay  be  noted  retention  of  placental 
fragments,  of  thick  membranes,  of  thick  decidua  (especiallj^  in  abortions),  and  some- 
times simply  a  hard  blood-clot.  A  large  piece  of  placenta  may  come  away,  more  or 
less,  or  not  at  all,  decomposed,  as  late  as  the  twelfth  day,  and  usually  there  is  not 
much  bleeding.  Cases  are  on  record  of  the  retention  of  pieces  of  placenta  for  as  long 
as  eleven  months,  and  Ries  found  placental  villi  in  the  uterine  vessels  eighteen  years 
after  the  last  delivery.  Ramsbotham  records  a  case  where  the  whole  placenta  was 
retained,  and,  as  far  as  the  woman  knew%  never  came  away.  Small  and  tliin  pieces 
of  placenta  may  dissolve  in  the  lochia,  which  are  then  profuse,  prolonged,  bloody, 
and  perhaps  fetid.  The  same  may  be  said  of  membranes  and  decidua.  If  bits  of 
placenta  or  decidua  do  not  become  infected,  blood  is  deposited  on  them  in  successive 
layers,  and  a  fibrinous  or  placental  polypus  results.  These  keep  up  irregular  hemor- 
rhage until  they  are  removed,  or  they  become  infected,  break  do^^ii,  and  are  dis- 
charged piecemeal,  with  fetid  discharge  and  fever,  sometimes  vrith.  hemorrhages, 
or  a  pyemia  may  ensue. 

Subinvolution  stands  next  in  frequency,  the  large  boggj^  uterus  bleeding  on  the 
slightest  provocation.  Low  grades  of  infection  are  responsible  for  many  cases  of 
subinvolution.  Displacements  of  the  uterus  are  usually  part  of  the  same  process, 
and  in  retroflexion  of  the  puerperal  uterus  hemorrhages  are  not  infrequent  and  pro- 
longed, and  bloody  lochia — in  some  cases  for  six  or  eight  w^eeks — are  very  common. 
Favored  by  subinvolution  and  displaced  by  a  full  bladder  or  rectum,  the  uterus 
may  bleed,  and  a  disquieting  degree  of  anemia  may  result. 

Nervous  influences  unquestionably  play  a  role.  I  saw  a  very  serious  hemor- 
rhage result  from  relaxation  of  the  uterus  on  the  eleventh  da}'  when  the  puerpera 


792  THE    PATHOLOGY    OF   LABOR 

had  been  frightened  b}-  a  domestic  quarrel.  We  know  that  the  menses  may  cease, 
and  that  metrorrhagia  may  ensue,  upon  a  nervous  shock. 

Sudden  physical  strain  often  causes  a  reappearance  of  the  bloody  lochia,  as  is 
so  oft^n  observed  when  the  puerpera  gets  up  for  the  first  time.  Severe  hemorrhages 
at  this  tune  are  rare,  but  do  occur  (subinvolution). 

As  occasional  causes  may  be  mentioned  myomata,  especially  the  mural  and 
submucous  varieties,  carcinomata,  cervical  erosions,  ulceration  of  a  cervical  vessel, 
ruptm-e  of  a  small  uterine  or  cervical  hematoma,  inversion  of  the  uterus,  chorio- 
epithelioma,  secondary  hemorrhages  after  suture  of  a  cervix  tear,  as  occurs  some- 
times after  gynecologic  operations,  traumatism  from  coitus,  sometimes  with  rupture 
of  the  vagina,  and  puerperal  septicemia  with  softening  of  the  thrombi  of  the  pla- 
cental site.     The  last  form  of  hemorrhage  is  very  fatal. 

Diagnosis. — Three  points  must  be  settled — first,  is  there  anything  in  the  uterus? 
second,  is  it  simply  a  case  of  relaxation  or  subinvolution?  third,  is  there  a  neoplasm? 

Early  in  the  puerperium  a  vaginal  examination  is  forbidden  unless  urgently 
indicated,  but  a  rectal  exploration,  combined  with  the  external  hand,  gives  nearly 
as  much  information  and  is  quite  safe.  Later  in  the  puerperium,  after  the  four- 
teenth day,  a  vaginal  examination  may  be  made.  If  the  cervix  is  too  soft,  patulous, 
and  the  uterus  large  and  globular,  a  retained  cotyledon  of  the  placenta  may  be 
suspected.  Sometimes  it  may  be  felt  through  the  open  cervical  canal.  If  the 
uterus  is  evenly  enlarged,  of  a  soft,  doughy  consistence,  but  the  cervix  not  admitting 
the  finger,  subinvolution  is  probably  present,  and  by  massage  it  may  be  possible  to 
get  the  organ  to  contract.  Between  placental  polyp  and  partial  iriversion  of  the 
uterus  the  combined  manipulation  must  decide,  and  it  is  usually  easy  if  the  latter 
condition  is  thought  of. 

Prognosis. — Even  though  severe,  the  hemorrhage  is  seldom  fatal,  and  it  re- 
sponds quickly  to  treatment.  The  most  dangerous  are  the  cases  of  placental 
polyp,  the  frequently  repeated  hemorrhages  depressing  the  puerpera  a  great  deal, 
and  especially  critical  are  the  infected  placental  fragments,  because  if  it  is  necessary 
to  remove  them,  the  unavoidable  manipulations  grind  the  infection  into  the  pla- 
cental site,  into  the  open  veins,  and  into  the  thrombi  here,  pyemia  easily  resulting. 

Treatment. — Early  in  the  puerperium  it  is  dangerous  to  submit  the  patient  to 
active  local  treatment,  especially  if  she  has  fever.  A  mild  infection  may  thus 
be  changed  to  a  fatal  one.  Therefore  external  remedies  are  at  first  to  be  tried. 
Ergot  and  hydrastis  internally,  massage  of  the  uterus,  and  the  ice-bag  or  a  hot 
vaginal  douche  may  be  ordered.  If  the  hemorrhage  persists,  the  uterovaginal 
tract  may  be  packed  with  slightly  antiseptic  gauze.  This  will  care  for  a  hemorrhage 
from  atony  as  well  as  one  from  the  retention  of  a  piece  of  placenta — indeed,  it  favors 
the  separation  and  expulsion  of  the  latter.  Manual  or  instrumental  curetage  is  not 
to  Vje  performed  in  the  early  puerperium.  It  is  best  to  temporize,  if  possible,  using 
frequent  tamponade,  rest,  medicine,  etc.,  until  the  fifth  or  sixth  week  of  the  puer- 
perium, by  which  time  involution  is  so  well  along  that  the  uterine  muscle  will  not  be 
easily  perforated,  and  the  blood-vessels  so  tightly  thrombosed  that  the  finger  or  the 
curet  will  not  be  able  to  carry  infection  into  them.  I  have  seen  two  fatal  infections 
result  from  neglect  of  this  advice.  Should  the  indication  to  remove  the  mass  be 
positive,  the  placental  forceps  and  the  finger  are  to  be  used,  not  the  curet;  an  anti- 
septic uterine  douche  precedes,  and  a  weakly  antiseptic  uterine  pack  completes,  the 
the  operation. 

A  retroverted  uterus  is  to  be  replaced  by  posture  or  the  colpeurynter,  not  by 
the  fingers,  early  in  the  pu(!rperium.  Later  a  pessary  may  be  applied.  Myomata, 
cancer,  erosions,  etc.,  are  treated  on  general  principles.  Temporary  tamponade  of 
the  vagina  may  tide  the  patient  along  until  the  best  time  for  operating  arrives. 


POSTrAKTlM    HEAIOlUtllAGE  793 


SYNCOPE  AND  SUDDEN  DEATH  IN  LABOR 

A  gravida,  a  jiarturicnt,  or  a  jjiicrpcra  may  collapse  and  die  suddenly,  th(;  cause 
})einfi;  sonietiines  deteruiinahle  only  at  the  autopsy.  Often,  liovvever,  the  complica- 
tion may  he  expected,  knowinfj;  previ(jus  disease;  to  exist,  (^nly  a  i)artial  enumera- 
tion of  the  causes  may  here  be  attempted,  otherwise  we  would  have  to  cover  the 
entire  field  of  medicine.  The  causes  may  be  divided  into — (a)  Those  which  may  be 
jiroperly  said  to  accomi)any  the  puerjieral  state;  and  (b)  tliose  which  are  extra- 
ji;enital,  but  in  which  the  i)erformance  of  tlie  reproductive  function  is  the  excitiiifi; 
factor.      (See  E.  P.  Davis.) 

A.  (1)  Sudden  collapse  and  death  may  Ijc  due  to  hemorrhage  and  shock  from 
any  of  the  obstetric  accidents  already  discussed,  for  example,  ruptured  ectopic 
gestation,  i)lacenta  pricvia,  abruptio  placentae,  rupture  of  the  uterus,  postpartum 
hemorrhage,  inversio  uteri,  rupture  of  the  pelvic  joints,  rupture  of  a  varix  in  the 
broad  ligament. 

(2)  The  acute  toxemias  which  go  with  the  pregnant  state,  the  prostration  and 
collapse  of  hyperemesis  gravidarum,  the  toxemia  of  eclampsia,  of  pernicious  anemia, 
uremia  (StriimpcU,  Bartcls),  and  those  of  sepsis.  Almost  fatal  s^'ncope  from  acute 
uremia  or  from  acute  pregnancy  toxemia,  with  characteristic  urinary  findings,  I 
have  observed  twice.  Zweifel  reported  such  a  case,  confirmed  at  autopsy,  and  Norris 
another.  Eclamptic  toxemia  may  cause  sudden  death  by  cerebral  hemorrhage,  and 
this  may  occur  when  the  convulsions  and  other  signs  of  the  disease  are  absent. 
Syncopal  attacks  in  severe  sepsis,  due  to  passing  cardiac  weakness,  are  common,  and 
the  end  in  such  cases  is  often  due  to  paralysis  of  the  heart,  which  ma}''  come  on 
suddenly. 

(3)  Pulmonary  embolism  is  an  often  mentioned  cause,  the  clot  usually  being 
found  plugging  one  or  more  of  the  pulmonary  arteries.  The  embolus  almost  always 
comes  from  the  thrombosed  veins  in  the  pelvis  or  thigh.  Slowing  of  the  circulation 
in  the  veins  allows  the  blood-platelets  to  accumulate  on  the  wall  and  build  a  white 
thrombus,  on  which  the  red  clot  will  always  be  found.  Alteration  of  the  blood  may 
predispose  to  thrombus  formation,  especially  if  the  vessel-wall  is  injured.  It  is 
possible  that  clots  may  form  in  the  large  veins  of  the  thigh  if  the  limbs  are  held  in  a 
cramped  position  for  a  long  time,  as  in  protracted  operations  with  the  patient  in  the 
exaggerated  lithotomy  or  Trendelenburg  positions.  Puerperal  infection  acts  in 
two  ways,  first,  b}'  an  alteration  of  the  blood,  predisposing  to  throml^i  distant  from 
the  site  of  the  disease,  and  second  the  infection  may  spread  along  the  veins  or  to 
the  veins,  directly  causing  thrombosis.  Although  most  authors  emphasize  the 
mechanical  factors,  the  precipitation,  the  agglutination,  etc.,  I  have  never  seen  a 
thrombosis  Avhere  infection,  either  endogenic  or  exogenic,  could  be  ruled  out. 
Thrombosis  may  follow  as  the  direct  result  of  an  intestinal  infection.  In  cases  of 
severe  anemia  or  profound  shock,  the  circulation  in  the  heart  l^eing  almost  in 
abeyance,  a  clot  may  form,  and,  after  a  few  daj'S  of  only  partial  recovery,  sudden 
death  from  cardiac  paralysis  may  occur.  Pus  from  a  pelvic  abscess  may  break 
into  a  vein  and  reach  the  heart. 

Air-embolism  has  frequently  been  given  as  a  cause  of  sudden  death  in  preg- 
nancy and  labor.  A  colleague  of  the  author  told  of  a  woman,  pregnant  four 
months,  who,  while  taking  a  douche  with  a  bulb  sjTinge,  died  suddenly  from  this 
cause.  Such  deaths  have  been  reported  from  attempts  to  produce  abortion  by  in- 
jecting air  into  the  uterus.  During  obstetric  operations,  especially  with  placenta 
prajvia,  the  accident  has  time  and  again  occurred.  Curiously  enough,  experiments 
on  animals  have  sho\Ani  that  enormous  quantities  of  air  can  ])e  injected  into  the  veins 
leading  directly  to  the  heart,  without  any,  or  quickly  passing,  bad  sjanptoms  (Fitz- 
patrick).  In  the  human,  however,  the  danger  of  the  admission  of  air  into  the  veins 
through  the  uterine  sinuses  is  a  well-established  fact.     During  the  operation  of 


794  THE    PATHOLOGY    OF   LABOR 

uterine  tamponade  in  placenta  prsevia  the  author  had  one  case  of  collapse  from  air- 
embolism  (recover}^.  In  personal  communications  Dr.  Skeel  and  Dr.  Bogardus 
report  two  others,  one  of  which  was  fatal.  Vavra  reports  a  fatal  one.  Gases  of  de- 
composition which  accumulate  in  the  uterus  may  gain  entrance  to  the  veins.  The 
Bacterium  aerogenes  capsulatus  has  been  found  in  these  cases,  and  the  presence  of 
such  gases  may  bring  the  diagnosis  into  question. 

(4)  The  nervous  shock  of  labor  may  cause  syncope  and  even  death,  and  a 
psychic  shock  at  the  time  of  labor  may  be  fatal.  In  the  First  Book  of  Samuel,  Ch. 
iv:19,  20,  it  is  said  that  Eli's  daughter,  learning  that  her  husband  and  father-in- 
law  were  killed  and  the  ark  of  God  taken,  went  into  labor  and  died.  Hirst  tells  of  a 
widow,  illegitimately  pregnant,  who,  on  being  shown  the  child,  went  into  delirium 
and  died.  Sue  (Histoire  des  Accouchements)  relates  that  a  pregnant  woman  was 
told  by  a  gypsy  that  she  would  die  in  labor.  She  made  her  will  and  expired.  Wil- 
liams had  a  similar  experience,  but,  by  giving  morphin,  he  put  the  woman  asleep, 
during  which  time  she  forgot  her  obsession.  That  profound  nervous  influences  can 
produce  postpartum  hemorrhage  I  am  convinced  from  actual  experience.  Acute 
delirium  in  labor,  the  result  of  excessive  pain  in  a  nervously  disposed  individual,  may 
be  an  indication  for  the  termination  of  labor.  Loss  of  consciousness  may  occur 
during  the  second  stage,  the  result  of  intense  pain,  and  the  child  may  be  delivered 
Avithout  the  knowledge  of  the  mother.  I  have  observed  this  myself,  and  agree  with 
Freyer  that  in  medicolegal  cases  cognizance  should  be  taken  of  it  as  a  fact — for  ex- 
ample, in  cases  where  a  mother,  bearing  alone,  is  accused  of  infanticide.  Syncope 
after  delivery,  in  the  absence  of  hemorrhage,  rupture  of  the  uterus,  etc.,  is  very 
rare,  and  may  be  due  to  nervous  or  physical  shock  in  susceptible  individuals.  I  have 
seen  syncope  follow  the  delivery  of  the  child  in  a  case  where  the  woman  had  been  en- 
forced to  breathe  very  rapidly  and  deeply  with  a  view  of  preventing  her  making  bear- 
ing-clown efforts,  the  object  of  the  same  being  to  keep  the  child  back  until  the 
accoucheur  could  get  to  the  bedside.  This  phenomenon  is  probably  an  acapnia. 
Traction  on  the  uterine  ligaments  by  forced  delivery  through  an  unprepared  par- 
turient canal  may  produce  peritoneal  shock.  I  have  seen  the  same  during  the 
removal  of  gauze  used  for  packing.  Sudden  loosening  of  a  Momburg  belt  may  be 
followed  by  syncope. 

Anderson  and  Rosenau  try  to  find  a  connection  between  the  admixture  of  fetal 
to  maternal  blood  and  eclampsia,  a  sort  of  anaphylaxis.  While  the  idea  is  not 
proved  for  eclampsia,  some  cases  of  collapse  and  sudden  death  postpartum  resemble 
certain  forms  of  anaphylaxis.  The  status  thymicus  has  not  been  studied  in  this 
connection. 

Acute  dilatation  of  even  a  nonnal  heart  may  occur  at  the  end  of  a  protracted 
second  stage,  with  exhaustive  bearing-down  efforts. 

Faintness  or  even  real  syncope  may  occur  when  a  puerpera  gets  out  of  bed  for 
the  first  time.  Formerly,  when  puerperae  were  kept  in  the  horizontal  position  for 
many  days,  such  accidents  were  commoner  than  now,  when  more  activity  in  the 
lying-in  period  is  allowed. 

B.  Sudden  death  may  be  due  to  causes  which  have  indirect  connection  with 
the  parturient  function — for  example,  heart  disease,  especially  mitral  stenosis  and 
myocarditis,  hydropcricardium,  adhesive  pericarditis,  hydrothorax,  displacement  of 
the  heart  and  lungs  in  kyphoscoliosis,  struma  with  acute  strumitis,  etc.  The  strain- 
ing of  labor  may  rupture  the  heart,  the  spleen,  the  aorta,  the  splenic  or  mesenteric 
veins,  the  gut,  the  gall-bladder  (Ri(>s),  peritoneal  adhesions,  or  a  walled-off  abscess 
(appendix  or  tube),  and  cause  collapses  and  speedy  death.  The  same  may  be  said  of 
rupture  of  a  blood-vessel  in  the  brain,  of  the  bronchioles  of  the  lung  with  emphysema 
(very  exceptional  as  a  cause  of  death  alone),  of  hemoptysis,  of  hemorrhage  into  the 
stomach  from  gastric  ulcer.     Brain  diseases,  tumor,  abscess,  thrombosis  of  the 


POSTPARTUM  HEMORRHAGE  795 

sinuses,  and,  fniall\',  poisoning  liy  diii.us  oi-  antiseptics,  chloroform,  morphin,  sco- 
polainin,  tiichlorid,  iodoforni,  cai'holic  acid,  lyscjl — must  be  mentioned. 

Symptoms. — These  depend  on  whetlier  the  dcatli  is  cerebral,  puhnonary,  or 
cardiac,  and  Ihe  underlying  cause  will  determine  which  one  occurs.  Pulmonary 
eml)olism  witii  cardiac  death  is  the  most  freciuent  form.  The  patient  falls  as  if 
struck,  cries  once  with  i)ain  over  the  heart,  gasps  for  air,  becomes  cyanotic,  develops 
edema  of  the  lungs  with  bloody  expectoration,  and  dies  in  a  few  minutes.  Some- 
times one  attack  passes  over,  or  the  woman  may  have  several  mild  ones,  but  usually 
the  second  or  thirtl  is  fatal.  Between  attacks  cyanosis,  dyspnea,  fast  heart,  dilata- 
tion  of  ])U])iIs,  nervous  excitation,  Avith  fear  of  impending  dissolution,  are  more  or 
less  marked.  If  the  eml)olus  is  small,  it  may  pass  on  into  the  lungs  and  the  patient 
may  recover.  ]\Iild  symptoms  of  shock,  with  pain  on  the  affected  side,  bloody 
expectoration,  and,  locally,  perhaps,  a  friction-sound,  will  enable  one  to  make  the 
diagnosis.  The  embolus  may  pass  through  an  open  foramen  ovale  into  the  general 
circulation.  Fever  of  a  mild  t}j>e  almost  always  precedes  the  occurrence  of  the 
embolism,  and  experience  shows  that  women  with  varicosities,  with  myomata,  and 
those  on  whom  operations  near  the  veins  have  been  performed,  are  oftenest  stricken. 
Infection,  however,  is  accountable  for  the  majority  of  cases.  Mahler  believed  to  have 
proved  that  a  regularly  increasing  frequency  of  the  pulse  indicates  thrombosis  in  the 
veins.  I  cannot  confirm  it.  In  air  embolism,  on  the  occasion  of  local  interference,  the 
patient  goes  into  collapse,  breathing  becomes  difficult,  she  has  sharp  precordial  pain, 
and  in  three  to  ten  minutes  expires.  In  one  case  I  observed  a  severe  chill  wdth  the 
pulmonary  and  cardiac  symptoms,  followed  by  profuse  sweating.  Skeel,  in  his 
case,  heard  "ty^Dical  churning  noises"  over  the  heart,  and  J.  Y.  Simpson  refers  to 
a  reddish  suffusion  of  the  cheeks.  At  autopsy  in  such  cases  the  heart  and  pul- 
monary vessels  are  filled  with  frothy  blood,  and  death  is  due  to  heart  paralj^sis — it 
cannot  pump  such  a  mixture.  Perhaps  the  coronary  vessels  are  sometimes  plugged 
with  an  air-embolus  which  acts  just  like  any  other,  the  clinical  picture  now  resem- 
bling angina  pectoris. 

Diagnosis. — When  a  woman  faints  or  collapses  after  delivery,  the  accoucheur 
should  rapidly  review^  the  course  of  the  labor  for  signs  of  any  of  the  following  condi- 
tions: Postpartum  hemorrhage,  rupture  of  the  uterus,  inversion  of  the  uterus,  intra- 
]:)eritoneal  hemorrhage,  excessive  operative  traumatism.  Next,  uremia  and  toxemia 
must  l)e  considered,  then  heart  and  lung  diseases.  Emboli  are  commoner  in  the 
pueri:)eriuni.  True  syncope  and  shock  can  be  diagnosed  only  by  exclusion.  Post- 
anesthetic collapse  must  always  be  borne  in  mind.  Chloroform  is  the  most  danger- 
ous in  this  regard,  and  the  amount  administered  need  not  be  large,  especially  if  the 
woman  had  any  slight  latent  kidney,  heart,  or  liver  disease.  Late  chloroform  death, 
due  to  fatty  degeneration  and  cytolysis  of  the  liver,  kidneys,  and  heart,  may  occur 
from  a  few  hours  to  twelve  days  after  delivery.  I^  resembles  acute  yellow  atrophy 
of  the  liver,  with  delirium,  coma,  jaundice,  and  cardiac  paralj'sis.  It  may  be  very 
acute,  terminating  fatally  within  twelve  hours  (author's  case). 

Treatment  is  on  general  lines,  and  depends  on  the  diagnosis. 

Trendelenburg,  for  pulmonary  embolism,  advised  exposure  of  the  vena  pul- 
monalis  and  extraction  of  the  clot.  Four  cases  are  on  record,  all  fatal,  though 
Klein  states  two  might  possibly  have  been  saved. 

An  attempt  should  be  made  to  prevent  air-embolism  when  operating  or  moving 
the  patient.  In  packing  the  uterus  a  large  vent  should  be  left  alongside  the  hand. 
Sometimes  the  chance  must  be  taken. 


DELIVERY  OF  THE  FETUS  POSTMORTEM 

About  100  cases  of  spontaneous  delivery  of  the  child  after  death  of  its  mother  are 
on  record.     The  expulsion  of  the  fetus,  which  may  occur  within  six  or  more  hours, 


796  THE    PATHOLOGY    OF   LABOR 

or  after  days,  depending  on  the  cause,  is  usually  produced  by  the  gases  of  decomposi- 
tion in  the  intestines,  but  it  may  be  accomplished  by  gases  in  the  uterus  itself,  or 
even  by  contractions  of  the  uterus  postmortem.  In  such  cases  labor  had  begun  be- 
fore death,  and  the  parts  were  thus  prepared  for  delivery.  Outside  of  the  scientific 
interest  of  these  cases,  they  are  important  in  a  medicolegal  sense,  since  the  attending 
accoucheur  may  be  accused  of  criminal  neglect,  or  even  of  having  permitted  the 
burial  of  the  woman  alive.     (See  Reiman.) 


INFECTION  DURING   LABOR 

A  temperature  of  100°  to  100.6°  F.  may  frequently  be  found  toward  the  end  of 
the  second  stage  of  labor.  It  is  usually  ascribed  to  the  muscular  exertion,  to  absorp- 
tion of  fibrin  ferment,  excitement,  etc.,  but  the  author  believes  they  are  due  to  the 
absorption  of  toxins  from  the  parturient  canal.  Infection  during  labor  may  be  car- 
ried over  from  the  pregnancy,  from  coitus,  self-examinations,  etc.,  or  it  may  result 
from  instrumental  interference  (colpeurynters,  gauze,  etc.),  or  it  may  be  purely 
endogenic.  If  the  membranes  have  been  open  a  long  time,  bacteria  may  wander 
upward.  Warnekros  has  shown  that,  if  the  placental  circulation  is  in  action, 
bacteria  from  the  interior  of  the  uterus  easily  pass  into  the  blood. 

The  sjTnptoms  of  infection  during  labor  are  the  same  as  those  at  any  other  time. 
The  child  is  endangered — it,  too,  may  become  diseased.  I  have  seen  a  pneumo- 
coccus  infection  thus  conveyed,  also  gonorrheal  ophthalmia.  The  liquor  amnii  is 
usually  discolored  and  odorous,  depending  on  the  kind  of  the  bacterium,  and  the 
wounds  around  the  introitus  and  cervix  are  often  covered  with  grayish  exudates. 
Pus  may  issue  from  the  genitals.  When  fever  begins,  the  pains  are  usually  strength- 
ened, but  unless  delivery  is  soon  accomplished,  gas  develops  in  the  uterus  and  paraly- 
sis with  distention  results. 

Treatment.— If  the  uterovaginal  canal  is  prepared  for  delivery,  this  may  be  per- 
formed at  once.  If  not,  the  accoucheur  may  well  hesitate  to  force  the  birth,  be- 
cause of  the  danger  of  making  extensive  injuries,  into  which  the  infection  will  be 
literally  ground.  The  greatest  danger  exists  in  the  presence  of  an  invasive  strepto- 
coccus. It  is  wiser  to  await  the  spontaneous  termination,  at  least  until  the  head 
comes  down  onto  the  perineum,  interfering  only  when  absolutely  necessary.  Before 
such  operation  the  parts  are  to  be  carefully  douched  with  0.75  per  cent,  solution  of 
tincture  of  ioclin.  It  is  my  practice  in  such  cases  not  to  suture  lacerations,  but  to 
leave  them  wide  open  for  drainage.  I  often  pack  the  whole  parturient  canal  lightly 
with  0.5  per  cent,  lysolized  gauze.  Some  authors  advise  not  to  put  the  hand  up  into 
the  uterus,  since  this  ma,y  carry  the  infection  to  the  placental  site,  advice  which 
may  be  heeded  if  the  conditions  of  the  case  are  favorable.  A  chill  with  sharp  rise  of 
temperature  often  follows  opera;tion,  but  the  fever  usually  subsides  in  twelve  hours 
unless  the  streptococcus  was  causative. 

J>ITEI{ATURE 

Ahlfeld:  Zeitschr.  f.  Geb.  u.  Gyn.,  vol.  li,  H.  2;  ibid.,  vol.  Ixvii,  p.  224.— A schoff:  "Thrombosis,"  Centralbl.  f.  Gyn., 
1911,  No.  4.5. — Curtis  and  David:  Jour.  Amer.  Med.  Assoc,  October  28,  1911. — Davis:  "Sudden  Death,  etc.," 
Trans.  Amer.  Gyn.  Soc,  190.5,  vol.  xxx,  p.  34.5.  Gives  literature. — Filzpalrick:  New  York  Med.  Jour.,  November 
26,  1910.— Fo(/es;  Centralbl.  f.  Gyn.,  1910,  p.  1.502,  also  1911,  No.  i.— Klein:  Arch.  f.  Gyn.,  1911,  vol.  xciv,  Heft 
l.—Kumpf:  Centralbl.  f.  Gyn.,  1897,  p.  280.— Labhnnll:  Zeitschr.  f.  Geb.  u.  Gyn.,  1910,  vol.  Ixvi,  p.  407.— Les- 
pinasse:  "Transfusion  of  Human  Blood  in  Infants,"  Surg.,  Gyn.,  and  Obstet.,  1912,  vol.  ii. — Momburf/:  Centralbl. 
f.  Chir.,  1908,  No.  2.3.  .41so  L'Obstetrique,  .January,  1911.  Literature. — Neu:  Arch.  Gyn.,  1908. — Norris: 
Amer.  .Jour.  Obstet.,  July,  1903. — Opitz:  Centralbl.  f.  Gyn.,  1908,  p.  1503. — Reiman:  Arch.  f.  Gyn.,  vol.  xi,  p. 
21.5. — Ries:  Personal  communication,  July,  1912. — Siawart:  Arch.  f.  Gyn.,  1909,  vol.  1,  p.  47. — Warnekros: 
Centralbl.  f.  Gyn.,  1911,  p.  101.5.— IFeHs.-   Therapeutic  Gazette,  October  1.5,  1910. 


riiAPTi<:R  LXii 

ACCIDENTS  TO  THE  CHILD 

Ideal  obstetrics  (l(Miuimls  that  every  child  not  congcnitally  deformed  be  de- 
hvercd  ahve  and  absolutely  uninjured.  This  ideal  is  far  from  iK'inj;-  realized.  Sta- 
tistics show  that  over  4  per  cent,  of  the  children  die  during  l^irth.  Schultze,  in  1877, 
estimated  tliat  5  per  cent,  of  children  are  still-born,  and  1..5  per  cent,  die  very  shortly 
after  birth,  the  result  of  the  trauma  of  lal)or.  A  large  percentage — how  large  it  is 
impossible  to  say — is  more  or  less  injured,  and  this,  too,  in  so-called  normal  delivery. 
Any  one  performing  autopsies  on  new-born  children  will  be  struck  by  the  frequency 
of  liemorrhages,  i^unctate  and  larger,  in  the  brain,  in  the  larger  ganglia,  along  the 
sinuses  and  the  sutures.  It  is  certain  that  such  extravasations  leave  scars,  per- 
haps minute,  in  the  cerebral  structures,  which  may  explain  some  cerebral  symptoms 
later  in  life. 

The  greatest  danger  which  besets  the  child  on  its  way  into  the  world  is  the  in- 
terruption of  its  respiratory  function.  It  often  comes  in  a  condition  of  partial  or  com- 
])let(>  anaerosis.  The  old  and  universally  used  termtoexpress this  state  is  "  asphj^da," 
l)ut  this  is  etymologically  incorrect,  because  it  means  "without  pulse"  (from 
a-  a(f)u^Ls),  and  the  children  are  not  so  at  all — the  pulse  being  the  last  to  disap- 
pear. Numerous  terms  have  been  suggested  to  take  the  place  of  the  generally  and 
long-recognized  inappropriate  ''asphyxia,"  such  as  dysapnea,  euapnea,  ecchysis 
pneumocardia,  anhematosis.  The  one  here  suggested  by  the  author,  anaerosis, 
from  a,  privative,  arjp,  air,  and  -osis,  the  condition  of,  expresses  the  state  of  the  child 
and  covers  practically  all  the  causes.  In  the  succeeding  pages  the  two  terms, 
anaerosis  and  asphyxia,  and  their  derivatives,  will  be  used  sjTionymously,  or  as 
indicating  that  the  former  leads  to  the  latter. 


ASPHYXIA  NEONATORUM 

As  pregnancy  nears  the  end  the  fetus'  l)lood  l^ecomes  more  and  more  venous, 
which  is  due  to  the  gradual  narrowing  of  the  ductus  Botalli  and  ductus  Arantii. 
It  is  generally  said  that  the  fetus  cannot  stand  a  sudden  increase  of  this  venosity  as 
well  at  term  as  earlier  in  i:)regnancy,  but  my  o^Am  experience  does  not  confirm  such  a 
statement.  From  Hippocrates'  time  a  popular  notion  has  prevailed  that  seventh 
month  babies  are  more  likely  to  live  than  those  of  the  eighth  month,  and  proba))ly 
this  idea  is  founded  on  the  possible  greater  tolerance  of  asphyxia  by  fetuses  of  the 
earlier  months  of  pregnancy. 

The  cliild  exists  in  a  state  of  apnea,  that  is,  Avithout  respiration,  because  it  has 
(>nough  oxyg(Mi  for  its  wants.  Ol^servation  of  the  fetus  at  cesarean  sections,  and  of 
the  foot  or  arm  in  the  intact  bag  of  waters,  shows  a  slight  bluish  tint  of  the  skin, 
which  would  indicate  that  there  is  a  shght  increase  of  CO2  over  that  of  the  delivered 
child.  The  fetus,  therefore,  is  not  in  a  state  of  acapnia.  During  labor  there  is  a 
gradually  increasing  anaerosis,  which  reaches  its  acme  just  as  the  head  is  expelled 
through  the  vulva.  With  each  pain  there  is  a  slight  retardation  of  the  maternal 
blood-current  through  the  placenta,  and  at  the  same  time  a  very  slight  increase  of 
pressure  on  the  fetal  head,  if  the  latter  has  already  entered  the  pelvis.  After  the 
bag  of  waters  has  ruptured  both  conditions  are  more  marked,  and  as  the  head  passes 
the  vulva  the  greatest  change  takes  place,  that  is,  the  head  suffers  the  greatest 

797 


798  THE    PATHOLOGY    OF   LABOR 

pressure,  the  uterus  contracts  the  hardest,  forcing  the  maternal  blood  out  of  its 
meshes,  and,  in  addition,  the  placental  site  undergoes  slight  reduction  in  size  and 
there  may  be  some  detachment  of  the  placenta.  All  these  factors  have  a  positive, 
sometimes  marked,  influence  on  the  child.  In  the  first  stage  of  labor  they  usually 
cause  a  slight  slowing  of  the  fetal  pulse.  Seitz  finds  the  opposite — a  slight  increase 
of  rapidity.  In  the  second  stage  the  slowing  is  the  rule,  and  at  the  very  end 
it  is  invariable,  a  fact  easily  proved  by  palpating  the  chest  of  the  child  still  in 
the  vagina,  or  the  cord  directly  after  birth.  When  born,  the  child  is  in  a  state  of 
slight  anaerosis,  or  if  the  second  stage  was  not  prolonged,  only  apneic.  As  a  result 
of  the  slight  pressure  which  the  head  undergoes  the  blood  is  forced  out  of  the  head, 
and  a  moderate  degree  of  anemia  of  the  base  of  the  brain,  the  medulla  included,  en- 
sues. The  sloAving  of  the  maternal  blood-stream  and  the  changes  at  the  placental 
site  cause  a  mild  deoxidation  and  hypercarbonization  of  the  fetal  blood,  and  the 
anemia  of  the  medulla  accentuates  the  general  lack  of  oxygen.  Together  the  result 
is  that  the  cardiac  and  respiratory  centers  in  the  medulla  do  not  receive  good  blood. 
Since  the  respiratory  center  is  naturally  torpid,  almost  inactive,  it  responds  very 
slowly  and  late  to  this  condition,  but  the  cardiac  center,  the  origin  of  the  vagus,  the 
pneumogastric,  is  very  sensitive,  and  the  deoxygenated  and  hypercarbonized  blood 
stimulates  it  to  action.  The  same  is  true  of  the  vasomotor  centers.  The  heart  is  de- 
pressed, the  pulse  is  slowed,  and  the  blood-pressure  slightly  raised.  Whether  it  is 
the  lack  of  oxygen  or  the  excess  of  CO2  which  irritates  the  vagus  center  and  slows  the 
pulse  was  much  discussed.  Later  experiments  seem  to  prove  that  it  is  the  excess  of 
CO2.  If  the  anaerosis  is  acute,  the  stimulation  of  the  vagus  center  is  strong,  the 
heart  is  very  much  slowed,  and  the  asphyxia  is  increased. 

Now  the  respiratory  center  awakens  and  elicits  spasmodic  contraction  of  the 
muscles  of  respiration.  The  fetus  gasps,  and  whatever  lies  near  its  mouth  is  sucked 
into  the  lungs — liquor  amnii,  vernix  caseosa,  meconium,  blood,  vaginal  mucus,  feces, 
etc.  This  inspiration  also  dilates  the  capillaries  of  the  lungs,  and  unless  there  is 
something  in  the  alveoli  (air)  to  exert  counterpressure,  some  of  the  capillaries  may 
burst.  As  a  fact,  smaller  and  larger  hemorrhages  in  the  lungs  and  pleurae  are  the 
rule  in  cases  of  asphyxiation.  If  the  loss  of  oxygen  and  increase  of  CO2  are  very 
slow,  the  respiratory  center  may  be  benumbed  and  the  fetus  may  die  without  having 
made  any  attempt  at  respiration.  These  cases  offer  a  bad  prognosis,  even  if  the 
child  is  delivered  with  the  heart  still  beating.  The  continued  stimulation  of  the 
vagus  center  results  finally  in  its  paralysis,  its  inhibitory  action  is  gone,  the  pulse 
jumps  to  180  to  200  or  more.  Sometimes  the  fetal  heart  becomes  irregular,  a  few 
powerful  beats  succeeding  a  run  of  weak,  almost  uncountable  pulsations.  In  other 
cases  of  threatened  intra-uterine  asphyxia  the  fetal  heart-tones  are  very  rapid  from 
the  start — 180  to  210.  It  is  possible  that  such  frequencies  are  preceded  by  slowing 
of  the  pulse,  though  in  several  cases  in  which  the  heart-tones  were  carefully  noted 
the  latter  was  not  ol^served.  It  is  hard  to  explain  the  primary  acceleration  of  the 
pulse,  though  perhaps  cerebral  compression  may  do  it  (Schroder).  Why  compres- 
sion of  the  brain  should  slow  the  heart  in  one  instance  and  hurry  it  in  another  is  not 
understood.  Direct  irritation  of  the  cortex  can  stimulate  the  cardiac  and  respira- 
tory centers,  and  pcrijohcral  irritants  may  act  likewise.  It  is  possible  that  some  of 
the  irregular  phenomena  observed  during  labor  may  be  explained  in  this  way. 

Etiology. — Death  of  the  fetus  during  pregnancy  may  be  due  to  a  great  variety 
of  causes,  though  interference  with  the  function  of  respiration  is  found  in  the  last 
analysis  of  nearly  all  of  them.  All  the  acute  infectious  diseases,  especially  if  com- 
Ijined  with  high  fever;  chronic  infections,  syphilis,  tuberculosis;  poisoning  by 
eclamptic,  uremic,  or  other  toxemic  poisons,  by  chemicals,  morphin,  phosphorus, 
etc.;  asphyxia  and  anemia  of  the  mother;  injuries  to  the  fetus  by  stab  or  blow; 
congenital  deformities;  divseases  of  the  fetus  itself,  as  leukemia,  sarcomatosis,  Buhl's 
disease,   heart  and  abdominal  affections;    all  these  and  more  like  them  may  be 


ACCIDENTS    TO    THE    (III  LI)  799 

found.     Sudden  nervous  sliock  to  tlic  mot  licr  may  kill  the  child  in  u  manner  not  yet 
explained. 

DuriiKj  Idhor  the  causes  of  fetal  anacFOsis  may  he  divided  iiit(^  t\v<j  classes: 
(1)  Those  wliieli  diicctly  cut  off  the  supplx'  of  oxygen;  (2)  those  whieli  cause  com- 
pression of  the  brain. 

1.  Those  Cutting  Off  Oxygen  Supply. — (a)  ProlongcMl  and  hard  labor  pains,  re- 
currin<;-  so  freciuently  that  the  blood  in  the  placental  sinuses  cannot  be  renewed,  are 
the  most  common  factor.  This  is  observed  at  tlu;  end  of  the  second  stage,  with 
rigid  pelvic  floor,  in  contracted  pelvis,  with  tetanus  uteri,  and,  but  rarely  nowadays, 
with  the  use  of  ergot.  The  general  mortality  of  the  children  in  protracted  labor 
increases  in  proportion  to  the  length  of  labor;  (h)  excessive  retraction  of  the  uterus 
away  from  the  child,  with  diminution  of  the  placental  area,  and  perhaps  with  some 
partial  separation  of  the  placenta,  for  example,  neglected  shoulder  presentation, 
threatened  ruptura  uteri;  (c)  compression  of  the  placenta  when  it  is  low  in  the  uterus, 
or  of  the  insertion  of  the  cord,  either  by  the  head  or  trunk,  or  sometimes  by  the  col- 
peurynter;  or  compression  of  the  placenta  by  the  head  when  the  child  presents  by  its 
breech ;  (d)  compression  of  the  umbilical  cord,  either  with  prolapse  of  same  or  while 
it  still  lies  in  the  uterus;  coiling  of  cord  around  the  neck  of  the  child  may  cause 
anaerosis,  and  here,  too,  it  is  especially  exposed  to  injurious  pressure  from  the  tip 
of  the  forceps  blade;  knots,  rupture,  hematoma  of  the  cord;  (e)  partial  and  com- 
plete abruption  of  the  placenta,  either  normally  or  abnormally  implanted,  in  either 
head  or  breech  presentations;  (/)  anemia  of  the  child  from  rupture  of  the  placental 
vessels  (placenta  pravia)  or  tearing  of  a  velamentous  vessel;  (g)  narcosis  (morphin), 
asphyxia,  anemia  of  the  mother,  the  child  dying  first,  since  it  gives  back  oxj^gen  to 
its  mother. 

During  the  first  few  minutes  after  birth  the  child  may  be  asphyxiated  by  its 
air-passages  being  blocked.  A  tight  caul;  the  aspiration  of  vaginal  mucus,  blood, 
meconium,  or  the  mucus  which  often  lies  in  the  child's  own  glottis  and  is  drawn  down 
by  the  first  breath;  edema  of  the  glottis  and  throat  consecutive  to  face  presentation; 
congenital  atelectasis  (syphilis,  etc.);  heart  and  other  diseases;  gross  and  micro- 
scopic deformities — all  these  have  been  found  more  or  less  often. 

2.  Compression  of  the  brain  brings  about  asphyxia  in  several  ways,  depending 
partly  on  the  manner  of  compression,  whether  internal  or  external.  Internal  com- 
pression from  hemorrhage  or  fracture,  as  well  as  external  pressure  from  a  contracted 
pelvis,  may  slow  the  pulse  and  cause  anaerosis,  because  the  blood  is  hindered  from 
reaching  the  placenta.  Internal  local  compression  of  the  cardiac  and  respiratory 
centers  may  cause  asphyxia  by  directly  paralyzing  the  vagus  or  stimulating  respira- 
tory action.  The  slowing  of  the  heart  from  cerebral  compression  can  be  easily 
demonstrated  during  forceps  operations  if  the  accoucheur  will  but  listen  while  he 
closes  the  blades  of  the  instrument.  In  some  cases  the  effect  is  not  immediate,  but 
it  is  always  present  if  the  pressure  is  kept  up  a  few  seconds  or  if  it  is  made  quite 
strong.  Sudden  and  marked  slowing  of  the  beat  is  proof  that  the  cord  has  been 
caught  in  the  grasp  of  the  blades.  It  is  probalile  that  in  cases  of  cerebral  compres- 
sion without  hemorrhage  there  is  also  an  additional  external  cause  which  reduces  the 
amount  of  oxygen  in  the  fetal  blood  which  may  be  found  under  Class  1. 

Finally  may  be  mentioned  the  premature  respirations  made  by  the  child,  the 
result  of  external  stimuli,  version,  forceps,  pulling  on  the  leg  in  breech  extraction, 
and  the  presence  of  air  in  the  uterus.  Compression  of  the  vessels  in  the  neck  (face 
presentation,  coiling  of  the  cord)  produces  a  local  venous  congestion  of  the  brain. 

Pathology. — Postmortem  findings  vary,  of  course,  with  the  cause  and  the  rapid- 
ity of  the  asphyxia.  In  general  one  finds  the  effects  of  an  intense  venous  congestion 
combined  with  that  of  localized  spasm  of  the  arterioles.  The  auricles  of  the  heart, 
the  pulmonary  system,  the  liver,  and  the  spleen  are  engorged  with  blood.  The 
back  pressure  in  the  veins  of  the  lungs,  pleurae,  pericardium,  peritoneum,  brain, 
kidneys,  and  suprarenals  causes  extravasations  of  blood,  varying  in  size  from  a  pin- 


800  THE    PATHOLOGY    OF    LABOR 

head  to  one  inch,  and,  particularly  in  the  brain,  immense  hematomata  may  form. 
INIinute  hemorrhages  in  the  retina,  the  ear,  and  in  the  ganglia  at  the  base  of  the 
brain  may  cause  serious  disturbance  of  function  if  the  child  withstands  the  primary 
asphyxia.  Serosanguineous  transudations  may  be  found  in  the  pericardium,  pleurae, 
peritoneum,  and  in  the  brain.  If  respiratory  movements  had  been  made,  liquor 
anmii,  meconium,  blood,  etc.,  may  be  found  in  the  lungs,  parts  of  which  are  ate- 
lectatic and  parts  full  of  air.  Seitz  emphasizes  the  importance  and  frequency  of 
edema  of  the  prevesical  connective  tissue  around  the  hypogastric  arteries,  and  edema 
of  the  genitals,  particularly  of  the  scrotum.  Edema  of  the  vulva  and  scrotum  is 
not  rarely  observed  after  natural  labors,  and  Seitz  says  it  is  likewise  due  to  asphyxia. 
When  the  umbilical  cord  is  compressed,  the  back  pressure  is  felt  first  in  the  vein  and 
then  the  arteries  near  the  navel. 

S3niiptoms  and  Diagnosis. — Before  Delivery  of  the  Child. — 1.  The  most  im- 
portant, because  the  most  reliable,  external  evidence  of  danger  besetting  the  child 
in  utero  is  a  change  in  the  fetal  heart-sounds.  These  may  be  altered  as  to  fre- 
quency, regularity,  strength,  and  rhythm.  A  persistent  slowing  of  the  fetal  heart 
to  100  beats  a  minute  is  always  significant  of  danger,  and  if,  during  the  uterine  con- 
traction, the  rate  goes  down  to  80  or  less,  there  is  no  doubt  about  it,  and  delivery 
is  demanded  forthwith.  As  the  rate  sinks  from  the  usual  140-136  to  124-112,  then 
to  112-100,  the  two  rates  given  as  those  between  and  during  the  pains,  respectively, 
the  accoucheur  becomes  more  and  more  certain  that  there  is  some  factor  causing  a 
stimulation  of  the  vagus.  At  the  same  time  the  tone  becomes  stronger,  and  occa- 
sionally a  little  accentuation  of  the  second  sound  may  be  distinguished.  Prim- 
arily increased  rapidity  of  the  heart-tones  is  not  so  good  a  sign,  but  if  the  heart- 
tones  are  continuously  above  175  (Winckel  says  160),  without  fever  of  the  mother, 
danger  to  the  life  of  the  child  may  be  apprehended.  The  sudden  change  from 
slowed  heart-tones  to  excessive  rapidity  denotes  paralysis  of  the  vagus  center 
and  is  of  very  bad  omen.  As  a  rule,  at  this  time  the  respiratory  center  awakens 
and  elicits  inspirations.  Irregularity  of  the  fetal  heart  is  also  significant.  A  few 
strong  beats  are  followed  by  a  run  of  light,  short  taps,  and  sometimes  the  heart 
may  run  and  stumble  along  in  a  most  erratic  manner.  This  irregularity  is  very 
ominous  if  it  follows  a  period  of  slowed  action.  Sometimes  the  rate  of  the  heart 
will  run  from  140  to  170  without  definable  cause  and  without  relation  to  the 
uterine  contractions.  It  is  wise  to  distrust  such  cases.  The  strength  of  the  tone 
gives  additional  information,  a  slow,  strong  sound  indicating  vagus  stimulation,  a 
rapid,  weak  one,  paralysis  or  general  fetal  weakness.  If  the  first  sound  of  the  heart 
is  booming,  a  healthy  muscle  may  be  diagnosed;  if  it  is  weak  and  valvular, 
gallop-rhythmus  being  present,  danger  exists.  In  general,  the  above  findings  are 
positive  of  threatening  danger,  but  in  rare  instances  most  of  them  may  be  present 
and  the  child  is  born  alive  and  well,  while  still  more  rarely  the  heart  may  show 
no  evidences  of  distress  and  yet  the  infant  is  still-born  or  asphyctic.  Cerebral 
hemorrhage  may  sometimes  do  this.  Other  signs  of  intra-uterine  anaerosis  will 
aid  the  accoucheur  here,  but  he  will  not  be  much  amiss  if  he  interferes  in  the  labor 
on  the  indication  given  by  a  study  of  the  fetal  heart-tones. 

(2)  The  passage  of  liquor  amnii  stained  with  fresh  meconium  is  a  valuable  sign 
of  imponrling  intra-utcrine  asphyxia.  It  was  the  only  one  the  ancients  had.  The 
sign  is  of  no  valu(!  if  the  presentation  is  a  breech,  unless  the  latter  has  not  neared  the 
inlet.  The  passage  of  meconium  is  due  to  an  active  peristalsis  set  up  by  the  anaerotic 
blood,  and  finds  its  analogy  in  the  bowel  movements  of  drowned  or  otherwise 
asphyxiated  persons.  It  is  true  that  the  use  of  quinin  will  cause  the  discharge  of 
meconium,  and  that  in  a  certain  percentage  of  natural  deliveries  meconium  will 
come  away  in  the  liquor  amnii  and  the  child  will  show  no  evidences  of  distress  when 
bom.  My  experience  and  Rossa's  agree,  that  the  character  of  the  labor  in  these 
cases  was  such  that  anaerosis  would  be  very  likely  to  occur.     While  I  am  wilhng  to 


ACCIDENTS    T(J    THE    CHILD  801 

agree  tlial  the  sign  does  not  have  the  absolute  significance  that  some  writers  ascribe 
to  it  (Kiistner),  I  am  inclined  to  give  it  more  value  than  does  Seitz  in  his  monograph. 

Liciuor  amnii  stained  with  old  meconium  is  olive-green  in  color  and  th(;  mecon- 
ium is  thoroughly  mixed  with  it.  Fresh  meconium  is  dark  sea-green  and  is  lumpy. 
If  such  a  mixtur-e  is  expelled,  the  accoucheur  should  study  the  fetal  heart -tones  and 
the  nature  of  the  labor,  and  if  any  cause  for  anaerosis  or  any  irregularity  of  the 
heart-tones  is  discovered,  the  sign  becomes  of  positive  value.  In  obstructed  labors 
the  passage  of  meconium  may  long  precede  the  slowing  of  the  heart. 

If  the  asphyxia  is  fairly  well  estaV)lished,  the  child  makes  respiratory  movements 
and  these  may  be  seen,  felt,  or  heard  by  the  attendant.  (3j  During  breech  de- 
liveries one  may  sec  and  feel  the  diaphragm  come  down;  during  forceps  operations 
it  is  often  possible  to  feel  and  see  the  gasps  of  the  child  as  jerks  of  the  forceps  or  as  a 
jarring  of  the  lower  abdomen.  It  may  be  impossible  to  distinguish  these  jerky 
gasps  from  fetal  hiccup.  The  fetal  heart-tones,  the  nature  of  the  lal)or,  and  the 
meconium  must  aid  in  the  differentiation.  Unless  the  child  can  be  extracted  within 
a  few  minutes  after  it  gasps  it  is  lost,  and  even  if  delivered  alive,  it  will  very  likely 
die  within  a  few  days  from  atelectasis  pulmonum  or  cerebral  hemorrhage. 

Vagiius  Uterinus. — This  term  has  boen  applied  to  the  crying  of  the  child  in  utero — before 
it  is  born.  Many  authentic  cases  are  on  record.  It  is  said  that  Mahomet  and  St.  Bartholomew 
made  themselves  heard  while  in  the  uterus,  but  these  probably  are  fables.  If  air  is  introduced  into 
the  uterine  cavity  alongside  the  hand,  as  in  version,  or  with  instruments,  or  by  a  simple  examina- 
tion, or  if  gases  develop  there,  the  child  may  inspire,  and  on  expiration  may  produce  a  cry.  Some- 
times this  may  occur  without  other  evidences  of  dyspnea,  and  the  child  may  be  delivered  in  good 
condition,  but  usually  the  condition  is  due  to  anaerosis,  and  unless  the  infant  is  at  once  delivered, 
it  will  suffocate.  In  Kristeller's  case  the  child  cried  S  different  times,  when  the  forceps  were  closed 
on  its  h(>ad.  From  a  medicolegal  point  of  view  the  cases  of  vagitus  uterinus  are  very  important, 
since  the  lungs  may  be  partly  inflated  and  the  child  die  before  birth.  Finding  air  in  the  child's 
lungs  would  be  no  e\-idence  against  the  individual  accused  of  infanticide. 

Other  signs  of  threatening  intra-uterine  asphyxia  are:  (4)  Very  active  fetal 
movements,  felt  by  the  mother  or  by  the  attendant,  a  phenomenon  which  occurs 
especially  if  the  anaerosis  is  sudden,  and  may  indicate  a  death-struggle  or  attempts 
to  respire;  (5)  the  persistence  of  a  loud  umbiHcal  souffle;  (6)  the  loss  of  tonus  of 
the  anus  in  breech  cases;  (7)  the  weakening  and  disappearance  of  the  pulse  in  a  foot 
or  hand  which  may  ])e  brought  down,  or  from  the  cord,  which  maj'  have  prolapsed. 
In  many  cases  I  have  passed  the  hand  into  the  uterus  to  feel  the  heart.  (8)  Pulsa- 
tion of  the  fontanel  is  not  discoverable,  but  in  one  case  I  could  feel  the  child's 
heart  through  the  thin  abdominal  wall. 

After  Delivery. — Cazeaux  defined  two  degrees  of  asphyxia  in  the  new-l:)orn 
child — asphyxia  livida  and  asphyxia  pallida.  The  sj'mptoms,  of  course,  depend  on 
the  degree  of  the  anaerosis,  and  between  the  two  states  mentioned  there  are  many 
gradations. . 

In  asphyxia  livida  the  child  is  dark  blue,  sometimes  purplish  and  mottled,  the 
face  swollen  and  congested,  the  eyes  somewhat  prominent,  and  the  conjunctivae 
injected;  the  skin  around  the  nose  and  mouth  may  be  slightly  pale,  but  the  lips  are 
deep  l)lue.  Tonus  of  the  muscles  is  not  lost;  the  arms  are  held  up;  the  body  is 
fairly  rigid;  the  mouth  closes  on  the  finger;  the  throat  reacts.  If  the  face  is  blo'UTi 
upon  or  wet  with  cokl  water,  the  muscles  t\\'itch.  The  heart  and  cord  pulsate  slowly 
and  strongly;  there  is  an  occasional  gasp,  accompanied  by  a  gurgling  sound,  the 
mouth  and  bronchi  being  full  of  mucus.  These  are  the  mild  cases,  and  they  respond 
quickly  to  treatment. 

In  asph^-xia  pallida  an  entirely  different  aspect  is  presented.  The  child  is 
\)sde  and  waxy,  but  the  lips  alone  are  blue.  The  body  is  limp,  the  ex-tremities  hang- 
ing dowai  -without  any  tonus  at  all;  the  jaw  drops  relaxed — the  throat  does  not  react. 
There  are  no  respiratory  movements,  or  a  rare  gasp  which  is  very  superficial  and 
may  be  simply  a  movement  of  the  jaw.  The  only  evidence  of  life  is  a  weak  and 
slow,  or  perhaps  very  rapid,  heart-beat.  This  mav  not  be  palpable,  but  will  be 
51 


802 


THE    PATHOLOGY    OF   LABOR 


audible  with  the  stethoscope.  The  cord  is  limp  and  collapsed;  the  baby  looks  like  a 
corpse.  The  criteria  of  this  severe  form  of  asphyxia  are  the  absence  of  muscular 
tonus  and  the  loss  of  reflex  excitability.  This  condition  is  of  much  worse  prognosis, 
and  even  if  the  infant  is  revived,  it  may  die  later  of  secondary  asphyxia.  The  lung 
is  not  fully  inflated;  areas  of  atelectasis  exist  which  offer  great  resistance  to  the 
flow  of  blood.  As  a  result  of  the  permanent  deoxidation  and  hypercarbonization  of 
the  blood  which  supplies  the  heart  muscle  this  organ  cannot  develop  sufficient  power. 
The  anaerosis  also  affects  the  nerve-centers,  and  the  child  gradually  sinks  into  coma; 
the  respiration,  which  never  was  adequate  and  was  attended  by  a  grunt  or  whine, 
becomes  more  and  more  superficial  and  rapid,  finally  ceasing.  The  heart  continues 
to  act  for  a  while  through  its  own  automaticity,  but  soon  this  disappears.  At  the 
autopsy  hypostatic  edema  is  determined  in  addition  to  the  other  findings. 

Diagnosis. — Not  all  children  that  are  born  in  an  apparently  moribund  state 
are  asphyxiated.  Other  conditions  are  pressure  on  the  brain,  anemia,  apnea,  and 
morphin-poisoning.     Brain  compression  may  be  both  the  cause  and  the  result  of 


Fig.  728. — Tn.^ctxGS  of  the  Two  Types  of  Heart-toxes  in  Asphyxia  in  Utero.     Lower  Curve  the  Usual  Type. 


asphyxia.  We  have  seen  how  it  can  cause  asphyxia.  In  cases  of  asphyxia  there  are 
great  cerebral  congestion  and  sometimes  spasm  of  the  arterioles.  The  thin-walled 
vessels  of  the  brain  may  burst,  causing  hemorrhage,  which  may  be  subdural,  sub- 
arachnoid, or  intraventricular.     This  in  turn  causes  anaerosis. 

The  diagnosis  of  cerebral  compression  is  not  easy,  and  the  character  of  the  labor 
must  be  the  guide,  e.  g.,  a  hard  forceps  or  extraction,  in  which  it  is  known  that  in- 
juries to  the  skull  have  been  made.  Focal  symptoms  are  usually  absent  in  the  very 
early  stages.  In  some  cases  of  cerebral  hemorrhage  it  is  possible  to  keep  the  heart 
going  for  many  hours  with  artificial  respiration,  but  the  infant  cannot  be  made  to 
l)reathe.  The  treatment  must  be  like  that  of  asphyxia.  An  anemic  fetus  resembles 
one  with  pale  asphyxia,  and  the  diagnosis  may  be  made  only  if  it  is  known  that  the 
infant  suffered  a  loss  of  blood,  as  from  tearing  of  the  placenta  when  it  is  prsevia,  or 
rupture  of  a  velamentous  vessel. 

An  apneic  child  is  often  called  an  anacrotic  one,  and  frantic  efforts  are  made 
to  get  it  to  breathe  when  only  a  few  minutes'  patient  waiting  is  all  that  is  required. 


ACCIDENTS   TO   THE    CHILD  803 

Such  au  ofcurrcncc  is  frcciucut  ul  ct'sarcaii  scclicjii.  In  apnea  llic  ('iiild  Icjuks  nat- 
ural, the  Hps  are  shghtly  cyanotic,  the  features  are  not  distorted,  the  color  is  light 
grayish  blue,  the  heart-beat  is  strong  and  not  much  slowed  at  first.  Tlradually 
the  cyanosis  deepens,  the  i)ulse  slows,  the  child  becomes  anacrotic,  which  stimulates 
the  respiratory  center  or  prepares  the  center  for  the  reception  of  the  stimulus  from 
the  outside  air,  and  the  first  gasp  occurs,  or  a  sneeze  which  removes  the  mucus 
from  the  air-passages.  A  few  tiny  respirations  precede  the  gasp,  and  a  vigorous 
cry  follows  it. 

Moi'phin-poisoning  is  not  rare  under  the  use  of  scopolamin-morphin  anesthesia 
and  when  the  latter  drug  is  given  in  eclampsia.  The  child  is  very  quiet  and  limp, 
cyanotic,  the  pupils  contracted,  the  conjunctivae  insensible,  but  the  heart-beat  is 
usually  strong,  regular,  and  not  very  slow,  unless,  in  addition,  the  infant  is  asphyxi- 
ated. If  spanked,  the  child  opens  its  eyes  or  grimaces  with  pain,  })ut  does  not  cry 
nor  breathe.  Usually  there  is  no  mucus  in  the  air-passages.  Resuscitation  is  at 
first  successful:  the  child  may  be  brought  to  cry  or  even  to  open  its  eyes,  })ut  it 
soon  relaxes  into  somnolence  and  then  into  coma.  I  have  kept  such  an  infant  alive 
for  six  hours  until  finally  the  heart  gave  out. 

Prognosis. — It  is  naturally  impossible  to  form  a  true  estimate  of  the  frequency 
and  of  the  mortality  of  asphyxia  neonatorum,  since  there  is  no  standard  })y  which 
the  severity  of  such  cases  may  be  measured.  In  general  it  may  be  said  that  the 
milder  and  shorter  the  asphyxia  is,  the  better  the  chances  of  immediate  and  per- 
manent recovery  are,  and  the  severer  and  more  prolonged  it  is,  the  more  dark  the 
prognosis.  It  has  been  found  that  many  children  die  from  the  effects  of  asphj-xia  as 
late  as  the  fourteenth  day,  though  the  greatest  secondary  mortality  occurs  within 
forty-eight  hours.  Children  that  have  been  for  a  long  time  in  a  state  of  partial 
anaerosis  in  utero, — two  to  six  hours, — even  though  delivered  alive,  often  die  im- 
mediately or  shortly  after  birth.  This  fact  must  be  taken  into  consideration  when 
selecting  obstetric  operations.  Children  on  whom  efforts  of  resuscitation  had  to 
be  prolonged  to  bring  them  back  to  life  also  die  in  large  numbers  within  a  few  hours 
or  days,  simply  because  the  asphyxia  was  very  deep  and  fatally  damaged  vital 
structures.     Poppel,  in  1865,  confirmed  these  daily  clinical  experiences  by  statistics. 

Asphyxiated  children  are  more  liable  to  infection,  to  iDronchopneumonia,,  in- 
testinal inflammation,  melsena  neonatorum,  icterus,  hemorrhage  into  the  parathy- 
roids, with  spasmophilia  (Graham),  meningitis,  acute  and  chronic  atelectasis  pul- 
monum,  and  they  often  suffer  from  the  effects  of  the  anaerosis — cerebral  and  other 
hemorrhages,  as  well  as  from  the  injuries  which  sometimes  are  inflicted  on  them 
with  too  violent  methods  of  resuscitation.  These  are  bruises,  burns,  fracture  of  the 
ribs  and  sternum,  blowing  foreign  matter  into  the  lungs,  rupture  of  viscera,  etc. 

Boys  cUe  from  asphyxia  in  a  greater  number  than  girls,  because  they  are  larger 
and  harder,  causing  dystocia  more  often.  Children  of  primiparse  suffer  from  it 
oftener  than  those  of  multiparse.  Rigid  pelvic  floor  causes  a  high  infant  mortality. 
Asphyxia,  directly  due  to  operative  deliveries,  and  also  the  shock  to  the  fetus 
attending  the  same,  must  always  be  considered.  Of  great  interest  and  importance 
is  the  well-established  fact  that  children  that  were  asphyxiated  or  brain-injured 
during  birth  often  suffer  from  severe  psychic  and  nervous  diseases  later  in  life. 
Prolonged  labor  and  operative  deliveries  with  asphyxia,  combined  or  singly,  produce 
the  untoward  results — for  example,  spastic  cerebral  and  spinal  paralj-sis,  poren- 
cephalus  with  idiocy,  syringomyelia,  congenital  athetosis,  chorea,  epilepsy,  back- 
wardness, stuttering,  and,  the  author  would  like  to  add,  retinal  atrophy,  strabismus, 
and  mental  aberration.  We  know  that  in  adults  concussion  of  the  brain  is  often 
followed  by  weakness  of  memory,  lack  of  concentration,  easy  fatigue,  emotionalism, 
susceptibility  to  alcohol,  traumatic  neuroses,  etc.,  and  it  is  not  illogical  to  assume 
that  the  tender  brain  of  the  new^-born,  in  a  formative  state,  could  be  similarly 
affected  by  the  concussion  of  a  violent  delivery.     On  the  other  hand,  even  the 


804 


THE    PATHOLOGY    OF   LABOR 


severest  cerebral  compression  and  prolonged  asphyxia  may  leave  no  traces  discover- 
able in  after-life.  Beach,  in  810  idiots,  fomid  a  history  of  hard  forceps  in  4  per  cent., 
and  in  26.6  per  cent,  spontaneous  but  difficult  labor.  Porter  states  that  17  per  cent. 
of  the  epileptics  in  the  Indiana  School  for  Feeble-minded  had  a  history  of  difficult 
labors. 

Treatment  Before  Birth. — The  prevention  of  asphyxia  of  the  child  in  utero 
comprises  the  recognition  of  the  causes,  and  a  studied  avoidance  of  them,  which 
means,  in  short,  that  the  accoucheur  should  direct  the  course  of  labor  into  normal 
channels  and  interfere  only  when  really  necessary.  In  every  labor,  and  especially  if 
it  is  foreseen  that  the  child  may  be  anacrotic,  preparations  for  same  must  be  made. 
A  suitable  table  or  a  place  on  the  bed  is  arranged,  with  a  supply  of  warm  towels,  a 
hot-water  bag,  a  warm  bath  of  100°  to  110°  F.  (bath  thermometer !),  and  two  tracheal 
catheters  (Fig.  729).  These  are  No.  14  and  No.  15  (Fr.)  linen  catheters.  They 
may  not  be  boiled,  but  are  thoroughly  washed  inside  and  out  after  using,  then  im- 
mersed in  1 :  1000  bichlorid,  flushed  with  alcohol,  and  dried.     In  maternities  they 

may  be  sterilized  in  a  tall  jar  in  formal- 
dehyd  gas.  No  obstetric  satchel  is  com- 
plete without  tracheal  catheters.  The 
glass  bulb  shown  in  the  illustration  is  a 
saliva  trap,  and  at  the  same  time  pre- 
vents mucus,  meconium,  etc.,  from  being 
drawn  into  the  operator's  mouth. 

At  an  interval  of  an  hour  or  oftener 
in  the  first  stage,  and  at  least  thirty  to 
fifteen  minutes  in  the  second  stage,  or 
even  every  five  minutes  if  the  delivery  is 
laborious,  the  fetal  heart-tones  should  be 
auscultated.  For  this  purpose  the  author 
uses  a  boiled  stethoscope,  or  has  an  assist- 
ant attend  to  it.  At  the  first  sign  of  fetal 
distress  redoubled  watchfulness  is  prac- 
tised, the  fetal  heart  listened  to  almost 
continuously,  and  preparations  for  oper- 
ative delivery  are  made. 

As  soon  as  the  fact  of  fetal  danger  is 
established  two  courses  of  treatment  are 
indicated — either  the  cause  of  the  anaero- 
sis  must  be  removed  or  the  child  be  gotten 
out  where  it  can  get  air.  If  the  pains  are 
too  strong  and  frequent,  preventing  the  change  of  blood  in  the  uterus,  ether  may 
be  given  to  quiet  them,  and  thus  allow  freer  circulation  in  the  placental  site;  a  pro- 
lapsed cord  may  be  replaced  or  otherwise  relieved  from  compression,  but  this  is 
about  all  we  can  do  to  aid  the  child  before  birth.  Rapid  delivery  offers  the  best 
hope,  Ijut  it  may  not  always  be  possible,  and,  further,  often  the  operative  trauma 
itself  kills  the  infant.  Delicate  questions  are  here  involved,  and  the  principle  of 
primum  nil  nocere  should  not  be  violated.  Broadly  speaking,  in  cases  of  threatened 
asphyxia  in  utero  the  child  should  be  delivered  as  soon  as  possible,  having  due  re- 
gard— (1)  To  the  state  of  the  child  and  the  probability  of  its  Ijeing  gotten  out  alive 
and  of  living  aftcjrward;  (2)  to  the  amount  of  injury  which  the  interference  will 
inflict  on  the  mother;  and  (3)  to  the  actual  danger  to  her  life  which  it  will  incur. 
Treatment  After  Delivery. — When  a  child  is  born  apparently  dead  it  is  of 
instant  importance  to  determine  if  the  asphyxia  is  mild  or  severe,  because  in  the 
last  condition  no  time  may  be  wasted  on  inefficient  measures,  while  in  the  former 
the  simplest  remedies  are  usually  successful.     The  heart-beat,  the  presence  of  re- 


FiG.   729. — Tracheal  Catheter. 
This  is  a  woven  catheter,  open  at  the  end,  size  14 
or  1.5,  French  scale.     For  premature  infants,  size  10  or 
11  is  used.     These  catheters  may  not  be  boiled,  but  are 
sterilized  chemically  or  in  formaldehyd  vapor. 


ACCIDENTS   TO    THE    CHILI) 


805 


action  in  tho  skin  and  tiiroat,  and  tiic  deforce  of  body  tone  will  enable  a  quick 
diagnosis.  Three  grand  principles  govern  the  treatment:  (1)  Clear  the  air-passages 
from  obstructions;  (2)  maintain  body  heat;  (3)  supply  oxygen  to  the  blood. 

The  importance  of  keei)ing  the  baby  warm  is  not  generally  afjpreciated.  The 
infant  is  wet;  exjiosure  is  often  i)rolonge(l;  evaporation  is  ra[)id;  the  body  temper- 
ature sinks  rai)idly.  This  is  very  depressing,  and  the  shock  of  delivery  is  thus  aug- 
mented— indeetl,  it  has  occasionally  happened  that  the  infant,  wrapped  up  and 
put  away  as  dead,  has  recovered  through  the  influence  of  warmth  ahjne.  There- 
fore the  baby  should  be  received  in  warm  towels,  and  kept  ctjvered  as  much 
as  possible  during  the 
subsequent  manipulations. 
Some  of  these  may  be  car- 
ried out  while  the  child  is 
in  a  warm  bath. 

The  first  duty  is  to 
clear  the  air-passages.  It  is 
dangerous  to  perform  arti- 
ficial respiration  when  the 
trachea,  bronchi,  and  some- 
times the  alveoli  are  full  of 
amniotic  fluid,  meconium, 
blood,  or  vaginal  secretions. 
These  must  be  removed  be- 
fore any  attempt  is  made  to 
bring  air  into  the  lungs, 
otherwise  the  foreign  sub- 
stances would  be  forced  still 
further  down  and  give  rise 
to  atelectasis,  pneumonia, 
and  sepsis. 

During  the  delivery,  as 
soon  as  the  child's  nose  and 
mouth  appear,  they  are 
wiped  with  pledgets  of  lin- 
tine  or  soft  linen.  In  breech 
labors  one  of  the  fingers  in- 
troduced for  the  perform- 
ance of  the  Veit-Smellie 
manoeuver  should  block  the 
glottis  to  prevent  the  gasp- 
ing infant  from  aspirating 
mucus,  blood,  etc.     In  head 

labors,  after  delivery  of  the  head,  while  clearing  the  phar^aix,  two  fingers  gently 
strip  the  neck  toward  the  jaw  in  an  effort  thus  to  bring  inspired  matter  into  the 
throat.  It  is  important  to  clear  the  uppermost  air-passages  before  the  child  makes  the 
first  gasp.  In  the  mildest  cases  this  is  all  that  is  required,  because  the  irritation 
of  the  throat  excites  cough  and  respiration.  When  the  child  is  fully  delivered,  it 
is  held  up  by  the  ankles,  while  the  head  rests  on  the  knee  of  the  accoucheur,  and  in 
this  position  the  throat  is  cleared. 

In  the  more  severe  cases — real  asphyxia  livida — the  child  usually  has  gotten 
foreign  matter  deeply  into  the  lungs,  and  this  must  be  gotten  out — best,  in  my 
experience,  by  means  of  the  tracheal  catheter  (Fig.  730).  With  a  little  practice  the 
use  of  this  instrument  becomes  easy. 

When  the  air-passages  are  free,  it  is  time  for  external  stimulation.     As  a  rule, 


Fig.  730. — Introducing  the  Tracheal 
Catheter. 
The  index-finger  of  the  left  hand  pulls 
the  epiglottis  forward  and  comes  to  touch 
the  arytenoid  cartilages.  At  the  same  time' 
the  catheter  is  passed  along  this  finger  until 
it  lies  over  the  rima,  just  behind  the  epiglot- 
tis. Now  the  inside  index-finger  pulls  the 
very  tip  of  the  catheter  sharply  forward, 
while  the  right  hand,  giving  the  tube  a  slight 
twisting  motion,  pushes  it  down  into  the 
trachea.  The  lips  are  applied  to  the  glass 
mouth-piece,  and  a  light  suck  draws  the 
contents  of  the  trachea  into  the  catheter, 
which  is  then  removed  and  its  contents  for- 
cibly blown  out  on  a  towel  for  inspection. 
Sometimes  the  sucking  on  the  catheter  is 
continued  as  it  is  withdrawn  to  clear  the 
whole  tract.  It  may  be  necessary  to  re- 
peat this  procedure  several  times.  It  is  wise 
also  to  compress  the  chest  between  the 
thumb  and  four  fingers  to  force  the  mater- 
ial out  of  the  smaller  bronchi,  to  gain  the 
advantages  claimed  for  Schultze's  swing- 
ings.     By  pushing  the  catheter  deeply  into 

the  chest  and  turning  the  head  and  neck  of  the  child  sharply  to  either  side, 
the  right  and  then  the  left  bronchus  may  be  emptied. 


806 


THE    PATHOLOGY    OF    LABOR 


the  catheterization  of  the  trachea  has  stimulated  the  respiratory  center,  and  respir- 
atory movements,  in  the  form  of  gasps,  usually  follow  this  operation.  If  the  re- 
action is  too  slow,  the  buttocks  may  be  spanked,  the  back  rubbed  vigorously,  or 
gentle  traction  made  on  the  tongue  (Laborde,  1892).  Grasping  the  tongue  be- 
tween the  thumb  and  index-finger,  it  is  gently  drawn  out  and  let  go  back  30  to  40 
times  a  minute. 

Among  the  liost  of  external  irritants  employed  for  this  purpose  may  be  mentioned  the  hot 
bath,  with  or  without  mustard,  wine,  etc.,  the  hot  and  cold  plunge,  cold  bath,  tickling  the  nares, 


Fig.  7.31. — Prochownick's  Method  of  Resuscitation. 
The  child  is  .suspendod  by  the  feet,  the  forehead  resting  lightly  on  the  table  so  as  to  deflex  the  chin  and  straighten 
out  the  trachea.  The  body  is  gently  shaken,  and  the  chest  compressed  between  the  thumb  and  four  fingers  so  as  to 
squeeze  out  foreign  matter  from  the  bronchi.  Now  an  assistant  wipes  out  the  throat,  and  the  pressure  on  the  chest  ia 
suddenly  relaxed.  Air  may  be  heard  rushing  in.  The  compression  and  sudden  release  may  be  repeated  10  to  20  times 
a  minute. 


snuff,  dilatation  of  the  sphincter  ani,  hypodermic  injections,  electricity,  etc.  The  author  does  not 
use  the  hot  bath,  since  it  is  too  depressing.  Even  th(>  warm  bath  may  not  be  prolongetl„ over  five 
minutes.  A  better  method  is  to  wrap  tlw;  infant  in  warm  towels  and  lay  it  on  a  warm-water  bag. 
The  alternating  cold  and  hot  plunges  are  distinctly  shocking  to  the  tender  infant,  and  in  my 
opinion  dangerous,  as  well  as  unnecessary. 

Where  the  respiratory  center  is  still  responsive,  no  more  need  usually  be  done 
— indeed,  more  may  be  harmful.  The  accoucheur  simply  keeps  the  infant  covered. 
If  the  child  is  improving,  the  gasps  recur  with  increasing  frequency,  or  tiny  respir- 
atory motions  of  the  chest  become  visible  and  the  heart  impulse  grows  stronger 
and  regular.  Soon  the  gasps  become  double,  and  end  with  a  long  inspiration, 
expiration  Ijcing  attended  by  a  light  moan.     Now,  between  the  gasps,  the  tiny 


ACCIDENTS   TO   THE    CHILD 


807 


respiratory  movements  of  the  chest  become  tiiorc  pronoiinccd,  wliile  at  the  same 
time  the  cyanosis  l)ef2;ins  to  Hf^hten  and  p;ive  way  t(j  rcthicss,  soon  after  wliich  the 
chikl  ^ivcs  a  histy  er}'.  It  is  best  to  leave  the  infant  alone  as  lon^  as  it  improves, 
and  in  all  eases  pi-eeipitate  and  frantic  haste  with  trials  of  ditlerent  methods  in 
rapid  succession  is  to  be  contlenmed. 

If  improvement  is  not  immediate,  and  if,  from  llie  slait,  (he  case  impresses 
one  as  one  of  as])hyxia  pallida,  this  simple  treatment  does  not  sufHce.  Time  maj' 
not  be  wasted  trying  the  various  skin  reflexes,  but  two  serious  purposes  must  be 
accomplished — first,  oxygen  is  to  be  gotten  into  the  fetus'  blood  by  artificial  res- 
piration; second,  the  circulation,  which  is  almost  in  abeyance,  must  be  started 
again.  Of  the  numerous  methods  of  artificial  respiration,  only  three  are  realU' 
valuable — riiythmie   compression  of  the  child  in  inverted  suspension  (Fig.  731); 


Fig.  732. — Mocth-to-luxg  Ixsufflatiox  with  the  Trachf..\l  Catheter  CSmpllie). 
Aftor  insnrting  the  catheter  a.s  was  done  for  the  removal  of  mucus,  the  operator  fills  his  lungs  and  mouth  with  fresh 
air,  then  ajiplies  his  lips  to  the  mouth-piece,  inth  his  f/lollf.s  closed,  and  simply,  under  the  gentle  action  of  the  cheeks 
(like  a  glass-blower),  forces  pure  warm  air  into  the  child's  lungs.  Only  as  much  as  can  be  held  in  the  mouth  may  be 
forced  in.  Compression  of  the  chest  causes  the  air  to  escape,  and  this  procedure  may  be  repeated  fifteen  times  a  minute. 
Chaussier,  in  June,  ISOd,  recommended  oxygen  for  this  purpose.  I  have  used  it  instead  of  air,  and  in  a  few  desperate 
cases  it  has  seemed  to  me  to  be  better,  but  there  is  danger  of  giving  too  much  and  causing  acapnia. 


mouth-to-lung  insufflation  with  the  tracheal  catheter  (Fig.  732),  and  Schultze's 
swingings  (Fig.  733). 

Which  of  these  three  methods  will  be  chosen  depends  on  the  severity  of  the 
asphj'xia  and  the  preference  of  the  operator.  Authorities  are  divided  as  to  the 
relative  value  of  tracheal  insufflation  and  Schultze's  swingings.  The  former  is  said 
to  be  dangerous  because  of  the  possible  production  of  emph3'sema  from  rupture  of 
the  alveoli,  and  it  requires  considerable  skill  in  intubation,  while  it  does  not  produce 
the  stimulating  effect  on  the  heart  and  blood-vessels  which  the  swingings  do. 
Bichat  proved  that  it  is  possible  to  blow  air  into  the  vessels  of  the  heart  and 
general  circulation  if  too  much  force  is  used.  Performed  as  here  described,  I  be- 
lieve there  are  none  of  these  dangers,  and  insufflation  has  most  of  the  advantages 
of  the  swingings. 

Schultze's  swingings  are  really  dangerous,  though  most  of  the  accidents  re- 
ported are  due  to  errors  of  technic  or  to  the  injuries  suffered  in  operative  delivery. 


808 


THE    PATHOLOGY    OF   LABOR 


Rupture  of  the  liver  or  of  the  spleen,  hemorrhages  into  the  peritoneum,  the  pleura, 
the  suprarenals,  and  spinal  cord;  shock;  deep  aspiration  of  matters  from  the  upper 

air-passages,  even  fractures 
of  the  clavicles  and  ribs,  have 
been  charged  against  this 
method,  perhaps  unjustly, 
Schultze's  method  is  contra- 
indicated  in  premature  chil- 
dren, and  with  fracture  of  any 
of  the  bones,  and  where  the 
accoucheur  suspects  a  cerebral 
hemorrhage. 

To  start  the  circulation 
again  all  the  above  methods 
of  artificial  respiration  help. 
Schultze's  swingings  are  a 
strong  cardiac  stimulant,  the 
warm  bath,  with  rubbings,  an- 
other. In  a  few  cases  I  have 
successfully  stimulated  the 
heart  by  rapid  vibratory  per- 
cussion, and  to  hasten  the  cir- 
culation through  it  have  com- 
pressed the  heart  against  the 
chest-wall  from  below,  through 
the  relaxed  abdominal  wall. 
If  the  child  is  anemic  from 
bloocl-loss,  salt  solution  may 
be  supplied. 

My  routine  practice  in 
cases  of  asphyxia  pallida  is  as 
follows:  As  soon  as  the  child 
is  delivered  it  is  laid  on  a  sterile 
platter,  which  lies  on  the  lap; 
the  air-passages  are  cleared 
by  the  catheter;  the  cord  is 
tied  and  cut;  Prochownick's 
method  (Fig.  731)  is  used  for 
thirty  seconds,  during  which 
time  the  cardiac  pulsations 
and  any  respiratory  action  are 
determined ;  the  tracheal  cath- 
eter is  inserted,  and  the  lungs 
are  filled  with  air  systemati- 
cally for  two  or  three  minutes, 
the  child  being  well  wrapped 
up;  if  there  is  no  improvement, 
which  is  the  rare  exception, 
one,  two,  or  three  Schultze's 
swingings  are  given,  and  the 
child  is  laid  in  a  warm  bath  to 
observe  the  effects;  if  none, 
the  tracheal  catheter  is  again 
inserted,  the  operator  arranges 


Fig.  7.33. — Schultze's  Swingings.     Above,  Expiration;  Below,  In- 
spir.vtion. 

Schultze's  swingings,  recommended  in  1866,  are  the  most  powerful 
and  dangerous  of  all  methods,  and  are  re.served  by  the  author  for  most 
desperate  cases.  The  child  is  grasped  with  the  thumbs  over  the  front 
of  the  chest,  the  index-fingers  in  each  axilla  to  prevent  it  from  flying 
out  of  the  operator's  grasp,  the  three  fingers  of  each  hand  distributed 
over  the  back.  The  head  is  held  steady  by  pre.ssure  with  the  wrists. 
The  accoucheur  stands,  planting  the  feet  firmly  wide  apart.  The 
child  is  slowly  swung  up  over  the  head,  so  that  its  feet  fall  downward, 
and  thus  held  for  a  few  seconds.  This  is  expiration,  and  often  foreign 
bodies  are  emptied  from  the  air-passages.  An  assistant  removes  these 
with  the  little  finger  wrapped  in  gauze.  Now  the  child  is  swung  out, 
forward,  and  then  down  between  the  legs,  letting  the  motion  begin  and 
end  very  evenly  and  gently.  An  audible  inspiration  must  accompany 
this  movement.  The  child  is  then  put  in  a  warm  bath  or  wrapped  in  a 
warm  towel,  the  efTocts  being  watched.  The  heart  is  felt  to  beat  power- 
fully, and  a  gasp  usually  rewards  the  effort.  If  no  improvement  is  ob- 
served, the  process  may  be  repeated.  It  is  rare  that  more  than  10  swing- 
ings are  required,  but  Knapp  gave  one  infant  over  600,  and  while  it 
lived,  he  is  inclined  to  ascribe  the  recovery  to  other  causes.  It  is  import- 
ant not  to  compress  the  chest  laterally,  to  hold  the  head  securely  by 
the  wrists,  not  to  throw  the  child  forward  with  a  jerk,  and  to  have  the 
flexion  of  the  spinal  column  take  place  only  in  the  dorsolumbar  and  not 
in  the  thoracic  region.  Only  if  thus  performed  are  the  swingings  suc- 
cessful and  safe. 


ACCIDENTS   TO   THE    CHILD  809 

things  conveniently  and  keeps  up  the  artificial  breathing  until  the  child  recovers  or 
until  its  condition  shows  that  furtiier  effort  is  useless.  Several  instruiiients  have; 
been  dcxiscd  for  suppl\'iiig  oxygen  through  the  catheter  autoniul  ically,  and  f(jr 
artificial  respiration  (iMigehiianj. 

How  long  to  keep  up  efforts  at  revival  (le])eiKls  un  the  case.  Usually  an  h(jur 
suffices  to  show  if  there  is  any  hope  at  all  of  saving  the  infant,  and  the  remedial 
measures  should  l)e  kept  up  for  two  or  even  three  hours  if  the  heart  beats.  Cases 
are  on  record  of  recovery  after  two,  three,  and  even  four  hours'  effort.  A\'ith 
a  cerebral  hemorrhage  or  a  fracture  at  the  base,  the  heart  may  beat  as  long  as  the 
blood  is  kept  supplied  with  oxygen.  In  one  such  case  I  kept  up  mouth-to-lung  in- 
sufflation for  nine  hours  steadily,  the  heart  beating  strongly  and  the  child's  color 
being  good  until  I  stopped,  when  the  circulation  gradually  ceased,  there  not  having 
been  a  single  gasp  to  reward  the  jirolonged  effort. 

After-treatment. — Asphyxiated  and  premature  children  and  children  delivered 
by  seven*  operative  procedures  should  always  be  watched  for  the  first  hours  and 
days  after  labor.  Not  seldom  they  develop,  in  a  few  minutes  to  a  few  hours,  a 
secondary  asphyxia.  This  is  due,  usually,  to  atelectasis  pulnionum,  but  the  author 
has  reason  to  believe  that  there  is  some  pulmonary  circulatory  trouble  in  addition. 
In  other  cases  a  small  hemorrhage  occurs  in  the  medulla.  The  child  may  be 
found  dead  in  its  crib,  or  it  may  turn  pale,  cyanotic,  with  a  reddish  line  at  the  skin 
margin  on  the  lips;  it  whines  or  grunts  at  each  expiration;  soon  it  becomes  uncon- 
scious, will  not  cry  on  being  hurt,  and  dies  under  a  slo\v  asphyxia.  These  chil- 
dren are  also  more  subject  to  icterus,  to  sepsis,  especially  the  bronchial  and  in- 
testinal forms,  and  if  they  grow  up,  are  not  likely  to  be  so  strong  as  other 
children — chronic  atelectasis.  Unless  they  can  have  mother's  milk,  they  often 
die  sim]:»ly  from  exhaustion.  The  treatment  of  secondary  asphyxia  with  atelec- 
tasis is  not  at  all  satisfying.  I  have  tried  all  kno'WTi  methods  of  distending  the  lungs 
and  have  failed.  The  lung  is  solid  with  exudate.  Often  cerebral  hemorrhage  is  the 
cause  of  the  secondary  asphyxia,  the  pathologic  basis  of  which  is  pulmonary  edema. 
The  incubator  connected  with  outside  air  helps  a  great  deal  in  the  treatment. 
Attacks  of  syncope  are  treated  with  the  warm  bath,  oxygen  insufflation,  and  artifi- 
cial respiration. 

INJURIES  TO  THE  CHILD  IN  BIRTH 

Manifestly,  it  is  impossible  to  consider  all  the  injuries  which  the  infant  may 
suffer  during  birth.  Only  a  few  of  the  most  common  and  most  important  will  be 
described,  and  as  many  of  the  others  as  possible  named.  A  glance  at  the  list  will 
show  the  reader  what  a  gantlet  of  perils  the  infant  runs  on  its  way  into  the  world. 
Since  a  great  manj'  of  them  are  preventable,  the  list  will  also  show  what  a  hea^•y 
responsil)iIity  rests  on  the  shoulders  of  the  modern  accoucheur. 

The  Head. — Caput  succedaneum,  the  soft,  boggj'  tumor  which  forms  on  the 
presenting  part  in  prolonged  labor,  was  discussed  on  p.  144.  It  must  be  dis- 
tinguished from  cephalhematoma,  which  is  a  hemorrhage  under  the  periosteum  of 
the  skull  (Fig.  734).  Cephalhematomata  are  always  due  to  injmy,  which  may  be 
made  by  the  accoucheur  in  forceps  or  breech  extraction,  or  by  the  natural  forces, 
especially  in  cases  of  spacial  disproportion.  I  have  seen  tw'o  cases  after  spon- 
taneous breech  deliveries.  Fissure  of  the  bones,  that  is,  linear  fractures,  often 
accompanj'  the  blood  extravasation.  They  may  be  single  or  multiple,  are  ahvaj's 
limited  by  the  sutures  (unless  the  latter  are  ossified),  and  are  absorbed  in  from  two 
weeks  to  three  months,  depending  on  their  size.  At  the  edge,  where  the  periosteum 
is  lifted  up,  a  ridge  of  bone  develops,  and  this  requires  still  longer  time  to  dis- 
appear. The  diagnosis  is  easy;  there  is  a  soft,  non-pulsating,  fluctuating,  elastic 
tumor  over  one  of  the  flat  cranial  bones.  In  the  differential  diagnosis  caput 
succedaneum,  hernia  cerebri,  and  neoplasm  are  to  be  considered. 


810 


THE    PATHOLOGY    OF   LABOR 


Caput  Succedaneum. 

1.  Is  present  at  birth. 

2.  Soft,  boggy,  and  pits  on  pressure. 

3.  Not  well  circumscribed. 

4.  Dark  red,  mottled,  sometimes  purple  and 

ecchymotic. 

5.  Lies  over  sutures. 

6.  Movable  on  skull  and  seeks  dependent  por- 

tions. 

7.  Is  largest  at  birth  and  grows  smaller,  dis- 

appearing in  a  few  hours. 


Cephalhematoma. 

1.  May  not  appear  for  a  few  hours  or  days  after 

birth. 

2.  Soft,  elastic,  no  pitting. 

3.  Sharply  circumscribed,  and  with  a  distinct, 

sometimes  hard,  edge. 

4.  Unless  under  a  caput,  normal  skin. 

5.  Limited  by  sutures  to  individual  bones. 

6.  Fixed  to  site  originally  taken. 

7.  Appears  after  a  few  hours,  grows  larger  for  a 

time,  and  disappears  only  after  weeks  or 
months. 


Fig.  7.34. — Double  Cephalhem.\toma. 
This  followed  a  spontaneous  and  relativelj'  easy  deliverj-. 


Fig.  7.J.5. — Cephai.hk.m.vtoma  (from  lln-  (•■ilji'ct  ion  of  ])r.  \V.  W.  .JaKgard). 


In  hernia  cerebri  the  location  of  tlie  tumor,  the  more  or  less  marked  peduncula- 
tion,  the  translucency,  the  impulse  when  the  child  cries,  the  meningeal  symptoms, 
will  make  the  diagnosis  easy. 


ACCIDENTS   TO   THI<:    CHILI)  811 

Direct  injuries  to  tiie  scalp;  cuttiiiji;  \>y  forceps;  pressure  necrosis  from  con- 
tracted pelves  and  exostoses;  punctures  and  tears  witii  instruments  under  tlie  mis- 
taken idea  that  the  scalp  was  the  memhranes;  teariiif;-  olT  ol"  an  ear;  crushing  of  the 
nose  (later  deflected  septum  and  ethmoid  1  roubles);  subcutaneous  hematomata  in 
the  cheeks  and  neck  from  forceps;  fracture  and  dislocati(;n  of  the  jaw  (breech  extrac- 
tions) ;  tearing  off  of  an  eyelid;  complete  enucleation  of  the  eyeball ;  conjunctival  hem- 
orrhages— all  these  I  have  seen  either  in  my  own  or  in  consultation  practice.  Wolfl 
and  Paul  have  found  retinal  hemorrhages  and  detachment  in  a  large  percentage  of 
normal  labors,  and  almost  always  after  operative  delivery  with  more  or  less  as- 
phyxia. Fracture  of  the  orl)ital  plates;  hemorrhages  into  the  chambers  of  the  eye 
and  around  the  eye  (exophthalmos),  in  the  optic  nerve;  dislocation  of  the  lens; 
paralysis  of  the  eye  muscles  (from  intracranial  as  well  as  extracranial  trauma); 
congestion  of  the  optic  nerve  vessels  and  secondary  atrophy  of  the  bulb — have  all 
been  reported,  and  should  lead  to  care  in  operations  (Wolff,  Lequeux).  Similar 
hemorrhages  occur  in  the  ears  and  may  cause  deafness.  It  would  be  interesting 
to  learn  how  many  deaf-mutes  had  difficult  births. 

Other  Injuries. — Fractures  of  the  skull  have  already  l:»een  considered.  The 
sjioon-shaped  and  grooved  depressions  of  the  bone  which  need  not  always  be  com- 
plicated with  fracture  or  fissure  are  the  commonest,  but  fracture  at  the  base, 
disruption  of  the  occipital  plate  from  the  condyles  (with  breech  extraction);  tear- 
ing of  the  tentorium  cercbelli,  which  is  not  infrequent  (Beneke),  laceration  of  the 
capsular  ligament  between  axis  and  atlas,  and  rupture  of  the  sutures  have  been 
observed. 

Hemorrhage  into  or  on  the  hrain  may  accompany  a  fracture,  a  fissure,  or  come 
from  rupture  of  a  cerel)ral  or  meningeal  vessel;  it  may  be  the  result  of  asphyxia — 
indeed,  from  no  apparent  cause,  as  in  one  of  my  cases  after  a  spontaneous  labor 
attended  with  no  compression  of  the  head  and  no  anaerosis.  S3''philitic  children  are 
predisposed  to  brain  hemorrhages  (Osier).  Bleeding  may  take  place  in  the  spinal 
canal   also,  and  be  limited  here. 

The  symptoms  come  on  within  three  or  four  days, — usually  the  second  day, — 
and  if  the  bleeding  is  a  slow  one,  may  last  a  week  or  more.  They  are  restlessness, 
crying,  refusal  of  food,  twitchings  of  groups  of  muscles,  of  one  whole  side,  or 
general  tremors,  especially  of  the  lower  jaw,  signs  of  local  irritation,  for  example, 
chewing  or  sucl-dng  movements,  irregular  pupils,  nystagmus,  Babinski  sign,  sharp, 
high-pitched,  cramp-like  ciy,  coma,  cyanosis  of  the  lips,  often  fever,  even  103°  F., 
pallor  of  the  skin  with  dermographism,  rapid  and  irregular  respiration,  sometimes 
Cheyne-Stokes',  rapid  pulse,  160  to  180,  prominent  tense  fontanels,  convulsions, 
rigidity  of  the  body,  then  paral^'sis  with  cj'anosis,  cessation  of  respiration,  and 
finally  of  the  heart. 

The  jirognosis  of  cere])ral  hemorrhage  is  not  absolutely  bad.  A  few  of  the 
children  j^resenting  even  positive  signs  may  recover,  but  usually  the  later  history 
is  unfavorable — epilepsy,  idiocy,  spastic  paralyses,  etc. 

]\Iild  symptoms  of  "meningisme"  are  not  seldom  observed  after  operative 
deliveries.  They  are  probably  due  to  acute  cerebral  congestion,  possibly  with  tiny 
hemorrhages,  and  subside  in  a  few  days.  The  treatment  of  cerebral  hemorrhage 
in  infants  is  symptomatic.  It  consists  of  the  administration  of  sodium  bromid 
and  chloral,  of  each  2  grains  per  rectum  every  six  hours;  mother's  milk,  and  quiet; 
ice-cap.  Luml^ar  puncture  may  ho  used  for  diagnosis;  as  a  therapeutic  measure 
it  offers  little  hope.  If  the  symptoms  point  to  cortical  pressure,  that  is.  if  they  are 
localized,  trephining  should  be  considered.  ]\Iore  is  to  be  hoped  from  a  decom- 
pression operation  than  we  have  heretofore  expected  (Commandeur,  Cushing). 

Facial  paralysis  frequently  results  from  injurj'  to  the  nerve  as  it  leaves  the 
stylomastoitl  foramen.  Forceps  are  usually  to  blame,  Init  compression  from  a  con- 
tracted pelvis  or  abnormal  attitude  of  the  child,  for  example,  sharp  flexion  of  the 


812 


THE    PATHOLOGY    OF    LABOR 


neck  on  the  shoulder,  maj^  cause  it  (Mace).  Central  lesions  of  the  nerve  are  due 
to  cerebral  trauma  and  hemorrhage.  Here  the  paralysis  comes  on  after  the  first 
day,  and  in  the  peripheral  forms  it  appears  right  after  delivery.  Usually  in  a  few 
hours  to  a  few  days  the  facial  deformity  is  gone,  but  it  may  last  three  months  or 
longer.  In  central  types,  and  if  there  is  a  fracture  of  the  temporal  bone,  it  may  be 
permanent.  The  paralysis  may  be  only  part  of  a  congenital  facial  hemiatrophy. 
The  differential  diagnosis  between  the  two  types  is  made  on  the  usual  lines;  periph- 
eral paralysiS;  when  there  is  extensive  involvement  of  the  distribution  of  the 
nerve,  lagophthalmus,  absent  reflexes,  etc.,  and  central,  when  the  eye  is  not  in- 
volved, the  reflexes  present,  and  there  are  other  cerebral  symptoms,  etc.  No  treat- 
ment is  required.  In  the  chronic  cases  muscular  atrophy  should  be  prevented  by 
massage  and  electricity. 

The  Trunk. — Fractures  of  the  spine,  disruption  of  the  vertebrae,  separation 
of  the  condyles  from  the  occipital  plate,  dislocation  of  the  atlas  on  the  axis,  occur 
in  violent  breech  deliveries  and  cause  instant  or  rapid  death.  In  nearly  all  cases 
they  are  errors  of  art.  Palpation  of  the  spine  from  the  outside  or  through  the 
phar;yTix  will  enable  the  diagnosis  to  be  made.  Complete  avulsion  of  the  trunk 
from  the  head  is  rare;  the  head  may  be  torn  off  the  body,  or  the  body  from  the 
head,  leaving  the  latter  in  the  uterus,  two  cases  of  which  have  come  to  my  knowl- 
edge. Unless  the  tissues  are  pathologically  soft,  macerated,  or  actually  brittle, 
such  an  occurrence  is  the  result  of  delirium  operatorium,  an  acute  lapse  of 
operative  reason  which  may  affect  the  accoucheur  after  much  loss  of  sleep,  the 
nervous  wear  of  a  prolonged  labor,  the  exactions  of  the  family,  combined  with  the 
sudden  appearance  of  extraordinary  difficulties.  The  head  in  these  cases  is  usually 
easily  removed,  but  it  has  been  left,  to  come  away  finally  by  prolonged  suppur- 
ation, with  fistulas,  lasting  months  or  years,  or  the  woman  may  die  of  sepsis. 

Rupture  of  the  sternocleidomastoid  muscle  is  not  so  rare  an  accident  as  statistics 
would  show  it  to  be.  It  is  often  overlooked  or  intentionally  secreted  for  fear  of  the 
legal  responsibility,  which  older  authors  erroneously  attached  to  it.  Rupture  of 
a  healthy  sternomastoid  can  'be  brought  about  only  by  very  violent  traction,  com- 
bined with  extreme  torsion  of  the  head.  I  have  often  demonstrated  the  possibility 
of  turning  the  head  of  a  new-born  infant  through  an  arc  of  200  degrees  or  more 
without  even  making  it  cry.  The  blade  of  the  forceps  may  directly  crush  the  muscle, 
and  this  injury,  in  the  absence  of  antecedent  disease,  in  my  opinion  is  more  likely 
to  cause  permanent  caput  obstipum,  than  that  of  overstretching  in  breech  de- 
liveries, though  most  of  the  reported  injuries  (not  developed  wry-neck)  occurred 
with  breech  presentation.  Injury  to  other  cervical  muscles  may  increase  the  scar 
formation  and  consequent  distortion. 

Two  conditions  are  found — a  hematoma  in  the  muscle,  usually  in  the  upper 
third,  and  a  fusiform  enlargement,  attended  with  great  tenderness  and  often  febrile 
reaction.  Without  doubt — and  in  this  the  author  is  sustained  by  Pincus  and  Peter- 
sen— the  muscle  was  already  shortened  and  pathologically  altered  while  the  child 
was  still  in  utero,  and  the  labor  was  only  the  acting  cause.  Caput  obstipum  may 
follow  normal  and  easy  labors,  with  and  without  injury  to  the  muscle  determin- 
aljle  at  birth,  all  of  which  is  important  from  a  medicolegal  point  of  view.  Indeed, 
the  frequent  concomitant  facial  hemiatrophy  points  to  a  central  origin  of  the 
disease.  Shortening  or  rigidity  of  the  muscles  will  be  found  not  infrequently  in 
new-born  children  which  have  lain  in  the  uterus  in  a  cramped  attitude  for  longer 
periods,  and  especially  if  the  liquor  amnii  is  scanty.  Indeed,  even  the  head  of  the 
child  may  be  flattened  or  twisted.  For  example,  in  breech  cases,  in  primiparae,  the 
posterior  sternomastoid  is  shortened  and  the  anterior  parietal  bone  flattened; 
in  multiparse,  owing  to  the  pendulous  Ijclly,  the  posterior  parietal  is  flattened  and 
the  anterior  sternomastoid  shortened.     Sometimes  the  arms  or  the  legs  of  the  child 


ACCIDENTS   TO   THE   CHILD  813 

urc  fixed  hy  tlio  shortened  niu.scles  in  bizarre  attitudes,  and  it  reciuin-s  .some  force 
to  straishton  them.     The  l)oncs  may  be  bent  and  broken  by  the  forces  of  labor. 

If  the  healthy  muscle  is  crushed  or  torn,  whether  or  not  a  hematoma  form.s, 
spontaneous  recovery  is  th(^  rule,  and  slioriening  is  absent,  a  fact  which  experience 
in  g(>neral  surgery  will  confirm.  If  the  injured  muscle  becomes  infected,  by  way 
of  the  blood,  from  the  bowel,  the  navel,  or  the  lungs  (Mikulicz),  a  myositis  may 
occur  and  shortening  will  follow.  Hematomata  are  usually  observed  shortly  after 
l)irth  as  a  hard  knot  in  the  nmscle,  which  is  onl}^  slightly  tender.  Myositis  is  found 
later — fourth  to  twenty-first  day — as  a  hard,  fusiform  swelling  of  the  whole  muscle, 
exceedingly  tender,  together  with  febrile  symptoms.  Myositis  causes  the  child  to 
cry  much,  especially  when  handled;  indeed,  these  symptoms  may  attract  atten- 
tion to  the  trouble.  The  early  diagnosis  is  easy, — one  finds  the  head  turned  to  the 
affected  side,  the  tenderness,  and  the  tumor.  In  paralysis  of  the  nervus  acces- 
sorius  the  head  is  turned  to  the  well  side.  This  latter  is  similar  in  cause  to  facial 
paralysis,  and  usually  heals  quickly.  In  later  life  dislocation  of  the  vertebrse  and 
facial  hemiatrophy  come  up  for  consideration. 

Treatment  of  injury  to  the  sternomastoid  and  of  the  other  cervical  muscles 
consists  of  prevention,  in  the  first  place,  and  rest  of  the  muscle  after  it  occurs. 
During  breech  deliveries  the  possibility  of  injury  must  be  borne  in  mind,  but  dur- 
ing forceps  operations  it  is  usually  impossible  directly  to  protect  the  muscles,  except 
by  a  strict  observance  of  the  indications  and  proper  technic.  After  delivery  the 
child  is  to  be  handled  as  little  and  as  carefully  as  possible,  the  nurse  being  prop- 
erly instructed.  In  several  cases  I  had  the  infant  strapped  to  a  well-padded  board 
like  a  papoose  for  a  week,  and  bathing  omitted  (Couvelaire,  Behm). 

Injuries  to  every  one  of  the  viscera  of  the  chest  and  abdomen  have  been  re- 
ported, rupture  with  hemorrhage  being  the  usual  finding.  Fractures  of  the  ribs  and 
sternum  in  version  and  breech  extraction  have  occurred.  In  one  case  I  found  that 
the  attending  accoucheur  had  dilated  and  ruptured  the  anus,  thinking  it  was  the 
tightly  closed  cervix,  and  in  another  the  child's  perineum  and  rectovaginal  septum 
had  been  torn  through  under  the  same  erroneous  impression.  The  swollen  scrotum 
has  been  held  for  the  membranes  and  punctured.  Spontaneous  rupture  of  the  um- 
bilical cord  occurred  in  two  cases  in  the  service  of  the  Chicago  Lying-in  Hospital 
Dispensary,  in  one  of  which  the  child  died.  The  cord  in  one  case  was  very  brittle. 
During  a  forceps  operation  I  inadvertently  cut  the  cord  clean  across  with  the  very 
tip  of  the  blade.  Tearing  of  the  cord  off  the  placenta,  off  the  belly,  once  with  strip- 
ping up  of  the  alxlominal  wall,  rupture  of  the  veins,  rupture  of  a  large  varicosity, 
have  all  been  observed,  either  with  or  without  the  action  of  external  trauma 
(important  medicolegally).  A  too  brittle  cord,  coiling,  or  a  knot  is  usually  respon- 
sible for  the  spontaneous  injuries. 

Paralysis  of  the  muscles  of  the  extremities  is  not  an  infrequent  result  of 
severe  operative  deliveries.  Central  cerebral  or  spinal-cord  lesions  result  usually  in 
extensive  paralysis,  often  with  rigidity  and  athetosis,  for  example,  cerebral  spastic 
paralysis  (Little),  diplegia,  hemiplegia,  paraplegia.  Of  the  local  paralysis,  Ducheime- 
Erb's  is  clinically  the  most  important,  though  isolated  paralyses  and  pareses 
occur — for  example,  one  whole  arm,  the  forearm  and  elbow,  from  brachial  nerve 
injury  or  callus.  Erb's  paralysis  is  due  to  injury  of  the  fifth  and  sixth  motor  roots 
of  the  brachial  plexus,  such  injury  being  due  to  direct  pressure  on  these  nerves  as 
they  issue  from  between  the  scaleni  muscles,  or  to  compression  between  the  clavicle 
and  the  first  rib,  to  tearing  of  the  nerves  by  direct  trauma,  as  from  a  broken  clavicle, 
or  overstretching  from  excessive  pulling  on  the  neck,  or  from  tearing  of  the  roots  of 
the  nerves  out  of  the  spinal  cord.  The  paralysis  is  usually  a  traction  lesion  and  may 
be  unilateral  or  bilateral.  Compression  by  the  blade  of  the  forceps  and  by  callus- 
formation  is  also  to  be  mentioned,  and  in  these  cases  the  paralysis  is  a  little  more 
likely  to  disappear.     The  muscles  involved  are  the  deltoid,  the  supraspinatus  and 


8U 


THE    PATHOLOGY    OF   LABOR 


infraspinatus,  the  coracobrachialis,  brachialis  internus,  the  biceps,  and  in  some 
cases  the  supinatores  longus  and  brevis.  A  characteristic  position  is  assumed  by 
the  arm.  It  hangs  flaccid  at  the  side  of  the  chest,  with  the  hand  rotated  inward, 
the  thumb  pointing  back.  Flexion  of  the  forearm  on  the  arm  and  supination  are 
impossible.  Sensibility  remains  intact,  but  muscular  atrophy  is  rapid.  The  prog- 
nosis is  bad.  A  few  cases  in  which  the  signs  are  mild,  and  perhaps  clue  to  bruis- 
ing, with  exudate  around  the  nerve-roots,  may  recover,  but  if  the  paralysis  lasts 
over  a  week,  or  if  neuritis  exists  the  outlook  is  gloomy  (Taylor  and  Clark). 

The  greatest  field  lies  in  prevention.  In  ordinary  labor,  during  the  delivery  of 
the  shoulders,  care  must  be  taken  not  to  lift  the  head  up  nor  to  pull  it  down  from 
behind  the  pubis  too  sharply,  and  in  breech  cases  the  neck  may  not  be  stretched 


Scalenus  medius 


Scalenus  anticus 
Scalenus 
posticus 


Fig.  7.36. — Semidiagrammatic,  to  Show  the  Part  of  Cervical  Plexus  Injured  by  Forced  Delivery. 

This  is  the  so-called  Erb's  point.     Sketches  below  show  usual   mechanisms  of  injury.     In  one  the  nerve-roots  may  be 

torn  out  of  the  spinal  cord,  in  the  other  the  plexus  is  crushed  by  the  instrument. 


too  much,  nor  the  fingers  allowed  to  draw  directly  upon  the  cervical  muscles 
and  nerves.  When  the  clavicles  are  fractured,  Schultze's  swingings  may  not  be 
practised.  In  one  case  I  was  convinced  that  the  end  of  the  bone  ground  into  the 
cervical  plexus  during  this  operation.  An  a:;-ray  should  be  taken  to  determine  if 
a  broken  bone  is  the  cause,  or  a  subluxation  of  the  head  of  the  humerus.  In  the 
differential  diagnosis  central  lesions,  syphilis,  etc.,  are  to  be  considered.  Treatment 
is  on  general  neurologic  lines.  Lately,  nerve  transplantation  operations  are  being 
done  on  such  cases. 

Fracture  of  the  hones  of  the  extremities,  especially  of  the  clavicle,  is  quite  common. 
A  critical  examination  of  new-l:)orn  children,  as  Riether  has  done,  will  show  that  this 
occurs  much  oftener  than  is  expected.     It  may  be  the  hard  lump  on  the  bone 


ACflDEXTS    TO    'IIIK    (1111,1) 


815 


(tlio  callus)  ■\vliich  first  draws  attention.  (  'la\irlc  tract  u  res  occur  from  dii-cct  t  raunia, 
as  by  pulling  on  the  l)on('  in  hrccch  prcscntat ion,  or  indirect ly  hy  pulling  on  1  he  arm 
or  the  head,  the  hone  heinji;  caught  between  the  source  of  the  [)ower  and  the  pelvis. 
Bringin.ij;  down  the  arms  in  either  head  or  breech  presentations,  pulling  up  or  down 
on  the  head  to  deliver  the  trunk,  pulliiif;'  with  the  finger  in  the  axilla,  and  even 
the  power  of  natural  labor  when  the  shoulder  stems  against  the  pelvis,  may  l)reak 
the  bone.  I  observed  one  fracture  of  the  clavicle  in  u  s))ontaneous  labor  with  very 
strong  expulsive  pains  and  heard  the  boi>e  crack.  If,  after  every  operative  delivery, 
the  child  bo  carefully  inspected  for  injuries,  such  a  fracture  will  not  escape  notice, 
mobility,  crepitus,  and  dt't'ormity  being  present.  Greenstick  fracture  may  occur. 
The  favorit(>  site  is  the  outer  tliird,  j)ut  the  middle  may  ])reak  under  direct  pres- 
sure, and  the  l)one  may  break  at,  or  be  torn  from,  its  attachment  to  the  sternum 


Fig.  737. — Fracture  of  Left  Clavicle. 
Breech  extraction  through  generally  contracted  pelvis  (slightly  retouched  by  author). 


or  scapula.  The  treatment  is  simple.  A  small  pad  of  absorbent  cotton  is  placed 
in  the  axilla,  the  arm  bandaged  to  the  side,  and  the  bandage  well  sewed  in  place. 

Fracture  of  the  humerus  results  from  direct  trauma  in  delivering  the  arms.  I 
have  twice  deliberately  broken  this  Jjone  to  save  the  chikl  and  succeeded.  Separa- 
tion of  the  diaphysis  from  the  epiphysis  is  much  more  common  and  more  serious 
because  it  may  easily  be  overlooked.  The  ejiiphysis  is  rolled  out,  the  arm  rolled  in 
(like  an  Erb's  paralysis),  and  if  healing  is  thus  allowed,  permanent  disability  and 
shortening  result.  To  prevent  such  injuries  the  proper  tcchnic  should  be  practised 
in  an  arm  and  shoulder  delivery.  Dislocation  of  the  humerus  is  very  rare — usually 
a  fracture  is  mistaken  for  it. 

Fracture  of  the  femur  is  almost  always  an  error  of  art.  too  much  force,  or  force 
applied  in  a  wrong  direction,  lieing  the  cause.  Bringing  down  the  leg  with  bad  tech- 
nic,  grasping  it  improperly,  and  pulling  out  of  the  axis  of  the  pelvis  are  usually  re- 
sponsible.    Nowadays  few  accoucheurs  put  the  forceps  on  the  breech  or  use  the  blunt 


816  THE    PATHOLOGY   OF   LABOR 

hook  or  slings.  Even  the  finger  in  the  groin  may  break  the  bone.  Dislocation  of  the 
femur  is  rarer  than  fracture,  but  separation  of  the  epiphysis  is  commoner.  It  may 
be  impossible  to  distinguish  between  congenital  and  acquired  dislocation  of  the 
femur — indeed,  a  traumatic  dislocation  can  hardly  occur,  fracture  of  the  epiphysis 
usually  being  the  result  of  force  exerted  on  the  joint. 

Spontaneous  fracture  of  any  of  the  long  bones  may  occur  in  labor.  In  one 
of  my  cases  two  children  of  one  mother  had  broken  clavicles  because  of  fragility 
of  the  bones.  Besides  fractures,  the  extremities  may  be  torn  or  bruised  or  infected 
by  the  attendant,  or  they  may  suffer  pressure  and  gangrene  by  being  imprisoned 
between  the  head  and  the  pelvis.  If  the  rc-ray  is  to  be  used  to  aid  the  diagnosis 
of  fractures,  etc.,  the  exposure  must  be  very  short,  since  young  infants  are  sus- 
ceptible (O'Donnell). 

A  very  important  consideration  is  the  medicolegal  aspect  of  all  these  injuries, 
since  too  often  the  physician  has  to  defend  himself  against  damage  suits  because 
of  them.  While  it  is  true  that  most  of  these  traumatisms  can  be  prevented  by 
proper  application  of  our  art,  it  is  equally  true  that,  with  few  manifest  exceptions, 
they  can  be  brought  about  by  the  forces  of  natural  labor  alone.  Since  this  is  a  fact,  in 
any  given  medicolegal  case  it  will  be  necessary  toprovethattheparticular  injury  was 
plainly  due  to  carelessness,  ignorance,  or  lack  of  skill  on  the  part  of  the  accou- 
cheur. In  passing  judgment,  also,  these  things  must  be  borne  in  mind:  Our  medical 
schools  do  not  as  yet  furnish  enough  material  so  that  the  general  practitioner  can 
get  the  proper  training  to  meet  all  the  emergencies  that  may  arise;  the  surround- 
ings of  the  labor  case  in  a  home;  a  low  bed  and  none  or  inefficient  assistance;  the  loss 
of  sleep;  the  nervous  wear  and  tear  of  a  confinement  case,  and  the  state  of  mental 
fatigue  in  which  the  accoucheur  often  has  to  undertake  the  most  dangerous  and 
delicate  operations,  involving  two  lives;  and,  finally,  many  of  the  accidents  named, 
have  occurred  in  the  hands  of  the  best  obstetricians  the  world  has  known. 

Literature 

Boehm:  "  Torticollis,"  Jour.  Amer.  Med.  Assoc,  September  18,  1909. — Bonnaire:  "Hemorrhages  of  Newborn," 
L'Obstetrique,  October,  1911.  Literature. — Commandeur:  L'Obstetrique,  July,  1910. — Couiietoire.- Annal.  deGyn. 
et  d'Obst.,  January,  1911;  also  Surg.,  Gyn.,  and  Obst.,  June,  1911. — Dorman:  "Fetal  Death,"  Amer.  Jour. 
Obstet.,  February,  1909,  p.  232. — Engelman:  Centralbl.  f.  Gyn.,  1911,  p.  7.  L'Obstetrique,  May,  1909,  p. 
362. — Ewarts  Graham:  Jour.  Exper.  Med.,  April,  1912. — Haskovec:  Wien.  med.  Blatter,  1899,  "Cerebral  In- 
juries," No.  37.  Literature. — Knapp,  L.:  Der  Scheintod  der  Neugeborenen.  Complete  monograph.  Litera- 
ture.— Legueux:  "Ocular  Lesions,"  L'Obstetrique,  February,  1912. — Mack:  L'Obstetrique,  1901,  519.  Litera- 
ture.— Rossa:  Arch.  f.  Gyn.,  vol.  xlvi. — Seitz:  Die  fotalen  Herztone  wahrend  der  Geburt,  Munich,  1903. 
Literature. — Taylor  and  Clark:  Jour.  Amer.  Med.  Sci.,  1906.  Wolff:  Beitrage  f.  Augenheilkunde,  1905.  Litera- 
ture. 


SECTION  VII 

PATHOLOGY  OF  THE  PUERPERIUM 


Nowadays  the  puerperium,  aside  from  af tor-pains  and  minor  disturbances 
of  urination  and  of  lactation,  is  usually  an  uneventful  convalescence.  When  the 
soreness  is  gone  from  the  nmscles  and  joints  and  the  body  functions  are  ordered, 
which  requires  about  seventy-two  hours,  the  puerpera  should  feel  as  well  as,  if  not 
better  than,  she  ever  did.  Two  dangers,  however,  beset  her:  infection  of  the 
genitalia  and  infection  of  the  breasts.  Naturally,  a  woman  at  this  time  may  be 
seized  with  any  general  or  local  disease,  as  typhoid,  pneumonia,  the  exanthemata, 
erysipelas,  etc.,  and  such  affections  are  usually  aggravated  by  the  puerperal  state. 
In  importance,  however,  puerperal  infection  overshadows  everything  else. 


CHAPTER  LXIII 

PUERPERAL  INFECTION 

Puerperal  fever  is  a  term  introduced  bj^  Richard  Morton  in  1692  to  apply 
to  an  acute  febrile  disease  which  seized  l^ing-in  women  and  exhibited  a  high  degree 
of  fatality. 

History. — In  the  primitive  practices  of  savages  untouched  by  civilization  are  found  many 
evidences  that  puerperal  fever  existed  among  them,  and  that  means  of  prevention  were  adopted 
— for  example,  the  isohition  of  the  parturient  and  puerperal  members  of  the  tribe,  the  cleansing 
bath  in  a  stream  after  hibor,  the  fumigations  of  the  vulva  with  aromatic  herbs,  fumigation  of  the 
apartment  after  the  puei^iera  left  it,  washing  the  belly  with  banana  wine,  etc.  In  the  Ayur  Veda 
of  Susruta,  a  thousand  j-ears  before  Christ,  it  is  mentioned.  Hippocrates  (-iOO  B.  c.)  describes  cases 
of  it  so  accurately  that  the  words  could  well  be  read  in  a  modern  class-room.  He  mentions  epi- 
demics of  the  fever.  Celsus  and  Galen  describe  it,  and  historic  references  to  it  throughout  the 
middle  ages  are  numerous.  The  first  authentic  report  of  an  epidemic  of  the  disease  is  given  by 
Hervieux,  and  is  said  to  have  occurred  in  Leipzig  in  16.52  to  166.5.  The  first  lying-in  ward  was 
established  in  Paris  at  the  Hotel-Dieu,  and  here  the  great  obstetricians,  IMauriceau,  de  la  Motte, 
Portal,  and  Peu,  obtained  their  experience.  jMauriceau  states  that,  in  1660,  an  epidemic  of 
puerperal  fever  broke  out  in  the  city  of  Paris  and  in  the  Hotel-Dieu,  and  here  two-thirds  of  the 
women  delivered  died  of  it!  Even  in  1831  the  mortality  still  was  9  per  cent,  in  the  Paris  ]^Iaternite. 
In  17.50  and  1761  epidemics  occurred  in  London;  in  1772,  in  Edinburgh;  in  Berhn  in  177S — to 
mention  only  a  very  few  of  those  reported.  Since  the  maternities  were  opened  to  students  at  the 
same  time  the  states  placed  dead  bodies  at  the  disposal  of  the  universities  for  study  and  instruction, 
it  is  easy — for  us — to  see  why  the  scourge  increased.  In  Vienna,  where  the  postmortems  of  the 
great  Kokitansky  were  so  assiduously  visited  by  the  students,  the  disease  raged  fearfully.  In 
1842  the  mortality  of  the  women  varied,  with  the  months,  from  IS  to  31  per  cent.  Every  day  there 
were  two  or  three  autopsies  on  such  cases,  and  the  students  went  directly  from  the  morgue  to  the 
lying-in  room.  In  England  the  disease  was  very  well  known,  and  it  was  there  considered  con- 
tagious, like  smallpox.     (For  History  see  Fasbender,  ■Mauriceau,  Semmelweis,  Holmes.) 

Definition. — Puerperal  fever,  or  puerperal  infection,  is  a  general  term  embrac- 
ing all  the  conditions,  usually  of  a  febrile  nature,  but  sometimes  non-febrile,  origi- 
nating from  infection  of  the  genital  tract  at  any  point  of  its  extent. 

It  matters  not  whether  the  sj'mptoms  be  mild,  lasting  but  a  few  hours  or  many 
days,  whether  there  be  a  vulvitis,  an  endometritis,  or  a  septicemia,  whether  one 
52  817 


818  PATHOLOGY    OF   THE    PUERPERIUM 

of  the  milder  forms  of  saprophytic  bacteria  or  the  most  virulent  streptococcus  be 
causative,  whether  the  patient  has  fever  or  rapid  pulse — if  the  complexus  of  symp- 
toms points  to  a  genital  infection,  the  woman  suffers  from  puerperal  fever.  This 
definition  shuts  out  the  so-called  miasmatic  fevers,  the  essential  infectious  fevers, 
for  example,  tj'phoid,  diphtheria  of  the  throat,  erysipelas  of  all  other  portions  of  the 
body  but  the  genitals,  etc.,  and  since  it  includes  many  and  widely  differing  clinical 
forms  of  disease,  makes  a  careful  classification  of  these  forms  necessary.  This  is 
not  easy.  The  exact  nature  of  puerperal  infection  has  been  discovered  through  the 
science  of  bacteriology. 

Up  to  the  seventeenth  century  the  theory  of  Hippocrates  was  the  generally  accepted  one. 
He  ascribed  the  disease  to  suppression  of  the  lochia,  taking  the  effect  for  the  cause.  Celsus  and 
Galen,  Avicenna,  Mauriceau,  Sydenham,  and  Michaelis  accepted  this  theory.  If,  as  the  pre- 
sumable result  of  fright,  of  taking  cold,  etc.,  the  lochia  ceased,  they  were  absorbed  into  the  blood 
and  caused  puerperal  fever.  Mercurialis,  and  especially  Puzos,  of  Paris,  taught  the  milk  theory. 
During  pregnancy  the  milk  secretion  begins,  but  it  is  all  determined  to  the  uterus,  where  the  fetus 
uses  it  for  nourishment.  After  labor  it  is  excreted  by  the  breasts.  If  by  catching  a  cold,  etc., 
the  secretion  should  be  checked,  so-called  milk  metastases  occur  and  cause  fever — again  mixing 
cause  and  effect.  Then  the  milk  appears  in  the  lochia  (the  purulent  lochia  of  sepsis),  in  the  peri- 
toneal cavity  (the  pus  of  puerperal  peritonitis),  in  the  pleural  cavities  (pus  from  pleuritis),  or  in 
the  joints  (pyemic  arthritis).  Chemists  even  claimed  to  have  made  butter  from  the  exudate  in  the 
peritoneal  cavity,  one  saying  he  had  found  sour  milk  and  butter  under  the  skin  of  a  woman  dead 
of  puerperal  fever. 

There  was  no  lack  of  other  notions.  Plater,  in  1602,  said  it  was  a  metritis;  Hunter,  in  1780, 
a  peritonitis;  Tonnele,  in  1830,  a  lymphangitis,  etc.  Mauriceau  called  it  malignant  fever,  others 
a  gastric  or  bilious  fever,  puerperal  erysipelas,  typhus,  omentitis,  putrid  fever,  etc. 

Cruveilhier  said  it  was  somewhat  like  typhoid,  while  the  "essentialistes,"  as  they  were  called 
in  France,  among  whom  are  the  names  of  Dubois,  Depaul,  Litzman,  and  MichaeUs,  said  it  was  due 
to  a  miasm  and  was  a  specific  contagious  process,  propagable  through  the  air,  and  governed  by 
telluric,  cosmic,  and  atmospheric  influences,  etc.,  a  view  later  held  by  Fordyce  Barker  in  America. 

ideas  of  the  infectious  nature  of  the  disease  had  long  been  held.  Levret  (Paris,  1770),  in 
speaking  of  Smellie's  leather-covered  forceps,  asks  if  contagion  could  not  be  carried  in  the  blood 
which  decomposes  in  the  meshes  of  the  leather.  In  England,  Charles  White,  in  1772,  said  that 
other  persons  could  be  infected  by  the  discharges  of  a  septic  puerpera;  in  1795  Gordon  referred 
to  the  contagiousness  of  the  disease,  and  Denman,  in  1768,  declared  it  was  carried  by  physicians 
and  midwiyes  from  one  puerpera  to  another.  One  quotation,  whose  origin  I  cannot  find,  states 
that  the  disease  may  be  carried  on  sponges  used  on  several  puerpera.  Dr.  Blackman,  in  Edin- 
burgh, in  1845,  said  that  puerperal  fever  was  conveyed  by  the  dirt  under  the  finger-nails.  Ab- 
stention from  obstetric  practice  was  enforced  on  physicians  who  had  a  succession  of  puerperal  fever 
cases,  and  even  the  use  of  chlorid  of  lime  for  the  hands  as  a  disinfectant  was  recommended. 

In  1842  our  own  Oliver  Wendell  Holmes  heard  a  report  of  the  case  of  a  physician  who, 
inoculated  at  a  postmortem,  died  of  septicemia,  but  before  this  had  attended  several  women  in 
labor  who  also  died  of  the  same  disease.  Struck  with  this  association  of  fatalities,  he  investigated 
the  subject,  and  in  184.3  published  his  results  in  a  paper  entitled  "The  Contagiousness  of  Puerperal 
Fever."  He  proved,  by  an  array  of  clinical  reports,  that  it  was  carried  from  one  patient  to  another 
as  a  contagium,  and  that,  also,  it  was  caused  by  inoculation  of  the  puerpera,  and  that  the  sources 
of  infection  could  be  erysipelatous  processes  as  well  as  cadaveric  poisons.  He  suggested  these 
rules  of  prophylaxis: 

"1.  A  physician  holding  himself  in  readiness  to  attend  cases  of  midwifery 
should  never  take  any  active  part  in  the  postmortem  examination  of 
puerperal  fever  cases. 

"2.  A  physician  ])resent  at  such  postmortems  should  use  thorough  ablu- 
tion, change  every  article  of  dress,  and  allow  twenty-four  hours  or 
more  to  elapse  before  attending  a  case  of  midwifery. 

"3.  Similar  precautions  should  be  taken  after  the  autopsy  or  surgical 
treatment  of  cases  of  erysipelas  if  the  doctor  is  obliged  to  unite  such 
duties  with  his  obstetrical  work,  which  is  in  the  highest  degree  inex- 
pedient." 

Holmes'  views  met  violent  and  bitter  opposition  from  the  two  foremost  obstetricians  of  the 
time,  Hodge  and  Meigs,  and  iiiado  very  little  impress  on  the  profession.  In  1855  he  again  took 
up  the  subject,  but,  unfortunately,  for  the  last  time. 

In  1847  Semmelweis,  a  young  assistant  in  the  clinic  in  Vienna,  which  was  later  occupied  by 
Carl  Braun,  announced  that  puerperal  fever  is  caused  by  the  absorption  into  the  blood,  from  the 
genitals,  of  decomposed  animal  matter  from  any  source;  that  the  hands,  or  any  article  brought  into 
the  genitals,  may  be  the  carriers  of  same.  He  did  not  come  upon  this  by  accident,  but  it  was  the 
result  of  years  of  hard  work  and  study.  He  noticed  that  the  division  of  the  clinic  which  was  used 
for  the  instruction  of  midwives  had  a  2.7  per  cent,  mortality  from  puerperal  fever,  while  that  for 
doctors  had  11.4  per  cent.,  and  that  the  children  were  affected  with  sepsis  proportionately  also. 
The  discrepancy  between  the  two  clinics  was  public  knowledge — it  was  the  subject  of  municipal 


PUERPERAL   INFECTION 


810 


investigation;  the  Miidwivcs  taunted  the  physicians  with  tho  facts,  and  the  patients,  wiu-n  thoy 
learned  tiiey  were  to  he  assigned  to  the  doctors'  chnic,  on  their  knees  would  hen  to  be  sent  home. 
Sennnelwcis  noted  that   tho  disease  prevailed  with  irregular,  unassignable  fluctuations,  year  in 


Fig.  73S. — Ignatz  Philip  Semmelweis. 
Below  is  the  monument  marking  his  grave  in  Buda-Pest,  Hungary. 


and  year  out,  in  the  hospital,  but  not  in  the  homes;  that  women  who  were  delivered  on  the  way  to 
the  hospital  seldom  sickened;  that  parturients  who  had  long,  hard,  or  instrumental  labors  were 
nearlv  always  affected;  that  one  or  the  other  assistant  had  the  most  cases;  that  maternities  where 


820  PATHOLOGY  OF  THE  PUERPERIUM 

students  were  not  taught  showed  the  best  results  (except  the  Paris  Maternite,  where  the  midwives 
made  autopsies);  that  overcrowding  of  the  hospital  had  no  influence;  that  fright  and  nervous 
influences  had  no  effect ;  that  the  disease  affected  the  married  as  well  as  the  single;  that  the  new- 
born children  died  of  the  same  disease  as  their  mothers;  that  no  alteration  of  the  diet,  of  the  venti- 
lation, of  the  methods  of  treatment,  produced  a  change  for  the  better — and  all  the  time  the  differ- 
ence in  the  conditions  of  his  clinic  from  that  of  the  midwives  mystified  and  oppressed  him.  He 
said:  "Everything  was  in  question;  everything  was  unexplained;  everything  was  doubtful — 
only  the  large  number  of  deaths  was  a  positive  fact."  Finally,  the  death  of  his  friend.  Professor 
Koiletschka,  gave  him  the  inspiration.  A  student  had  pricked  Kolletschka's  finger  at  an  autopsy, 
and  the  professor  died  of  septicemia.  The  postmortem  of  Koiletschka  struck  Semmelweis  by  its 
similarity  with  those  he  had  made  on  puerperal  fever  cases.  The  explanation  of  puerperal  fever 
w^as  then  clear.  The  hands  carried  particles  of  cadaveric  decomposition  into  the  puerperal  wounds, 
and  these  caused  puerperal  fever. 

With  the  cause  he  sought  the  remedy.  He  instituted  washing  of  the  hands,  cleaning  of  the 
finger-nails  ( !),  and  the  use  of  chlorin  water;  later,  chlorid  of  lime  solution.  The  result  was  dazzling. 
The  mortahty  sank  to  1.27  per  cent,  in  1848,  even  lower  than  it  was  in  the  midwives'  clinic. 
Later  an  incident — rather,  an  accident — showed  him  that  any  decomposing  animal  matter  can  be 
causative.  Thirteen  women  lying  in  adjacent  beds  were  examined  in  succession  by  the  assistant 
and  staff.  The  first  was  a  case  of  gangrenous  carcinoma  of  the  cervix  of  the  uterus;  the  rest  were 
normal  cases — 11  of  the  12  women  died  of  puerperal  fever.  Later  a  woman  with  caries  of  the 
left  knee  became  the  origin  of  a  run  of  19  fatal  cases  of  infection.  Experimentally,  he  proved 
that  the  introduction  of  pus  and  ichor  from  these  women  was  fatal  to  puerperal  animals. 

At  the  same  time  that  the  mothers'  mortality  improved  the  infections  of  the  new-born  were 
substantially  reduced. 

Semmelweis'  theory,  then,  reads  that  puerperal  fever  is  a  resorption  fever,  brought 
about  by  the  introduction  of  decomposed  animal  matter  into  the  genitals.  He  said  that  this  matter 
could  come  from  cadavers,  from  infected  wounds  of  all  kinds,  and  was  carried  into  the  genital 
wounds,  the  uterus,  the  cervix,  and  the  perineum  by  the  finger  of  the  accoucheur,  the  instruments, 
the  douche-nozle,  the  sponges,  infected  air,  the  bed-linen,  the  bed-pans — indeed,  everything  which 
could  transport  the  decomposed  animal  matter  from  its  source  to  the  parturient  canal.  He  said 
that  the  disease  was  only  one  form  of  pyemia,  that  it  also  occurred  in  surgical  cases,  and  he  recom- 
mended his  methods  of  prevention  to  the  surgeons!  If  the  word  "bacteria"  is  substituted  for 
the  words  "decomposed  animal  matter,"  the  definition  of  puerperal  infection  is  perfect  as  we  be- 
lieve it  today.  Semmelweis'  theory,  like  most  great  truths,  was  not  accepted ;  he  struggled  with 
his  opponents  for  fifteen  years,  when  signs  of  dementia  appeared.  He  died  without  the  recognition 
he  deserved,  in  an  insane  asylum,  and,  curiously,  of  pyemia. 

"With  Bretonneau,  Pasteur,  and  Koch,  the  germ  theory  of  disease  was  born,  and  when  Lister 
came  in  the  seventies,  the  true  worth  of  Semmelweis'  work  was  appreciated.  To  an  obstetrician, 
then,  is  due  the  credit  of  pointing  the  correct  way  to  modern  antisepsis  and  asepsis. 

While  Holmes  proved  that  the  propagation  of  puerperal  fever  took  place  by  contagion  or 
inoculation  in  a  general  way,  to  Semmelweis  the  credit  must  be  given  for  having,  with  unerring 
aim,  struck  the  exact  cause  of  the  disease,  for  having  shown  unequivocally  that  it  is  an  infection 
of  the  genital  wounds,  and  for  having  indicated  the  correct  manner  of  prevention.  Holmes 
dropped  the  subject  after  a  few  efforts;  Semmelweis  fought  for  his  theory  and  the  lives  of  myriads 
of  women  with  all  his  powers,  and  quit  the  struggle,  as  Sinclair  says,  only  to  descend  into  the 
tomb. 

Since  1870  the  history  of  puerperal  fever  has  been  that  of  listerism.  Whereas  at  first  the 
women  were  delivered  under  a  carbolic-acid  spray,  and  the  air,  which  Lister  believed  was  the 
dangerous  element,  excluded, — -one  Russian  author  even  wishing  the  women  delivered  in  an 
antiseptic  bath, — later  the  hands  and  instruments  were  recognized  as  the  materia  peccans,  and 
rigid  anti-sepsis,  both  objective  and  subjective,  practised.  In  the  eighties  and  early  nineties  the 
women  were  given  carbolic  and  bichlorid  douches  before,  during,  and  after  labor.  This  was  found 
harmful,  and  now  a  more  aseptic  tcchnic  is  practised,  identical  in  principles  with  that  suggested 
by  Semmelweis  in  1847. 

Etiology. — Puerperal  fever  is  nothing  more  nor  less  than  an  infectious  wound 
disease.  Cruveilhier,  in  1831,  said  that  the  puerpera  was  a  wounded  person,  and 
Mauriceau,  in  1668,  called  the  locliia  a  wound  secretion,  likening  it  to  that  of  an 
amputation. 

Since  puerperal  infection  is  a  surgical  wound  infection,  it  follows  that  the  germs 
which  attack  surgical  Avounds  will  also  be  found  attacking  the  puerpera.  This 
is  true.  The  pathology  of  puerperal  infection  is  the  same  as  that  of  surgical  infec- 
tions, but,  l^ecause  of  the  anatomic  structure  of  the  parts,  the  physiologic  changes 
of  pregnancy,  of  labor,  and  the  puerperium,  with  the  peculiar  chemisms  of  these 
functions,  many  variations  exist  which  demand  special  consideration. 

The  following  Vjacteria  have  been  found  as  positive  and  probable  causes  of 
puerperal  infeetifjn.  In  collecting  these  the  author  has  made  use  of  the  exhaustive 
articles  of  Walthard,  Schottmiiller,  and  Wegelius: 


PUERPERAL    INFECTION 


821 


Streptococcus  pyogenes. 

Diplostroptococcus  pucrpcralis. 
Stn'i)t()<;()cciis  put ridiis. 
Dii)l()coccu.s  liiiH('()l:itii.s  pneumoniae. 
Stiipliyloeoccus  ;iiireus  and  albu.s. 
Baeillus  coli  coinmunc. 
Goncjcoccus  of  Xcisscr. 
Bacillus  pneumonia'  of  Fricdliuidcr. 
Bacillus  pyocyaneus. 


Bacillus  [jfoteuH. 
Bacillus  aeroficnes  capsulatus. 
Bacillus  fusiformis  and  Ki)irilla  (hos- 
pital Kaiif^rcne). 
Bacillus  typhosus. 
Bacillus  tctaiii. 
Bacillus  anthracis. 
Bacillus  diphtheria;. 
Bacillus  influenza-. 


A  host  of  hactoria  of  putrefaction  and  docomposition  cxi.st,  a  few  of  which  may 
be  mentioned:  Micrococcus  fd^tidus,  Bacillus  funduliformis,  Bacillus  racemosus, 
Bacillus  radiiformis,  Bacillus  pseudotetani,  Bacillus  nebulosus,  Bacillus  caducus, 
Staphylococcus  parvulus,  anaerobic  streptococci,  and  many  more  named  and 
unnamed.  It  is  impossible,  with  our  present  cultural  methods,  to  grow  many  of 
the  l)acteria  which  appear  in  smear  preparations. 

It  is  rare  to  find  one  of  this  number  the  sole  cause  of  the  disease.  Usually  two 
or  more,  even  to  the  numl^er  of  15,  have  been  found.  The  streptococcus  combines 
with  the  staphylococcus,  or  the  Bacterium  coli  or  pyocyaneus,  the  latter  increasing 
the  virulence  of  the  former.  Symbiosis  seems  to  aggravate  virulence.  The  proteus 
and  the  Bacterium  coli,  or  the  proteus  wath  the  staphylococcus  group,  may  cause 
bad  infections,  as  do  the  combinations  of  coli  and  Bacillus  aerogenes  capsulatus. 

Sources  of  the  Infection.— These  bacteria  are  to  be  found  in  decomposing 
animal  and  vegetal:»le  matter,  cadavers,  in  diseased  animals  and  human  beings,  their 
excreta,  in  the  air,  and  in  dust.  The  most  important  ultimate  sources,  so  far  as 
our  subject  is  concerned,  is  the  diseased  human  being.  The  poisons  are  carried 
from  suppurations,  gangrene,  ulceration,  infections  which  are  excreted,  as  diph- 
theria, scarlet  fever,  pneumonia,  nasal  catarrhs,  etc.,  erysipelas,  necrotic  cancers, 
lochia  (even  of  normal  puerperse),  the  menstrual  blood,  and,  very  commonly,  from 
postmortems. 

Modes  of  Transmission  to  the  Genital  Tract. — Semmelweis  distinguished  two 
modes  of  inoculation — one,  from  without,  exogenous  infection;  and  one  from  within, 
endogenous  infection. 

Auto  infection. — As  our  knowledge  of  the  subject  grew  and  our  preventive 
measures  became  more  and  more  successful,  there  appeared  those  who  declared 
that  all  cases  of  puerperal  infection  were  exogenous  in  origin  (for  example,  Jaggard), 
and  that,  therefore,  wdien  a  woman  took  sick  with  a  puerperal  process,  some  one 
was  to  blame  for  it.  The  results  of  this  teaching  are  still  wide-spread  and  still  cause 
a  great  deal  of  injustice,  because  it  is  not  true.  Ahlfeld,  since  1885,  and  a  few 
others — Winckcl,  Koch,  Tarnier,  Doleris — had  always  maintained  that,  in  addition 
to  the  inoculation  from  without  (hetero-infection),  the  woman  occasionally  became 
infected  from  bacteria  which  she  carried  in  her  o^\ti  person — autoinfection.  Leo- 
pold, Doderlein,  Kronig,  Fochier,  Pestalozza,  and  Williams  denied  the  possibility. 
Some  of  these  authors  have  changed  their  minds.  Ahlfeld  distinguished  three 
kinds  of  autoinfection — first,  that  from  bacteria  in  the  genital  tract,  including  the 
vulva  (e.  g.,  gonorrhea),  w^hether  they  entered  the  tissues  themselves  or  w^ere  intro- 
duced by  absolutely  sterile  fingers  or  instruments;  second,  that  transported  to  the 
genital  canal  via  the  blood  from  a  distant  site  of  suppuration,  such  as  the  tonsil, 
the  lungs,  a  mastitis;  and,  third,  the  infection  of  the  genital  canal  from  contiguous 
disease,  for  example,  appendicular  abscesses,  pj'osalpinx,  pyelo-ureteritis.  To  this 
might  be  added  a  fourth,  the  inoculation  of  the  patient  by  herself  with  bacteria, 
either  present  on  her  hands,  or  carried  by  her  from  a  focus  of  suppuration,  for 
example,  ulcus  cruris,  tonsillitis,  a  sinus  disease,  otitis,  abscess  of  the  breast,  an 
intertrigo,  etc.  It  is  hard  to  differentiate  this  form  from  Ahlfeld's  second  form. 
With  Wegelius  and  Walthard  I  would  prefer  to  limit  the  term  autoinfection  to  those 
cases  where  the  bacteria  of  the  genital  tract,  including  the  vulva,  develop  virulence 
and  invade  the  tissues,  or  produce  poisons  which  are  absorbed,  without  any  possible 


822  PATHOLOGY    OF   THE    PUERPERIUM 

external  agency.  It  is  better  to  exclude  from  this  definition  all  reference  to  the 
transference  of  infection  from  other  foci  in  the  body,  as  well  as  the  admission  that 
the  even  aseptic  hand  may  introduce  the  bacteria  which  were  present  in  the  vagina 
into  the  puerperal  wounds. 

On  the  ground  of  clinical  experience  I  am  forced  to  admit  the  frequent  occurrence 
of  autoinfection,  in  the  broad  sense  that  Ahlfeld  holds,  and  in  the  narrow  definition 
just  proposed  it  also  occurs,  but  the  cases  are  very  few  in  number.  The  question 
has  held  the  attention  of  the  best  obstetricians  and  bacteriologists  of  our  time, 
and  innumerable  and  laborious  investigations  have  been  made,  but  the  results  were 
so  conflicting  that  its  solution,  until  within  a  few  years,  seemed  impossible.  Whether 
a  woman  may  or  may  not  be  infected  from  within  during  labor  depends  on  whether 
or  not  the  vagina  may,  under  the  usual  conditions  of  life,  the  woman  being  in  appar- 
ent health,  contain  pathogenic  bacteria.  Mention  of  only  a  few  who  took  part  in 
the  polemic  need  be  made — Doderlein,  Kaltenbach,  Ahlfeld,  Kronig,  Menge, 
Bensis,  Steffeck,  Vahle,  Walthard,  Winter,  Stroganoff,  and,  prominently  in  America, 
Williams,  of  Johns  Hopkins.  Kronig,  Menge,  and  Wilhams  believed  that  the 
vagina  of  apparently  healthy  women  contained  no  pyogenic  bacteria.  Walthard, 
Kaltenbach,  Ahlfeld,  Bumm,  Sigwart,  and  others  believed  that  it,  in  a  large  per- 
centage of  cases,  contained  many,  even  the  streptococcus.  Some  believe  that, 
given  favorable  conditions,  these  bacteria  could  become  very  virulent. 

The  latest  studies  by  Bumm,  Natvig,  Wegelius,  Kronig  and  Pankow  (1909), 
and  Winter  (October,  1911),  employing  very  favorable  culture-media  (grape-sugar 
bouillon  and  blood-agar),  seem  to  prove  that  the  vaginas  of  apparently  healthy 
women  in  the  last  weeks  of  pregnancy  contain  streptococci  and  staphylococci  in 
from  40  to  75  per  cent,  of  the  cases  examined,  and  that  these  bacteria,  while  usually 
living  a  saprophytic  existence,  may  wander  from  the  vulva,  the  vestibule,  the 
vagina,  up  into  the  uterus  or  into  the  wounds  during  the  puerperium  and  cause 
puerperal  fever.  From  general  practice  we  have  analogies  of  autoinfection  to  draw 
upon,  to  mention  only  two  examples,  the  acute  pelvic  peritonitis  of  virgins,  the  result 
of  "catching  cold"  or  refrigeration  during  the  menses  and  osteomyelitis  in  children 
after  severe  exposure.  It  must  also  be  remembered  that  cats  and  domestic  animals 
have  puerperal  fever. 

On  the  vulva,  as  was  to  be  expected,  streptococci,  staphylococci.  Bacterium 
coli,  Bacillus  pseudodiphtheria?,  and  many  saprophytes  are  to  be  found,  and  espe- 
cially if  there  are  pustular  or  eczematous  eruptions  near  by.  In  the  urethra  the 
same  germs  vegetate.  In  cystitic  urine  the  same  and  the  Proteus  vulgaris,  with 
others  still.  Ascending  ureteropyelitis  has  already  been  discussed,  and  germs  here 
present  may  be  dangerous  to  the  parturient  canal.  Even  in  apparently  normal 
women  bacteriuria  occurs,  and  the  streptococcus  (author),  the  colon  bacillus,  and 
typhoid  Imcilli  have  been  demonstrated. 

In  the  vagina,  under  apparently  normal  conditions,  the  following  bacteria  have 
been  demonstrated  (Walthard,  Bar,  and  Wegelius) : 

(1)  Facultative  anaerobic  streptococci  of  the  type  of  the  Streptococcus  pyo- 
genes puerperalis.  (2)  Facultative  anaeroljic  streptococci  of  the  type  of  the  Diplo- 
streptococcus  puerperalis.  (3)  Obligate  anaerobic  streptococci  of  the  type  of  the 
Streptococcus  anaerobius.  (4)  Staphylococci  of  the  type  of  the  Staphylococcus 
pyogenes  liquefaciens,  albus,  aureus,  and  citreus.  (5)  Bacterium  coli.  (6)  Gono- 
coccus.  (7)  Bacillus  funduliformis.  (8)  Pscudotctanus  bacillus.  (9)  Bacillus 
aerogencs  capsulatus  (Welchii).  (10)  Bacillus  vaginalis  (Doderlein).  (11)  Bacte- 
rium pseudodiphtheriffi.  (12)  Gram-positive  cocci,  diplococci,  bacilli,  and  diplo- 
bacilli.  (13)  Micrococcus  tetragenus.  (14)  Saccharomyces.  (15)  Bacillus  of 
Weeks.  (16)  Bacillus  bifidus  communis.  (17)  Various  other  anaerobic  and  aero- 
philic  cocci  and  bacilli  and  stn-ptobacilli. 

Doderlein   distinguishes  two   forms   of  vaginal   secretion — normal,  which   is 


PUERPERAL   INFECTION  823 

wliitc,  like  curdhMl  milk,  acid,  contains  no  nnicus,  and  is  small  in  amount;  and 
■/xilhohxjir,  which  is  thick,  yellowish  or  greenish  mucus,  sometimes  foamy,  usually 
alkaline,  but  not  necessarily  so,  and  contains  numerous  pathogenic  and  n(jn-patho- 
genic  microorganisms,  whereas  the  normal  vaginal  secretion  contains  only  the 
Bacillus  vaginie,  a  harmless  organism.  It  is  certain  that  the  pathologic  discharges 
contain  more  of  the  mentioned  organisms  than  do  the  normal,  Ijut  it  is  not  easy 
to  divide  the  cases  sharply  into  two  classes  either  clinically  or  bacteriologically. 

The  closed  cervix  is  infected  in  its  lower  third,  the  mucous  plug  here  being 
cloudy  yellow,  showing  the  presence  of  pus  and  bacteria.  It  is  white  in  the  next 
zone  and  clear  in  the  upper  part,  being  here  aseptic.  Under  normal  conditions,  ac- 
cording to  the  recent  res(>arches  of  Winter,  Menge,  and  Walthard,  the  uterine  cavity 
is  sterile,  but  it  may  harbor  bacteria,  and  they  then  live  in  the  decidua  and  fetal 
membranes.  Usually  they  do  not  go  through  the  villi  to  the  fetus,  but  pass  through 
the  membranes  into  the  liquor  amnii,  thence  to  the  blood  of  the  fetus  through  the 
stomach,  and  thus  to  the  capillaries  in  the  villi.  Bacteria  may  also  get  to  the  fetus 
through  the  villi,  having  reached  the  intervillous  spaces  via  the  maternal  blood — for 
example,  the  pneumococcus  and  the  typhoid  bacillus  in  corresponding  infections. 

Since  the  bacteria  mentioned  exist  in  the  genital  tract  of  the  gravida,  and  are 
there  even  during  labor,  why  does  not  every  woman  become  infected?  First,  they 
live  as  saprophytes,  requiring  special  conditions  to  develop  invasive  qualities  or 
virulence.  We  have  several  analogies.  In  the  mouth  and  nose  the  streptococcus, 
the  pneumococcus,  the  diphtheria  bacillus,  and  the  staphylococcus  may  live  harm- 
lessly, and  only  under  extraneous  influence  cause  sickness,  but  they  may  be  infec- 
tious for  others.  In  the  intestinal  canal  the  Bacillus  coli  and  other  bacteria  exist 
under  the  same  conditions.  In  the  horse  the  tetanus  bacillus,  verj^  fatal  if  inocu- 
lated into  a  wound,  lives  as  a  harmless  parasite.  Second,  the  vagina  has  some  power 
of  purification,  at  least  it  has  qualities  which  ordinarily  keep  the  activities  of  its 
flora  within  safe  bounds — in  a  way  similar  to  that  of  the  mouth.  Doderlein  ascribed 
this  powTr  to  the  lactic  acid  produced  by  the  Bacillus  vaginae,  which  makes  the 
vaginal  secretion  unsuitable  for  the  growth  of  other  bacteria.  Menge  believed  that 
phagocytosis  going  on  in  the  cervix  and  vagina  had  something  to  do  with  it.  Per- 
haps other  immunizing  forces  are  at  work  to  produce  local  cell  immunity,  and  the 
process  will  be  explained  when  the  biochemical  studies  in  immunity  of  ]\Ietchnikoff, 
V.  Behring,  Ehrlich,  and  others  are  carried  to  completion.  Third, during  labor  there 
are  the  mechanical  scouring-out  of  the  bacteria,  the  flow  of  the  liquor  amnii,  and  the 
outpouring  of  mucus  and  blood,  and  the  passage  of  the  child  and  placenta,  wdiich 
remove  large  numbers  of  bacteria.  Fourth,  newly  let  blood  has  antitoxic  properties 
for  a  short  time.  Investigations  of  the  lochia  (vide  infra)  in  the  first  forty-eight  hours 
have  showai  ver}"  few  bacteria,  while  on  the  third  day  the  increase  is  marked,  but  by 
this  time  the  wounds  have  closed,  a  bank  of  granulations  has  been  thro-\m  up, 
through  which  the  bacteria  may  not  easily  break,  excepting  the  virulent  strepto- 
coccus and  the  gonococcus,  and  the  cervix  has  closed,  shutting  off  the  uterine  cavity 
more  or  less.  Fifth,  the  do^\^lward  and  outward  current  of  the  lochia  and  the  mucus 
covering  the  surface  must  also  be  considered.  It  is  important  for  the  accoucheur 
to  bear  these  things  in  mind,  so  that  he  does  not  interfere  with  nature's  methods  of 
protecting  the  puerperal  woman,  and,  as  we  know,  these  methods  are  very  suc- 
cessful. 

Natvig  and  Wegelius  have  shown  that  the  flora  of  the  vagina  in  the  puerperium 
is  the  same  as,  or  at  least  very  similar  to,  that  of  the  vulva,  vestibule,  and  vagina 
before  labor,  and  many  of  the  bacteria  mentioned  on  p.  821  have  been  demonstrated 
in  the  lochia  of  fever-free  puerperse.  Therefore  the  bacteria  have  the  power  to  wander 
into  and  up  the  genital  tract.  In  three-fourths  of  the  cases  examined  the  bacteria 
were  found  in  the  uterus  itself  on  the  fourth  day.  They  were  few  in  number,  and 
almost  always  all  obligate  anaerobes,  the  facultatives  being  lightly  represented. 


824  PATHOLOGY  OF  THE  PUERPEKIUM 

On  the  ninth  day  90  per  cent,  of  the  cases  showed  bacteria  in  considerable  number, 
but  they  were  almost  entirely  obligate  anaerobes,  only  once  in  ten  cases  a  faculta- 
tive anaerobic  streptococcus  being  met.  In  spite  of  all  this,  if  the  woman  is  not 
molested  by  meddling  accoucheurs,  she  will  almost  always  recover  from  her  labor 
by  grace  of  the  immunities  provided  by  nature,  and  while  mild  cases  of  autoinfection 
may  occur  occasionally,  fatal  cases  are  exceedingly  rare.  The  practical  lesson  to 
be  learned  from  these  investigations  is  that  the  accoucheur  should  studiously  and 
consistently  avoid  those  conditions  which  render  these  bacteria  virulent  and  in- 
vasive, and  which  carry  them  to  regions  of  the  parturient  canal  where  they  may  un- 
fold their  latent  powers.  Conditions  favoring  autoinfection  are  excessive  bruising 
of  the  parts  from  prolonged  labor,  great  delay  in  delivery  after  rupture  of  the  mem- 
branes, the  retention  of  pieces  of  placenta  in  the  uterus,  or  membranes  which  hang 
dovm  into  the  vagina  and  form  a  bridge  on  which  the  bacteria  may  mount  into  the 
uterus,  or  blood-clots  in  the  vagina,  lochiometra,  and  lochiocolpos. 

Hetero-infection. — Infection  from  without — exogenous  infection — is  by  far  the 
most  common,  and  is  always  first  to  be  thought  of  when  a  puerpera  develops  fever. 
Infection  may  be  brought  to  the  genital  tract  from  the  outside  in  many  ways: 

(1)  The  most  common  carrier  is  the  physician  or  midwife,  rarely  the  nurse.  The 
finger,  or  an  instrument  insufficiently  sterilized,  introduced  into  thegenitalia,  deposits 
virulent  germs  in  the  tissues.  These  germs  have  been  brought  from  a  case  of  puer- 
peral sepsis,  from  the  dressing  of  an  ulcer,  or  any  suppurating  or  infected  wound, 
from  a  postmortem,  an  erysipelas  case,  a  cancer,  pneumonia,  typhoid,  scarlet  fever, 
diphtheria,  from  a  baby  with  infected  umbilicus  or  enteritis,  etc.,  from  the  lochia  of 
even  normal  puerperae,  or  even  the  ordinary  filth  under  the  finger-nails.  The  bacteria 
attain  great  virulence  by  "passage"  through  a  human  being.  The  attendant  may 
have  the  focus  of  infection  on  his  own  person — a  felon  on  the  finger,  furunculosis, 
a  wet  eczema  (they  often  contain  streptococci),  tuberculosis,  ozena  (as  the  famous 
case  of  Dr.  Rutter,  of  Philadelphia,  in  the  forties),  an  acute  rhinitis,  or  a  pharyngitis. 
A  small  epidemic  in  the  dispensary  service  of  the  Chicago  Lying-in  Hospital  orig- 
inated from  the  throat  of  an  intern.  In  the  discharges  from  the  nose  a  hemolytic 
aerobic  streptococcus  was  found  in  almost  pure  culture.  Some  years  ago  a  local 
hospital  suffered  an  epidemic  of  fatal  post-operative  peritonitis,  and  a  virulent 
streptococcus  was  isolated  from  the  throats  of  many  of  the  nurses  and  interns,  as 
well  as  from  the  dust  in  the  wards  and  operating-rooms.  Schatz  observed  two 
puerperal  fever  epidemics  of  similar  origin.  In  these  cases  the  bacteria  get  onto 
the  hands,  instruments,  or  sponges,  and  are  thus  carried  into  the  genitals,  or  they 
are  expectorated  directly  onto  and  into  the  vulva  and  puerperal  wounds,  or  they 
settle  on  them  from  their  suspension  in  the  air  as  droplets  or  as  dust  {vide  infra) . 

(2)  The  environment  has  much  to  do  with  the  causation  of  puerperal  infection, 
and  the  author  must  here  express  a  change  of  opinion  from  that  held  in  1898.  In 
my  mind  there  is  now  no  doubt  but  that  many  cases  of  puerperal  fever  are  due  to 
the  infected  dust  and  air  of  hospitals  and  other  places  where  the  birth  occurs. 
Bacteria  from  puerperal  cases,  from  the  dried  pus  of  suppurations,  from  the  autopsy 
room,  the  pathologic  lal^oratory,  and  from  the  innumerable  sources  of  infection  of  a 
general  hospital,  get  into  the  air  and  the  dust,  and  are  carried  by  air-currents  or 
persons  to  all  parts  of  the  institution,  including  the  delivery-room  and  the  lying-in 
chambers.  The  infection-laden  dust  settles  on  the  sterilized  tables,  the  towels,  the 
hand  solutions,  and  on  the  vulva.  From  here  the  bacteria  are  carried  into  the  va- 
gina by  sterilized  anrl  gloved  fingers,  the  instruments,  gauzes,  etc.  Or  they  settle 
on  the  bed-clothing  of  the  puerpera  and  thus  come  in  direct  contact  with  the  patu- 
lous vulva,  whence  they  wander  up  into  the  uterus.  The  staphylococcus  is  almost 
always  found  in  the  air  of  closed  rooms  where  people  congregate,  but  in  hospitals 
other  bacteria  also  are  found. 


PUERPERAL    INFECTION  825 

The  author  doos  obstetric  work  in  lour  ficncnil  hospitals  having  more  or  less  isolated  mater- 
nity wards,  in  the  Chicaf^o  Lyiiifz;-iii  Hospital,  wliirh  afc-cpts  only  maternity  eases,  and  in  the 
hoMics  of  the  patients.  (Ilovcs,  stciilizc(|  hy  hiniscll',  are  used  in  all  these  eases,  and  theteehriic 
einploye(l  at  all  the  places  is  |)ractically  identical.  Over  twice  as  many  fever  cases  are  (jhserved 
in  the  fjeiieral  hospitals  as  are  found  in  eases  treated  at  the  Chicago  Lj'iiiK-in  Hospital  and  in  the 
homes.  In  one  case  an  almost  fatal  staphylococcous  iJuerjK'ral  infection  occurred  in  a  patient 
occupyinp;  a  room  just  vacated  by  a  man  sulTeriiif^  with  a  suppurating  knee.  The  children  also 
show  the  etTeet  of  the  general  prevalence  of  infectious  material.  In  the  general  hospitals  marked 
rises  of  lem[)erature  on  the  third  to  sixth  day  are  observed  in  a  jjroportiori  reaching  at  times  30 
percent,  of  the  infants,  while  in  the  (jther  places  a  temperature  in  the  child  is  a  jrreat  rarity.  In 
one  of  the  fienera!  hospitals  two  epidemics  of  sepsis  carried  away  1")  children;  in  another  2  died 
from  sepsis,  pmhahly  piiarynjical  in  orijiin.      Intestinal  infections  are  very  conunon. 

In  discussiufi;  the  mortality  anil  morbidity  of  ob.stetric  in.stitutions  the  condition  of  the 
children  should  be  fjiven  more  consideration — the  new-born  child,  so  to  speak,  is  a  sterile  medium, 
and  nuich  more  sensitive  to  infection  than  gelatin  and  agar. 

W'erth,  and  Schroder  in  Kiel,  noticed  an  increase  in  fever  cases  of  women  nol  examined 
in  labor  during  the  prevalence  of  a  puerperal  fever  epidemic  in  the  institution.  Winter 
regards  as  dangerous  even  an  ajjparently  healthy  gravida  who  has  hemolytic  streptococci  in  the 
vaginal  secretions,  and  isolates  her  as  a  "carrier."  Semmelweis  recognized  the  danger  of  air- 
borne infection,  and  describes  an  incident  where  six  of  the  wom(>n  in  a  ward  containing  a  puerpera 
with  an  ichorous  tubercular  knee  died  of  child-bed  fever.  Another  epidemic  was  maintained  by 
imp(>rfectly  washed  bed-sheets.  Zweifel  rejjorted  in  1911  a  series  of  deaths  due  to  the  (jpening  of 
a  stinking  abscess  in  his  operating-room.  Bumm  (1912)  reports  a  long  endemic  originating  from 
a  septic  parturient.  Hektoen  and  Kirschsteiner  have  shown  that  the  streptococcus  and  staphylo- 
coccus will  live,  dried  in  the  air,  exposed  to  diffused  daylight,  from  eighteen  hours  to  ten  days,  and 
in  dark  cellars  over  a  month.  This  in  itself  is  sufficient  proof  that  open  wounds,  such  as  puer- 
pera' i)resent,  are  likely  to  become  infected  by  germs  carried  by  air-currents,  in  ventilating  flues, 
or  in  swirling  dust  from  one  part  of  the  hospital  to  another.  Schauta,  Chrobak,  Leopold,  Bumm, 
Tarnier,  Pinard,  Florence  Nightingale,  Walthard,  Zweifel,  and  others,  believing  these  things,  de- 
mand separate  confinement  rooms  and  lying-in  rooms  for  septic  cases.  Mackenrodt  in  1912  held 
that  air  infection  is  possible.  Space  docs  not  permit  a  presentment  of  the  many  further  proofs,  from 
my  own  experience,  of  the  dangers  of  air,  dust,  and  indirect  contact  infection  in  general  hospitals. 

(3)  The  preparatory  bath  before  delivery  may  be  a  source  of  danger.  In  a 
general  way  the  water  is  not  infectious.  In  Philadelphia,  some  years  ago,  an  epidemic 
of  tetanus  was  probalily  due  to  the  use  of  unboiled  Schuylkill  water.  Chicago  water 
contains  all  kinds  of  bacteria,  but  Gehrman  says  he  has  never  found  the  strepto- 
coccus in  it. 

Stroganoff  proved  that  the  bath-water  obtained  access  to  the  vagina  when,  as 
in  multiparse,  the  vulva  gapes  more  or  less,  and  other  laborious  investigations  have 
been  made.  The  question  can  be  very  simply  decided  by  asking  multiparous  women 
whether  the  bath-water  enters  the  vagina.  Most  of  them  answer  in  the  affirma- 
tive; therefore  the  scales  of  epithelium  and  soil  from  the  whole  body,  mixed  with 
the  water,  and  some  of  the  bacteria,  must  gain  entrance  to  the  vagina.  If  a  woman 
has  an  ulcer  or  other  suppuration  on  her  body,  the  danger  is  greatest.  In  such  cases 
the  general  bath  should  be  forl)idden.  Bumm,  when  in  Halle,  reported  two  cases 
of  severe  vulvar  streptococcus  infection  occurring  from  baths  in  a  tub  in  which  old 
culture  tubes  of  the  streptococcus  had  been  washed.  That  puerperal  infection  can 
be  carried  from  one  patient  to  another  on  the  bed-pan,  douche-points,  etc.,  is  a 
fact  known  since  before  Semmelweis. 

(4)  The  husband  as  a  source  of  infection  has  not  been  sufficiently  recognized. 
Among  the  lowest  classes  coitus  in  the  latter  weeks  of  gestation  is  by  no  means  rare, 
and  it  has  been  performed  even  during  labor.  Kisch  refers  to  the  practice  of  cer- 
tain midwives  who  ask  the  husband  to  have  intercourse  with  the  parturient  to 
stimulate  the  la):)or  pains.  In  one  of  the  fatal  cases  of  sepsis  in  the  dispensary' 
service  of  the  Chicago  Lying-in  Hospital  the  bag  of  waters  was  ruptured  by  the  act, 
and  the  child  was  born  before  the  arrival  of  the  physician.  In  another  coitus  was 
performed  thrice  during  the  night,  pains  beginning  at  3  a.  m.  and  delivery  being 
completed  at  11  a.  m.  Lustgarten,  Wassermann,  and  others  have  shown  that  the 
streptococcus  vegetates  in  the  urethra  of  healthy  men,  Asaciu'a  finding  it  in  12.5  per 
cent,  of  112  cases,  and,  further,  the  staphylococcous  group  and  pseudodiphtheria 
bacilli  are  often  found.  In  the  diseased  urethra  streptococci,  pyococci,  diplococci 
(Gram-negative),  gonococci.  Bacterium  coli,  and  cocci  which  resemble  the  Diplo- 


826  PATHOLOGY  OF  THE  PUERPERIUM 

streptococcus  puerperalis  hav,e  been  found.  Entirely  apart  from  the  finding  of 
bacteria  in  the  urethra,  it  is  certain  that  the  penis  is  never  sterile,  and,  if  it  were,  it 
would  carry  in  bacteria  from  the  vulva. 

(5)  The  patient  herself  may  carry  infection  to  the  genitalia  on  her  fingers.  I 
have  seen  severe  and  even  fatal  puerperal  disease  result  from  a  carbuncle  on  the  neck 
(a  precipitate  labor),  a  running  ear  (a  streptococcous  infection  following  influenza), 
ulcus  cruris,  a  paronychia,  and  there  are  on  record  authentic  instances  of  the  trans- 
portation, by  the  patient,  of  virulent  organisms  from  other  distant  parts  of  the  body 
to  the  genitals,  for  example,  from  the  purulent  cavity  of  an  artificial  eye,  from  a 
weeping  eczema,  a  mastitis,  an  intertrigo.  How  often  in  such  cases  the  germs  are 
carried  bj^  the  blood-stream  to  the  puerperal  wounds,  instead  of  by  the  hands,  can- 
not be  determined.  It  seems  probable,  in  several  reported  cases  of  tonsillar 
abscess,  in  influenza,  erysipelas,  scarlatina,  and  pneumonia,  that  the  infection  was 
thus  transmitted. 

A  suppurating  or  inflammatory  focus  in  or  near  the  genital  tract  is  often  a  source 
of  danger.  In  my  own  experience  a  vaginal  abscess  which  ruptured  during  delivery 
caused  an  extensive  bilateral  parametritis;  an  appendix  adherent  to  the  tube  caused 
a  fatal  endometritis  and  bacteremia;  a  gonorrheal  vaginitis,  late  infection  and  pyo- 
salpinx;  a  non-gonorrheal  vaginitis,  an  endometritis  saprophytica  with  toxinemia; 
a  recto-uterine  fistula,  fatal  peritonitis;  a  gangrenous  myoma,  a  severe  toxinemia; 
infected  urine  (streptococcus),  septicemia  and  double  phlegmasia  alba  dolens. 
Cases  are  reported  of  jouerperal  fever  from  ruptured  appendiceal  abscesses,  from 
cystitis,  from  bartholinitis  (gonococcus  and  streptococcus),  from  cancer  of  the 
uterus,  from  eczema  and  intertrigo  pudendi,  from  enterocolitis  (streptococcus  and 
Bacterium  coli).  It  must  be  added  that  many  women  affected  with  the  diseases 
mentioned  above  go  through  labor  without  the  development  of  infection,  it  being 
the  case  that  the  woman's  local  and  general  immunities  have  been  sufficiently  devel- 
oped to  repel  the  invading  microorganisms. 

Predisposing  Causes. — (1)  Pregnancy  itself  favors  the  attack  of  bacteria, 
which  is  perhaps  explained  by  the  changes  in  the  liver,  in  the  kidneys,  and  the 
demineralization  of  the  tissues.  Animals  are  more  sensitive  to  infection  at  this 
time.  (2)  The  shock  of  labor,  which  is  really  a  surgical  operation,  comprising  the 
making  of  wounds,  many  of  which  are  contused,  and  the  bruising  of  the  peri- 
toneum, lowers  the  vital  resistance.  (3)  All  conditions  which  reduce  the  vitality, 
as  profuse  hemorrhages,  eclamptic  toxemia,  coincident  affections,  as  typhoid, 
pneumonia,  grip,  syphilis,  cardiopathies,  alcoholism,  overwork,  hunger,  mal- 
nutrition, etc.  (4)  Lack  of  thyroid  or  action  of  other  blood-forming  glands 
may  be  operative.  (5)  Prolonged  labor,  especially  after  the  rupture  of  the  bag  of 
waters,  because  of  the  frequent  vaginal  explorations,  and  the  greater  time  and 
opportunity  for  Ijacteria  to  wander  upward,  increases  both  the  frequency  and  the 
severity  of  the  infections.  Demelin,  in  513  cases,  has  shown  that,  as  the  time  elaps- 
ing increased  from  twelve  hours  to  five  days,  the  percentage  of  infections  increased 
from  0.8  to  11.26  per  cent.  The  bad  influence  of  exhaustion  deserves  repetition 
here.  (6)  Operative  interference,  because  of  the  wounds,  contusions,  and  the  bacteria 
introduced  from  without,  increases  both  morbidity  and  mortality.  Too  early  rup- 
ture of  the  bag  of  waters  acts  in  this  way;  the  hard  head  tears  the  cervix  instead  of 
dilating  it  softly,  and,  besides,  dry  labors  often  have  to  be  terminated  instru- 
mentally.  (7)  Retention  of  pieces  of  placenta,  of  membranes,  and  of  blood-clots 
favors  infection,  the  most  dangerous  being  the  placental  remnants.  The  glycogen 
and  peptones  of  the  involuting  uterus  produce  favoring  cultural  conditions.  Lochial 
retention  causes  fever,  but  is  seldom  continued  long  enough  to  cause  real  sickness. 

The  author  has  gone  rather  fully  into  the  etiology  of  puerperal  fevers,  mainly 
with  the  view  to  pointing  out  a  rational  prophylaxis. 

Reaction  of  the  Organism  Against  Injection. — Very  properly  the  whole  parturient 


PUERPERAL    INFECTION  827 

canal  is  regarded  as  a  wounded  surface  after  delivery,  and  healing  takes  place  in  the 
manner  of  ordinary  surgical  wounds.  The  endometrium  is  more  or  less  covered  by 
a  layer  of  necrosing  decidua,  but  tlu;  ends  of  the  septa  between  the  glands  are 
partly  exposetl,  and  when  tin?  decidua  falls,  they  are  fully  exposed,  but,  fortunately, 
at  this  time  they  are  jirotected  b\'  the  bank  of  leukocytes  beneath  the  surface. 
Under  the  necrosing  decidua  an  active;  leukocytosis  occurs,  the  connective-tissue 
cells  increase  in  niuubers,  plasma  cells  are  thrown  out,  all  of  which  prevents  the 
invasion  of  all  but  the  most  virulent  bacteria,  and,  at  the  same  time,  aids  in  the 
casting  off  of  the  dead  decidua.  By  the  sixth  day,  in  normal  cases,  epithelization  is 
usually  complete,  except  at  the  placental  site.  Here  the  thrombi  in  the  open  vessels 
require  more  time  and  different  methods.  The  placental  site  is  rough  and  raised; 
often  is  covered  with  irregular  masses  of  thick  decidua,  tough  fibrin,  and  sometimes 
even  shreds  of  placenta  or  bits  of  villi.  Organization  occurs  in  the  thrombotic 
sinuses;  the  bank  of  granulations  thickens  and  causes  the  exfoliation  of  the  super- 
imposed foreign  masses.     This  may  require  two  weeks. 

The  effect  of  bacteria  on  these  healing  processes  varies  with  the  nature  of  the 
microorganism  and  the  manner  in  which  it  is  introduced. 

If  the  germs  are  saprophj^tic, — that  is,  without  invasive  qualities, — they  may 
not  disturb  the  healing  process  at  all;  at  most,  if  they  produce  caustic  toxins,  super- 
ficial necrosis  results.  Blood-clots,  decomposing  bits  of  membrane  and  of  placenta, 
and  dead  or  injured  tissues  harbor  saprophytic  bacteria.  Without  doubt  the  toxins 
they  develop  can  produce  cloudy  swelling,  even  necrosis  of  the  uppermost  layers  of 
cells,  and  these  toxins  may  be  absorbed  into  the  blood,  the  vagina  and  the  uterus 
postpartum  being  actively  resorptive.  Since  some  bacteria  produce  ptomains  and 
alkaloids,  for  example,  sepsin  and  putrescin,  these  may  likewise  be  absorbed.  Under 
the  necrotic  layer  a  bank  of  leukocytes  limits  the  further  advance  of  bacteria.  All 
this  is  very  superficial,  and  even  sutured  wounds  heal  in  the  depths — just  the  edges, 
being  exposed  to  the  noxa,  may  be  slightly  affected.  IMore  or  less  pus  i.s  formed  on 
the  surface,  and  its  discharge  continues  until  all  the  dead  tissue  is  removed.  Symp- 
toms, if  there  are  any,  are  due  to  the  toxins — and  few  bacteria — absorJDed,  and  the 
condition  is  called  toxinemia.     Duncan  named  it  sapremia. 

If  the  bacteria  are  pyogenic,  but  without  marked  invasive  qualities,  they  go  a 
little  deeper  into  the  tissues  and  the  wound  reaction  is  greater.  Owing  to  the  favor- 
ing conditions  of  the  puerperal  tissues,  the  succulence,  the  bruising,  with  lowered 
vitality,  and  the  presence  of  peptone  and  glycogen  from  the  involuting  uterus,  the 
bacteria  rapidly  multiply.  Their  presence  and  their  toxins  cause  a  dilatation  of  the 
local  l)lood-vcsscls,  and  b}'  a  positive  chemotaxis  phagocytes  and  leukocytes  are 
crowded  into  the  neighborhood  of  the  invaders,  and  exudations  rich  in  polymor- 
phonuclears and  eosinophiles,  plasma  cells,  and  lymphocytes  are  thrown  out. 
Gradually  the  fixed  connective-tissue  cells  and  the  leukocytes  form  a  firm  bank  or 
granulation  wall,  which  resists  the  further  advance  of  the  bacteria  and  prevents  the 
absorption  of  their  poisons.  This  granulation  wall  is  composed  of  polynuclear  and 
mononuclear  leukocytes,  eosinophiles,  fibroblasts,  and  polyblasts.  Absence  or 
paucity  of  the  multinuclear  neutrophiles  and  the  eosinophiles,  with  increase  of  the 
mononuclears,  indicates  poor  tissue  reaction  (Adami). 

Bacteria  produce  poisons  which  may  be  soluble,  leaving  the  body  of  the  cell, 
or  fixed  in  the  body  of  the  cell,  being  liberated  when  the  germ  dies  or  is  broken  up. 
The  former  are  called  exotoxins;  the  latter,  endotoxins.  Toxins  may  be  met  and 
neutralized  by  antitoxins  already  existent  in  the  body  or  produced  for  the  occasion. 
Endotoxins  are  not  thus  gotten  rid  of.  It  is  believed  that  the  bacteria,  laden  with 
poisons, — e.  g.,  aggressins, — are  met  by  certain  substances  in  the  blood-serum  which 
cause  the  dissolution  of  the  bacteria  (Ij'sins),  or  agglutinate  them  (agglutinins),  or 
so  Aveaken  them  that  they  may  be  successfully  attacked  by  the  phagocytes  (opsonins). 
It  must  be  remembered  that,  in  addition  to  the  poisons  made  by  the  bacteria,  the 


828  PATHOLOGY    OF   THE    PUERPERIUM 

b^'-products  of  the  decomposition  of  the  protein  of  the  cells,  ptomains  and  leuko- 
mains,  may  be  absorbed.  All  these  cellular,  biochemic  processes  may  be  limited  to 
the  region  around  the  site  of  entrance  of  the  infective  organisms.  The  outpouring  of 
lymph  may  be  large,  the  leukocytosis  marked,  and  the  swelling,  therefore,  be  great, 
and  all  the  classic  signs  of  inflammation  may  be  present.  Here  it  may  be  best  to 
emphasize  the  difference  between  infection  and  inflammation.  Inflammation  is  the 
reaction  of  the  tissues  against  the  invasion  of  the  noxious  elements,  and  is  nature's 
attempt  at  defense  and  repair.  If  the  tissues  and  leukocytes  are  much  injured  by  the 
toxins  of  the  bacteria,  or  if  their  nutrition  is  cut  off  by  the  plugging  of  the  capillaries, 
local  necrosis — pus-formation — occurs.  If  not,  the  poisons  are  neutralized,  the 
exudates  are  reabsorbed,  the  bacteria  dissolved  or  removed  by  the  leukocytes,  which 
also  help  remove  the  phagocytes  killed  in  battle,  and  the  fixed  connective-tissue 
cells  organize  into  more  or  less  permanent  fibrous  tissue,  leaving  scars.  During  all 
this  process  toxins — and  a  few  bacteria — get  into  the  blood,  producing  general  symp- 
toms— fever,  rapid  heart,  prostration,  etc.  The  process  is,  however,  quite  local, 
and  the  condition  is  still  called  toxinemia. 

If  the  invasive  power  of  the  bacteria  is  very  great,  a  quality  of  certain  strains 
of  streptococcus,  even  the  intact  vagina  may  not  be  able  to  withstand  the  attack. 
The  streptococcus'  aggressins  drive  away  the  leukocytes,  and  itself  quickly  invades 
the  lymph-vessels,  into  the  subcutaneous  and  submucous  tissues,  multiplying  rapidl}'. 
Within  an  hour  after  inoculation  (some  say  a  few  minutes)  it  is  beyond  the  reach 
of  the  most  powerful  antiseptic,  and  the  result  to  the  patient  depends  on  her  power 
of  resistance.  The  battle  between  the  streptococcus  and  its  toxins — streptocolysin, 
leukocidin,  etc.,  with  the  patient's  leukocytes,  and  immune  bodies,  alexins,  etc. — 
is  soon  transferred  to  the  blood  itself,  and  a  real  bacteremia  occurs.  (It  is  pos- 
sible, in  a  text-book  of  this  nature,  only  to  indicate  the  processes  involved.  For 
full  information  the  reader  is  referred  to  works  on  immunity  and  general  pathology, 
such  as  those  of  Ricketts  and  Adami.) 

The  Streptococcus  pyogenes,  discovered  by  Mayerhofer  in  1865,  cultivated  by 
Pasteur  in  1879  from  the  blood  of  women  dying  from  puerperal  fever,  and  isolated 
in  pure  culture  by  Ogsten,  in  1883,  is  the  cause  of  the  majority  of  the  cases  of  infec- 
tion after  childbirth.  It  gains  entrance  at  any  point  of  the  parturient  canal,  passes 
at  once  into  the  lymph-spaces  and  along  the  capillaries  into  the  blood-stream,  with- 
out producing  much  local  reaction.  Serous  and  seropurulent  exudate  may  be  slight 
or  much,  depending  on  the  virulence  of  the  invader.  The  streptococcus,  unless 
of  minimal  virulence,  does  not  produce  soluble  toxins,  but  its  body  contains  hemo- 
l3'sin  and  leukocidin,  although  the  actual  toxic  agent  is  unknown.  Various  forms 
of  streptococci — the  Streptococcus  longus,  S.  brevis,  S.  erysipelatis,  S.  capsulatus — 
are  the  result  of  different  cultural  conditions  within  and  without  the  body.  Hemo- 
h'sis  is  not  a  constant  characteristic,  and  does  not  indicate  excessive  virulence,  nor 
does  the  length  of  the  chains,  although  usually  the  long  chains  are  the  most  danger- 
ous. As  was  already  stated,  the  streptococcus  may  be  found  in  the  vagina  of  many 
apparently  healthy  women.  It  exists  in  a  state  of  very  low  virulence  as  a  sapro- 
phyte. By  proper  cultural  treatment  it  may  })e  made  very  active  and  extremely 
pathogenic  for  animals.  We  have  an  analogon  in  the  case  of  the  human,  when  strep- 
tococci, made  virulent  by  "passage"  through  one  puerpera,  are  introduced  into  the 
genitals  of  another,  there  causing  a  violent  infection,  or  when  they  are  carried  from 
the  inflamed  nose  or  throat  of  an  attendant  to  the  puerperal  wounds.  All  forms  of 
puerperal  infection,  from  a  simple  toxinemia  from  retained  lochia  to  the  bacter- 
emias which  may  be  fatal  in  a  few  hours,  may  be  produced  by  the  streptococcus. 
Which  it  shall  be  depends  on  the  natural  strength  of  the  inoculated  coccus,  the 
natural  resistance  of  the  patient,  the  number  of  the  bacteria  introduced,  the  con- 
comitant injury  of  the  tissues,  the  location  of  the  point  of  entrance,  and  the  time  of 
the  infection.     Severe  disease  will  result  if  only  a  few  chains  of  a  highly  invasive 


PUERPERAL   INFECTION  829 

organism  arc  introduced,  or  if  liic  woman's  resistance  happens  to  Ix- very  low  at  the 
time,  as  by  hemorrhafi;e,  shock,  renal  or  hepatic  disease,  etc.  If  the  tissues  are 
much  bruised  by  labor,  they  are  not  in  condition  to  resist  invasion  by  even  a  mild 
streptococcus.  If  the  germs  are  deposited  near  the  peritoneal  cavity,  for  example, 
in  a  deep  cervix  tear,  or  on  the  thrombi  of  the  placental  site,  dangerous  infections, 
peritonitis,  and  metro])hlebitis  are  more  apt  to  follow  than  if  they  were  inoculated 
into  a  perineal  laceration.  If  the  inoculation  occurs  late  in  the  puerperium,  the 
lymph-vessels  are  quite  closed,  the  blood-vessels  sealed,  the  local  immunities  well 
developed,  and  the  surface  w^ell  protected  by  a  granulation  wall — all  of  which  pre- 
serves tiie  i^atient  from  invasion.  The  severest  fevers  result  from  direct  inoculation 
of  the  endometrium  and  placental  site  during  labor  itself. 

The  .staphylococcus  was  separated  from  the  streptococcus  by  Ogsten  in  1883  in 
purulent  affections.  Doleris  found  it  in  1880,  and  Brieger,  in  1888,  demonstrated 
the  Staphylococcus  aureus  in  five  fatal  cases  of  puerperal  infection.  All  the  staphy- 
lococcus group — Staphylococcus  aureus,  albus,  flavus,  and  citreus — have  been  found 
in  these  cases,  and  occasionally  one  or  the  other  is  associated  with  the  streptococcus 
(Bar,  Tissier,  the  author).  Members  of  the  staphylococcus  group,  called  briefiy 
pyococci,  are  less  invasive  than  the  streptococcus.  They  elicit  marked  leukocytosis, 
but,  possessing  leukocidin  and  proteolytic  ferment,  they  kill  the  leukocj'tes  and 
licjuef}'  the  tissues,  producing  pus.  They  produce  soluble  toxins,  hemolysin  and 
leukocidin,  and  true  exotoxins,  which  elicit  the  antitoxins  of  the  blood,  but  the  viru- 
lence of  the  germ  depends  not  on  these,  and  since  an  endotoxin  has  not  been  de- 
monstrated, again  we  are  at  a  loss  to  explain  their  toxicity.  Local  and  general 
leukocytosis  characterizes  infections  with  this  bacterium,  and,  contrary  to  a  general 
belief,  severe  and  fatal  puerperal  fever  can  be  caused  by  it,  as  one  of  my  cases  proved, 
although  this  is  unusual. 

Pyococci  are  found  on  every  vulva  and  in  most  vaginas  before  and  during  the 
puerperium,  but  they  live  as  harmless  parasites,  unless  their  virulence  is  exalted 
by  accidental  conditions.  They  may  cause  suppuration  in  perineorrhaphies,  non- 
union of  cervix  tears,  and  are  responsible  for  many  cases  of  parametric  abscesses 
and  of  slow  pyemia,  but,  as  was  said,  they  may  cause  any  of  and  all  the  forms  of 
puerperal  fever  which  the  streptococcus  can  produce.  The  organism  reacts  against 
invasion  of  the  pyococcus  by  phagocytosis,  and  by  means  of  antibacterial  products 
present  in  the  serum,  and  thrown  oft"  l^y  the  leukocj'tes,  which  are  perhaps  of  the 
nature  of  opsonins. 

The  Bacterium  coli  commune,  or  the  colon  bacillus,  is  the  exponent  of  a  group  of 
organisms  inhabiting  the  intestinal  tract,  and  has  been  repeatedly  found  in  fatal 
cases  of  puerperal  infection.  In  one  case  it  was  introduced  by  the  gauze  used  for 
the  packing  of  the  uterus,  the  patient  having  a  diarrheal  evacuation  at  the  time,  un- 
observed by  the  operator.  Gebhard  demonstrated  the  Bacterium  coli  in  a  case  of 
tympania  uteri  which  I  had  the  privilege  of  observing,  and  Widal,  Bar,  Durante, 
and  von  Francjue  have  proved  it  causative  of  puerperal  infections.  Bar  called  at- 
tention to  the  "colibacillosc  gravidique,"  which  manifests  itself  as  appendicitis, 
cholecystitis,  or  utcropyelonephritis.  It  may  cause  general  septicemia,  with  or 
without  metastases,  endocarditis  (Rendu),  meningitis,  otitis,  peritonitis  (but  the 
local  symjitoms  are  minimal),  and  phlegmasia  alba  dolens  (Jeannin).  Usuallj'  the 
infection  is  local,  causing  decomposition  and  suppuration,  with  fetid  lochia  and 
toxinemia.  It  is  often  associated  with  the  streptococcus,  and  the  symbiosis  exalts 
the  virulence  of  the  latter  decidedly  (Bar  and  Tissier). 

The  gonococciis  was  proved  by  Kronig,  in  1894,  to  be  responsible  for  many  cases 
of  puerperal  infection.  It  acts  in  two  ways — first,  by  preparing  the  tissues  for  the 
invasion  of  other  organisms,  and  by  symbiosis  exalting  their  virulence,  as  well  as  its 
own,  or  it  takes  a  leading  role  itself.  In  a  fatal  puerperal  infection  I  demonstrated 
the  gonococcus  and  the  streptococcus  in  the  peritoneal  exudate.     Halle  and  Rendu, 


830  PATHOLOGY  OF  THE  PUERPERIUM 

Harris  and  Dabney,  have  shown  that  it  can  cause  general  septicemia  with  endocar- 
ditis. ]\Ietastases  may  occur  in  the  joints,  resembhng  those  of  pyococcal  and  strep- 
tococcal infections,  and  in  the  eye,  brain,  skin,  bones,  pleurae,  etc.,  but  usually  the 
processes  are  local,  that  is,  acute  urethritis,  endometritis,  salpingitis,  pelveoperi- 
tonitis,  parametritis,  and  ovarian  abscess.  A  latent,  apparently  cured  gonorrhea, 
may,  as  the  result  of  the  traumatism  of  labor  and  the  favorable  cultural  conditions 
of  the  puerperium,  become  acute  and  progredient.  The  gonococcus  produces  no 
exotoxin,  but  contains  endotoxin,  which  is  leukotactic,  yet  the  bacteria  seein  to 
harm  the  leukocytes  but  little.  Infections  with  the  gonococcus  develop  pus  and 
purulent  exudates,  the  general  toxinemia  being  mild  and  the  course  of  the  disease 
usually  favorable,  though  protracted.  Owing  to  the  slow  growth  of  the  organism, 
the  morbid  manifestations  usually  appear  late  in  the  puerperium. 

Many  other  well-known  bacteria  have  been  found  as  the  agent  of  more  or  less 
severe  puerperal  infections.  The  Bacillus  pyocyaneus,  a  dangerous  organism  for 
children,  rarely  causes  trouble  with  the  mother,  but  when  it  does,  the  reaction  is 
usually  severe,  with  high  fever,  much  prostration,  hemorrhagic  diathesis  (pyo- 
cyaneus hematoxin),  and  splenic  tumor.  Symbiosis  exalts  the  mutual  virulency. 
In  one  case  of  severe  puerperal  infection  I  found  the  pneumococcus.  It  is  impossible 
clinically  to  distinguish  this  infection  from  those  due  to  other  pus  cocci. 

Bacillus  Typhosus. — In  1898  I  found,  in  the  uterine  lochia  of  a  puerpera  who 
was  ill,  apparently  with  typhoid,  a  culture  of  the  Bacillus  typhosus.  The  Griin- 
baum-Widal  reaction  was  very  marked  in  her  blood.  An  internist,  on  the  general 
sj^mptoms,  would  not  make  a  positive  diagnosis  of  entero-tyiphoid,  while  the  local 
findings — large,  tender  uterus — pointed  to  an  infection.  The  disease  terminated  by 
lysis,  and  I  believe  this  case  is  similar  to  one  observed  by  Williams  in  the  same  year. 

The  bacillus  of  tetanus  has  repeatedly  been  demonstrated  in  puerperal  tetanus 
{vide  infra),  and  the  Klebs-Loffler  bacillus  of  diphtheria  has  been  found  in  true 
diphtheric  exudates  on  the  puerperal  wounds.  Over  40  cases  of  true  diphtheric 
infection  in  the  puerperium  are  on  record  (Bourret).  The  streptococcus  and  the 
staphylococcus,  especially  in  association  with  bacilli  of  the  colon  group,  may  pro- 
duce grayish,  greenish,  or  yellowish  pellicles  on  the  vulva  and  vagina,  but  these 
are  not  so  thick  as  those  due  to  true  diphtheria,  and  they  are  more  adherent  to 
their  base.     Bacteriologically,  they  are  easily  differentiated. 

Bacteria  of  decomposition  and  putrefaction,  of  which  there  is  an  immense  host, 
may,  if  given  proper  conditions, — large  amount  of  dead  material  to  feed  on, — pro- 
duce serious,  even  fatal,  toxinemias.  They  produce  toxins  (sepsin),  and  these,  with 
the  by-products  of  their  action  on  albumin  (ptomains,  leukomains,  etc.),  being 
absorbed,  cause  chills,  fever,  vomiting,  stinking  diarrhea,  prostration,  delirium,  etc. 
Duncan  gave  the  name  ^'sapremia"  to  this  condition,  and  if  thus  restricted,  it  is  a 
term  which  ought  to  be  retained.  Many  authors  use  the  term  as  synonymous  with 
toxinemia  from  all  local  causes.  These  putrefactive  bacteria  are  legion,  anaerobic 
and  aerophile.  Von  Herff  says  that  there  are  nine  forms  of  streptococci  among  the 
aerobic  saprophytes,  together  with  the  Bacillus  coli,  the  Bacillus  aerogenes  cap- 
sulatus,  the  Micrococcus  foetidus.  Staphylococcus  parvulus,  Bacillus  radiiformis. 
Bacillus  nebulosus.  Bacillus  racemosus  (habitual  in  gangrenous  processes).  Bacillus 
caducus,  and  others.  As  a  rule,  these  bacteria  possess  no  invasive  power,  but  some, 
the  Bacillus  coli  and  the  Bacillus  aerogenes  capsulatus,  the  Streptococcus  putridus, 
may  break  through  the  leukocyte  wall  into  the  lymphatics  and  the  blood.  If  there 
is  much  dead  or  deeply  injured  tissue  about,  these  bacteria  may  produce  putrid 
gangrene,  as  in  putrid  endometritis,  and  the  absorbed  toxins  may  be  fatal.  Some- 
times living  tissue  will  succumb  to  the  gangrene-producing  Ijacteria  and  slough  off 
— metritis  desiccans.  It  is  almost  invarable  that  the  streptococcus  and  staphy- 
lococcus— indeed,  any  germ  which  takes  the  leading  role  in  a  given  infection — 
will  have,  in  symbiosis,  one  or  many  of  the  putrefactive  bacteria. 


PUERPERAL    INFECTION  831 

Gas-forming  organisms  are  often  found  in  cases  of  fetid  and  frothy  lochia. 
Dangerous  gas  })uil(l('rs  are  the  Bacterium  coli,  the  Bacillus  aerogenes  capsulatus, 
BaciUus  (edeniatis  malignus,  and  the  jiseudobacillus  of  malignant  edema.  Of  these, 
tlie  best  known,  through  the  hihors  of  \\'('l('h  and  WilHams,  is  the  Bacillus  aerogenes 
capsulatus,  which  is  perhaj^s  identical  witii  the  "vihrion  septicjue"  of  l^asteur  and 
Doleris.  If  it  invades  the  tissues,  these  become  emphysematous  and  gangrenous; 
if  tiie  blood,  the  vessels  are  full  of  frothy  blood,  and  the  liver  and  the  spleen  become 
spongy  with  gas.  The  body  sw^ells  up  with  general  emphysema,  and  there  are 
hemorrhages  and  jcterus.  Some  cases  of  so-called  air  embolism  are  realh'  infections 
of  this  sort.  It  is  rare  to  find  this  organism  alone — usually  the  pyocyaneus,  the 
proteus,  the  Micrococcus  foetidus,  other  gas-forming  bacilli,  and  especially  the 
Streptococcus  ])V()gen(*s,  are  found  in  association.  The  symbiosis  makes  the  germs 
mutually  highly  virulent  and  the  clinical  pictures  intensely  complicated.  If  these 
gas-builders  once  get  beyond  the  confines  of  the  surface  of  the  genital  tract,  they 
usually  evince  terribly  invasive  qualities,  leukocytosis  is  scant,  and  toxinemia  rapid 
and  prostrating.  The  heart  is  quickly  depressed,  hemolysis  occurs,  with  jaundice 
and  blec'ding  into  vital  organs,  the  serous  surfaces,  and  the  skin. 

Finalh',  in  many  cases  of  puerperal  fever  bacteria  have  been  found  which  cannot 
l)e  placed  in  our  present  nosology,  and  many  occur  which  cannot  be  grown  on  our 
known  media. 

Classification  of  the  Forms  of  Puerperal  Infection. — Puerperal  fever  is  a  protean 
disease.  As  may  be  seen  from  the  above,  many  bacteria,  single  and  in  comljination, 
may  be  operative,  and  these  may  produce  local  and  general  infections,  both  mild 
and  severe.  Women  react  differently  to  these  various  agents — some  possess  im- 
munity, other  a  weakness  against  particular  bacteria.  Some  possess  idiosj^ncracies 
for  the  toxins  produced  by  certain  bacteria.  Diseases  of  the  vital  organs  alter  the 
general  reactions  of  the  system  against  invasion,  and  there  are  many  other  conditions 
which  make  the  clinical  pictures  exceedingly  complex,  so  that  a  perfect  anatomic  and 
pathologic  diagnosis  may  rarely  be  made.  For  the  same  reasons  no  classification  of 
them  so  far  offered  is  entirely  satisfactory.  We  may  now  appreciate  the  achieve- 
ment of  Semmelweis,  since  he  saw,  through  the  maze  of  apparently  divergent 
pathologic  processes,  that  they  all  were  due  to  one  underlying  cause — wound  infec- 
tion and  resorption. 

A  classification  founded  on  the  bacteriology,  a  botanic  or  biologic  classification, 
would  be  the  most  scientific,  but,  clinically,  this  is  impractical  because — (1)  Several 
(from  1  to  15)  different  organisms  may  combine  in  producing  the  s^anptoms;  (2) 
one  organism  can  produce  several  different  forms  of  puerperal  disease  and  differing 
degrees  of  severity;  (3)  the  organism  which  may  be  isolated  from  the  lochia  or  the 
blood,  though  it  often  is,  may  not  be,  the  cause  of  the  morbid  process;  (4)  it  may 
not  be  possible  to  identify  the  germ  which  is  causing  the  worst  s>Tnptoms,  or  even 
to  discover  it  at  all. 

Another  classification  is  that  based  on  anatomic  pathologic  findings,  and  which 
divides  the  cases  strictly  according  to  the  parts  involved.  Thus  there  are  vulvitis, 
vaginitis,  endometritis,  parametritis,  perimetritis,  metrophlebitis,  etc.  Clinically, 
this  is  better,  but  not  all  the  forms  of  puerperal  fever  are  localized  to  the  sites  at 
which  the  infection  enters — a  general  sepsis  may  occur  from  a  frenulmn  tear,  and 
any  of  the  germs  mentioned  may  gain  entrance  at  any  place  in  the  genitals  and  pro- 
duce various  and  complicated  sjanptom-complexes,  and,  further,  the  simple  knowl- 
edge of  the  site  of  the  disease  is  not  a  sufficient  guide  to  a  rational  treatment.  To 
say,  for  example,  that  a  woman  has  endometritis  is  In'  no  means  enough. 

Crede  divided  the  cases  into  local  and  general  infections,  a  plan  which  01s- 
hausen  and  Bumm,  to  a  certain  extent,  have  followed.  Bumm  first  describes  the 
cases  of  "wound  intoxication,"  or  toxinemia,  which  is  similar  to  the  sapremia  pre- 
viously defined,  and  then  mentions  'Svound  infection,"  which  he  divides  into — (1) 


832  PATHOLOGY    OF   THE    PUERPERIUM 

The  local  processes  in  the  perineum,  the  cervix,  and  the  endometrium;  (2)  the 
spreading  of  the  infection  beyond  the  wound — (a)  through  the  blood-vessels,  caus- 
ing septicemia,  thrombophlebitis,  pyemia;  (h)  through  the  lymph- vessels,  causing 
perimetritis,  parametritis,  metritis  desiccans,  etc. 

The  division  of  the  cases  into  three  forms — sapremia,  septicemia,  and  pyemia — 
is  an  old  one,  and  inappropriate.  Sapremia  has  already  been  defined.  It  had  better 
be  replaced  by  the  term  toxinemia,  or  ''septic  intoxication."  Septicemia  or  sepsis 
means  the  absorption  into  the  blood  of  living  ferments — bacteria,  which,  multiply- 
ing there  and  in  the  jBne  capillaries,  produce  intense  morbid  changes,  either  by  the 
toxins  or  by  capillary  embolism  and  thrombosis.  A  better  term  is  bacteremia, 
septicemia  being  etjTiiologically  incorrect.  Pyemia  literally  means  pus  in  the  blood, 
and  in  some  cases  it  may  be  appropriate,  and  if  it  is  understood  to  apply  only  to 
those  cases  where  suppurating  emboli  break  loose  from  an  infected  thrombus  in  a 
vein,  producing  distant  purulent  metastases,  it  may  be  retained.  It  were  better, 
however,  to  replace  it  with  the  term  metastatic  bacteremia,  because  this  describes 
those  cases  where  the  bacteria  themselves  are  transported  from  the  infected  throm- 
bus. These  three  clinical  forms  almost  never  exist  alone,  but  are  combined.  It 
cannot  be  doubted  that  in  all  local  infectious  processes  many  bacteria  get  into  and 
are  killed  in  the  blood-stream.  The  culture  of  the  germs  from  the  blood,  therefore, 
is  not  positive  evidence  of  progressive  bacteremia.  In  all  bacteremias  there  is  also 
toxinemia,  from  toxins  both  developed  in  the  blood  and  absorbed  from  the  site  of 
entrance  of  the  germ — the  wound  infection.  As  was  shown  above,  the  streptococ- 
cus, the  pyococcus,  the  colon  bacillus,  the  capsulated  gas  bacillus,  and  many  others 
may  play  the  role  of  a  saprophyte,  or,  as  the  most  invasive  infectious  agent,  causing 
a  mild  toxinemia,  a  deadly  bacteremia,  or  a  metastatic  bacteremia.  It  is  evident 
now  that  a  generally  applicable  single  classification  is  impossible,  and  for  the  pur- 
poses of  nosology  in  practice  it  will  be  necessary  to  state — (1)  The  site  of  the  en- 
trance of  the  infection  and  its  course ;  (2)  the  extent  of  the  infection,  whether  mainly 
local  or  already  generalized;  (3)  the  kind  and  degree  of  virulence  of  the  germ  which 
is  causative.  It  may  not  always  be  possible  to  get  all  this  information.  Our  diag- 
noses will  read  like  the  following  examples:  Toxinemia  due  to  vulvitis — Staphylo- 
coccus aureus;  toxinemia  due  to  placental  fragments  and  saprophytic  organisms; 
toxinemia — and  perhaps  slight  bacteremia — from  parametritis — streptococcus; 
bacteremia  from  endometritis — streptococcus,  virulent;  metastatic  bacteremia 
from  metrophlebitis — Staphylococcus  aureus,  mild;    and  so  on. 

Literature 

Adami:  Principles  of  Pathology,  1908,  vol.  i.  Inflammation. — Bourret:  L'Obstetrique,  October,  1911,  p.  883. — Bumm 
and  Sigwart:  Arch.  f.  Gyn.,  July,  1912,  vol.  xcvii,  Bd.  iii,  p.  628. — Fasbender:  Geschichte  der  Geburtshilfe, 
p.  804.  Literature. — Holmes,  Oliver  Wendell:  "Puerperal  Fever  a  Private  Pestilence,"  Medical  Essays. — 
Kronig  and  Pankow:  Centralb.  f.  Gyn.,  1909,  p.  101. — Lea,  A.  W.  W.:  Puerperal  Infection,  1910.  Oxford 
Medical  Publications.  Gives  literature. — Mackenrodt:  Centralb.  f.  Gyn.,  April  13,  1912,  p.  475. — Mauriceau: 
Chamberlain's  Translation,  10G8.- — Ricketts:  Infection  and  Immunity,  Chicago,  1908. — Semmelweis:  Gesam- 
melte  Werke,.  190.5. — Walthard:  Handbuch  der  Geb.,  v.  Winckel,  vol.  iii,  2. —  Wegelius:  Arch.  f.  Gyn., 
1909,  vol.  Ixxxviii,  H.  2,  p.  360.  Literature. — Williinns,  J.  Whittridge:  In  Jewett's  Practice  of  Obstetrics, 
gives  literature  to  1899.  Von  Winckol's  Handbuch,  up  to  1906;  Zcitschr.  f.  Geb.  u.  Gyn.,  vol.  Ixix,  p.  634,  up 
to  1912.— Winter:   Centralbl.  f.  Gyn.,  1911,  p.  irMl.—Zwei/el:   Centralbl.  f.  Gyn.,  1911,  p.  941. 


I 


CHAPTER  LXIV 
CLINICAL  TYPES  OF  PUERPERAL  INFECTION 

Even  th()Uf>;li  it  is  usually  impossible  clearly  to  distinguish  between  a  retention 
toxineniia  and  an  infection  or  bacteremia,  and  even  though  in  practice  the  various 
forms  of  puerperal  infection  to  l)e  mentioned  may  merge  into  each  other,  still  they 
often  present  clinical  pictures  which  are  fairly  characteristic  and  tj'pical,  and  suffi- 
ciently shar])  for  diagnosis,  prognosis,  and  treatment.  The  following  are  the  forms 
of  puerperal  infection  most  commonl}^  met,  being  placed  about  in  the  order  of  their 
frequency:  vulvitis  and  colpitis;  endometritis,  mild  and  malignant;  retention  in- 
toxication (the  sapremia  of  Duncan,  or  toxinemia,  from  material  pent  up  in  the 
genitalia);  parametritis;  peritonitis,  pelvic  or  general;  true  bacteremia  or  septi- 
cemia; metastatic  bacteremia  or  septicopyemia;  phlegmasia  alba  dolens;  endo- 
carditis;   tetanus  genitalise;    diphtheria  genitaliae. 

Vulvitis.— Causes  are  traumatism  during  labor  plus  infection.  Previous  dis- 
ease predisposes — for  example,  bartholinitis,  abscess,  fistulas,  etc.  As  a  rule,  after 
operative  deliveries  there  are  more  or  less  contusion  of  the  parts  and  many  little 
wounds  and  abrasions.  If  a  perineorrhaphy  has  been  done,  the  possibility  of  wound 
infection  is  greater.  The  alkaline  blood  and  serum  permit  the  saprophytic  strepto- 
cocci and  other  bacteria  to  regain  some  of  their  virulence,  and  it  is  not  unusual  to 
find  these  wounds  covered  with  grayish  or  greenish  exudates,  and  even  superficial 
ulceration  may  occur.  These  are  called  "puerperal  ulcers,"  and  are  often  accom- 
panied by  pronounced  swelling  of  the  whole  vulva.  In  from  six  to  eight  days  the 
swelling  subsides,  the  superficial  sloughs  are  cast  off,  pink  granulations  pushing  up 
to  the  surface,  and  epithelization  rapidly  takes  place,  scar  formation  being  slight. 
If  the  perineorrhaphy  w^ound  becomes  infected,  the  parts  are  swollen,  with  a  brawny 
exudate;  the  edges  of  the  wound  are  red,  their  line  of  apposition  not  united,  but 
separated  by  pus  and  sloughing  tissue,  serum  and  pus  oozing  out  of  the  stitch-holes. 

Symptoms. — If  the  drainage  is  free,  there  are  no  marked  sjTuptoms.  The 
patient  complains  of  burning  on  urination,  more  or  less  inability  to  urinate,  pain 
and  discomfort  from  the  swelling,  with  a  sense  of  local  heat.  The  temperature  is 
seldom  raised  alcove  101°  F.,  the  pulse  above  100.  If  suturing  prevents  the  exit  of 
the  infected  exudations,  or  if  the  infective  agent  w^as  an  alien  streptococcus,  a  sharp 
chill  and  fever,  even  of  104°  F.,  may  usher  in  the  disease;  the  pulse  maj'  go 
above  120,  and  this  may  be  the  starting-point  of  a  general  bacteremia. 

Vaginitis. — The  causes  are  the  same — too  much  traumatism  during  labor  plus 
infection.  Too  prolonged  labor,  too  frequent  examinations,  the  use  of  very  hot 
douches  or  of  too  caustic  antiseptics,  prolonged  application  of  the  colpeurjTiter,  of 
gauze  packing,  bruising  from  brutal  operating,  cutting  by  the  forceps,  bj'  spiculse  of 
bone  in  craniotomy,  the  retention  in  the  vagina  of  blood-clots,  membranes,  gauze 
sponges,  etc. — all  these  favor  infection  by  producing  conditions  which  develop  the 
virulence  of  the  germs  normallj'  present  in  the  vagina  (for  example,  the  streptococ- 
cus and  the  staphylococcus).  If,  in  addition,  alien  bacteria  are  introduced,  the 
woman  seldom  escapes  a  dangerous  malady,  because  they  find  ideal  conditions  for 
their  gro^^■th  in  the  contused  tissues  bathed  in  an  alkaline  blood-mixture  containing 
much  dead  material,  that  is,  the  lochia.  Astonishing  are  the  recuperative  powers  of 
the  vagina  in  the  absence  of  hetero-infection. 
53  833 


834  PATHOLOGY  OF  THE  PUERPEEIUM 

If  the  vagina  were  opened  toview  by  specula  (which  is  contraindicated),  the  usual 
signs  of  inflammation  would  come  into  view,  with  many  puerperal  ulcers  discharg- 
ing purulent  secretions.  If  many  injuries  had  been  laid,  the  wounds  will  be  seen, 
their  edges  covered  with  sloughs,  and  an  infiltration  extending  around  the  vagina, 
even  to  the  walls  of  the  pelvis,  and  a  lymphangitis  may  also  be  found.  These 
wounds  heal  by  granulation,  with  the  free  discharge  of  sometimes  foul-smelling  pus, 
and  leave  cicatrices  which  may  extend  to  the  base  of  the  broad  ligaments,  to  the 
periostemii,  or  under  the  base  of  the  bladder,  causing  fixation  and  distortion  of  the 
pelvic  viscera.  Alien  bacteria,  especially  the  streptococcus,  may  cause  pericolpitis, 
peritonitis,  and  even  bacteremia.  The  symptoms  are  severer  than  those  of  vulvitis, 
especially  if  the  causative  bacteria  are  invasive  or  produce  much  toxin.  If  drainage 
is  free,  the  general  reaction  is  usually  mild;  if  the  discharges  are  retained  (a  con- 
dition called  lochiocoljjos) ,  severe  toxinemic  manifestations  arise  {vide  infra). 

The  diagnosis  of  vulvitis  is  easily  made  by  inspection  of  the  vulva.  This  is  a 
good  place  to  call  attention  to  the  value  of  the  signs  present  on  the  vulva  indicating 
infection  higher  up.  Early  in  the  disease  the  presence  of  puerperal  ulcers  may  be 
very  significant  of  grave  infections  involving  the  uterus.  The  infectious  lochia 
washing  over  the  vulvar  wounds  almost  always  cause  superficial  necrosis.  As  the 
disease  heals  the  local  signs  disappear.  Vaginitis  is  never  present  without  some  in- 
flammation of  the  vulva. 

Treatment. — Douches,  internal  examinations  by  the  finger  or  with  specula,  are 
contraindicated.  If  the  retention  of  a  gauze  sponge  is  suspected,  a  rectal  examina- 
tion will  disclose  it.  If  there  are  sutures  in  the  perineum,  they  are  to  be  removed 
on  the  first  suspicion  of  an  infection.  To  leave  them  in  the  hope  of  getting  a  union 
in  spite  of  the  infection  is  to  trifle  with  an  unknown  foe,  and  usually  be  defeated 
in  the  end.  If  the  confined  infective  exudates  do  not  cause  paracolpitis,  para- 
metritis, or  even  general  infection,  the  tissues  break  down  into  pus  which  escapes 
into  the  vagina,  and  the  skin  only  uniting,  prolapsus  vaginae  and  descensus  uteri 
follow,  nevertheless.  After  removal  of  the  sutures  and  opening  up  the  recesses  of 
the  wound  widely  the  latter  may  be  flushed  with  tincture  of  iodin,  and  a  thin  strip 
of  gauze  laid  between  its  edges  to  keep  up  drainage.  External  flushings  with  a  weak 
antiseptic  are  frequently  practised,  but  no  vaginal  douches,  since  these  may  carry 
the  infection  higher.  Ergot  and  hydrastis,  15  minims  of  the  fluidextract  of  each, 
are  given  four  times  daily,  the  bowels  are  kept  free,  and  hexamethylentetramin,  5 
grains  four  times  a  day,  exhibited,  if  there  is  the  least  indication  on  the  part  of  the 
bladder.  I  often  use  the  latter  as  a  preventive.  For  the  relief  of  local  pain  and 
discomfort  a  warm  wet  boric  or  lead-water  dressing  may  be  used. 

Endometritis. — Very  few  puerperal  infections  occur  without  involvement  of  the 
endometrium.  Indeed,  the  cervix  and  endometrium  are  the  ports  of  entry  to  the 
parametrium,  the  perimetrium,  the  tubes,  and  the  shortest  way  to  the  blood  itself. 
The  reasons  for  the  frequent  involvement  of  the  endometrium  are:  (1)  The  cervix 
and  the  lower  uterine  segment  are  particularly  exposed  to  the  traumatisms  of  labor 
and  of  operative  delivery;  (2)  the  mucous  membrane  is  very  delicate  in  structure 
as  compared  with  that  of  the  vagina,  and  it  is  covered  with  a  layer  of  dying  decidua, 
favorable  to  the  growth  of  bacteria;  (3)  blood-clots,  membrane,  even  placental 
fragments,  may  be  retained;  (4)  the  infection  may  have  been  present  in  the  endo- 
metrium during  pregnancy  (see  Microbic  Endometritis),  or  brought  there  directly 
by  colpeurynter,  bougie,  or  decomposed  liquor  amnii;  (5)  shreds  of  membrane 
hanging  dowai  in  the  vagina  act  as  a  Ijridge  on  which  the  bacteria  mount  into  the 
uterus;  (6)  the  open  vessels  of  the  placental  site  are  particularly  favorable  to  the 
nidation  of  germs;  (7)  if  the  uterus  is  flabby  and  relaxed,  stasis  of  the  lochia  may 
occur,  a  condition  particularl}^  favorable  to  ])acterial  growth. 

It  must  not  be  supposed  that  the  presence  of  decidua  or  even  a  piece  of  pla- 
centa in  utero  means  that  it  will  cause  an  endometritis.     The  infection  must  also 


CLINICAL   TYPES    OF    PUERPERAL    IXFKCTIO.V 


835 


be  present.     Pieces  of  placenta  can  remain  in  the  uterus  for  weeks  without  decom- 
posing, until,  after  a  careless  examination,  the  infection  begins. 

The  importance  of  a  well-contracted  uterus  was  recognized  even  in  the  olden 
time.  A  uterus  that  is  relaxed  absorbs  very  actively  toxins  produced  in  its  interior, 
and  again  it  allows  them  to  accunmlate  here.  A  well-{;ontracted  uterus  exj)els  de- 
composing clots,  secretions,  etc.,  and,  in  addition,  has  less  absorptive  power,  since 
both  blood-vessels  and  lymphatics  are  held  cIoschI.  If  the  uterus  becomes  bent  on 
itself  at  the  cervix,  especially  after  the  sixth  day,  when  the  uterus,  being  strongly 
antev(>rted,  may  catch  behind  the  symphysis,  or  if  retroflexed,  under  the  promon- 
tory, the  lochia  may  be  pent  up,  and  a  condition  analogous  to  lochiocolpos  results. 


>•  Decidua 


ITluscularis 


Fig.   730. — Decidua    ix    Six-weeks'    Abortion.      Decidua    Only     Infected.      Eosin    and    Methylene-blue 
Stain   (spocimon  presented  by  Dr.  Reinhart).     See  detail  in  Fig.  740. 


It  is  more  common  than  tliis,  and  is  called  lochiometra.  It  usually  causes  a  severe 
chill  and  rise  in  temperature,  which  go  down  just  as  quickly  if  the  cause  is  removed. 
Pathology. — To  avoid  repetition,  the  reader  is  referred  to  p.  208  for  a  description 
of  the  changes  in  the  normal  uterus.  In  endometritis  the  mucous  membrane  is 
swollen,  rough,  covered  with  thickened  decidua  in  a  state  of  necrosis,  and  the  surface 
is  moist,  with  a  mucopurulent,  sometimes  hemorrhagic,  smeary  materiaL  The 
cervix  is  almost  always  involved  in  the  same  way;  it  is  swollen  and  eroded,  and,  in 
addition,  the  wounds  are  covered  with  puerperal  ulcers.  Involution  becomes 
slower,  and  the  uterus  becomes  edematous  and  relaxed,  giving  the  germs  ready  ac- 
cess to  the  blood.  Bumm  distinguished  two  forms  of  endometritis — first,  that  due 
to  putrid  or  bacillary  infection,  in  which  the  bacteria  were  limited  to  the  surface  and 
to  the  necrotic  material  there  by  a  protecting  bank  of  white  cells  and  granulations, 


836 


PATHOLOGY  OF  THE  PUERPERIUM 


and,  second,  a  coccal  or  septic  infective  form,  where  the  bacteria,  usually  strepto- 
cocci and  pyococci,  invade  the  lymphatics  and  blood-vessels  after  overcoming  the 
bank  of  leukocytes  and  granulations.     After  examining  many  specimens  I  was  able 


I  J 

Fig.  740. — Bacteria  in  Ixfected  DEciDtTA.     High  Power.     Eosin  and  Methylene-blue  Stain. 

to  find  only  one  where  the  bacteria  were  limited  to  the  surface  (Figs.  739  and  740). 
In  the  putrid  endometritis  the  surface  of  the  endometrium  is  covered  with  a  thick, 
fetid  material,  often  containing  gas-bubbles,  and  of  a  grayish  or  yellowish-greenish 
color — even  black  from  decomposed  blood.     It  is  impossible  to  wipe  the  surface 


lltCA-O^t 


~VC[  lA/a  0\JwLi>J\\h 


Fio.  741. — Postpartu.m  Endometritis   (Streptococcus). 

Granulation  wall  in  endometrium.     Hematoxylin  and  eosin  .stain.     Bactfria  have  pa.sscd  through  this  protecting  wal 

See  Figs.  742  and  743,  which  were  taken  from  the  places  liore  inflicated  by  A  and  B. 


smooth,  as  in  the  normal  uterus.  If  the  bacteria  are  more  virulent,  thej^  cause  ac- 
tual sloughing  of  the  endometrium,  Avith  many  superficially  ulcerated  areas,  covered 
Avith  a  diphtheroid  (not  diphtheric)  exudate,  and  the  whole  interior  of  the  uterus 
has  a  putrescent  appearance  and  odor — putrescentia  uteri.     Usually  the  pus  cocci 


CLINICAL   TYPES    OF    PUERPERAL    INFECTION' 


837 


and  the  hactciia  of  decomposition  arc  hero  associated.  If  the  gangrene  goes  deeper 
into  the  wall  of  the  uterus,  an  evidence  of  still  greater  virulence  of  the  bacteria 
(streptococci  and  anaerobes),  larger  or  smaller  portions  of  the  lining  of  the  uterus, 
or  even  of  the  muscle  itself,  may  slough  off— the  metritis  desiccans  of  Garrigues. 


&  :^ 


^^^^^0 

^^9^-^m 


~  *•'' 


©5  s^^.  i., 


^^ 


®) 


'■^■•A 


--^    ftS> 


r^ 


',  \1.    -SiKiri- ^1      \w:--.^.     l)i:c]|)r'Ai,    Vvaaj; 

I^NDOMICTKITIS   FosTI'A  liTL M,  GRAM  StAIN. 


From  point  A  in  Fig.  741. 


V 

y 


Fig.  743. — Strlptcji  (,r  .  I  i\   li  lium:  Mr.-,  m^.     EndO- 

.METKITIS   P(J.STl'AHTiJ-\l,   GKA.M   .StaI-S. 

From  point  B  in  Fig.  741. 


Bladder 


Internal  os 


External  os 


Fig.  744. — Uterus  on  Fifth  Day  Postpartum,  from  a  Case  of  Sepsis  (Barbour). 

Schottmtiller  showed  that  the  majority  of  cases  of  endometritis  putrida  were  due 
to  an  obligate  anaerobic  streptococcus.  He  demonstrated  this  coccus  in  parame- 
tritis and  i3crimetritis,  in  pyosalpinx,  and  in  the  blood  of  cases  wdiich  formerly 
were  called  toxinemia. 

Infections  due  to  Streptococcus  pyogenes  and  the  pyococci  alone  do  not  give 


838 


PATHOLOGY  OF  THE  PUERPERIUM 


rise  to  fetor,  and  the  surface  of  the  uterus  is  usually  smooth  and  not  deeply  necrotic. 
In  rare  instances  the  infection  is  limited  to  the  placental  site,  being  usually  mild,  due 
to  a  pyococcus  of  attenuated  virulence,  and  producing  little  local  inflammation,  but 
often  protracted  forms  of  metastatic  bacteremia.     (See  Pyemia.) 

As  a  general  rule,  the  bank  of  granulations  suflaces  to  limit  the  infection  to  the 
uterus,  unless  nature's  beneficent  processes  are  disturbed  by  the  meddling  accou- 
cheur; but  sometimes  the  bacteria,  especially  the  streptococcus,  pass  on  into  the 
lymphatics,  causing  parametritis  and  perimetritis,  even  general  peritonitis,  or 
bacteremia,  or,  through  the  veins  via  the  thrombi,  causing  metastatic  bacteremia 
of  an  acute  type.     To  these  forms  reference  again  will  be  made. 

Symptoms. — For  the  first  two  or  three  days  the  puerpera  is  fairly  well,  but  an 


Fig.  74.5. — Endometritis  in  Pueepeeio. 
A  streptodiplococcus  was  found  in  the  lochia.     Rccoverj'.     Upper  line  is  the  pulse. 


acute  observer  will  find  that  there  are  vague  indications  of  brewing  trouble.  Slight 
malaise,  unrest  at  night,  pain  in  the  uterus,  prolonged  after-pains,  or  their  recur- 
rence after  having  subsided,  will  attract  the  accoucheur's  attention.  On  the  third, 
fourth,  or  fifth  day  there  is  a  slight  chill  or  chilly  sensation,  with  rise  of  temperature, 
and  all  the  usual  febrile  symptoms — feeling  of  heat,  anorexia,  insomnia  (except  in 
the  very  mild  cases),  headache.  Objectively,  the  accoucheur  will  find  the  pulse  100 
to  140,  and  the  temperature  101°  to  104°  F.,  depending  on  the  severity  of  the  infec- 
tion. The  abdomen  is  perhaps  a  trifle  distended,  but  there  is  no  tenderness;  the 
uterus  is  usually  larger  than  it  should  be  on  the  day  in  question  (Fig.  744),  and  softer 
than  normal — that  is,  in  a  state  of  retarded  involution.  Rarely  is  tenderness  absent, 
and  the  sides  are  often  sensitive  to  even  light  palpation.  The  lochia  at  the  very 
first  are  unaltered,  but  within  forty-eight  hours  have  lost  their  characteristic  quali- 


CLINICAL   TYPES    OF    PUERPERAL    INFECTION  839 

ties  and  become  serous,  flesh-water  colored,  or  sero])urulent.  Unless  saprophytes 
have  deveiopetl  in  larji;e  iiuinhers,  the  lochia  are  not  foul,  but  they  have  an  in- 
sipid or  purulent  odor.  The  lochia  have  caustic  and  infective;  cjualities,  and  soon 
the  wounds  about  the  vulva  are  covered  with  a  diphtheroid  exudate,  forming  the 
puerperal  ulcers  already  mentioned. 

Unless  the  inlection  is  very  virulent,  the  symptoms  and  objective  signs  are  no 
more  thr(>atening  than  described;  the  temperature,  after  pursuing  a  remittent 
(1°  to  2°  F.)  course  for  four  or  five  days  (Fig.  745),  subsides  by  lysis,  the  pulse  slows, 
and  in  six  to  ten  days  recovery  is  established.  If  the  infecting  bacteria  are  strong 
enough  to  overcome  the  protecting  wall  of  kmkocytes,  the  blood  is  involved  and  the 
general  symptoms  are  marketl,  the  case  having  become  a  bacteremia  (see  below). 

Diagnosis. — Endometritis  has  no  characteristic  symptoms.  With  the  usual 
manifestations  of  infection  one  finds  a  large,  sensitive  uterus,  evidences  of  slight 
peritoneal  irritation,  and  altered  lochia.  The  vulvar  wounds  have  an  unhealthy 
aspect,  except  when  the  endometritis  is  due  to  ncjn-virulent  saprophytes,  in  which 
case  these  wounds  may  heal  under  healthy  granulations.  If  a  specular  examination 
is  made,  the  condition  of  the  cervix  will  be  a  criterion  of  the  condition  of  the  endo- 
metrium. The  lochia  in  the  putrid  infections  are  profuse,  thick,  and  foul,  while  in 
the  streptococcic  kinds  they  are  diminished,  thin,  sanious,  with  an  acrid  odor. 
The  absence  of  signs  of  peritonitis  and  of  tumor  eliminates  localization  outside  the 
uterus.     Prognosis  and  treatment  will  be  discussed  later. 

Sapremia,  Retention  Fever,  Toxinemia. — Clinically,  a  not  small  group  of  cases 
exists  with  fever  and  often  very  threatening  symptoms,  due  to  the  absorption  of 
toxins  from  decomposing  material  in  the  genital  tract.  Lochiocolpos  and  lochio- 
metra  have  already  been  referred  to.  If  the  toxins  were  always  the  result  of  the 
action  qf  saprophytic  bacteria,  the  organisms  of  putrefaction,  the  term  sapremia, 
proposed  by  Duncan,  would  apply.  But  the  streptococcus  and  other  cocci  and 
bacteria  may  grow  in  the  dead  tissue  and  produce  toxins,  which  are  absorbed,  and, 
further,  the  author  would  rather  agree  with  Schottmiiller,  Latzko,  and  Zangemeis- 
ter,  as  opposed  to  Doderlein,  Bumm,  and  others,  that  in  all  these  cases  manj^  bacteria 
get  into  and  are  killed  in  the  blood.  The  distinction,  therefore,  between  toxinemia 
and  bacteremia  is  mainly  one  of  degree,  and  the  term  sapremia  must  be  limited  to 
those  infections  where  only  putrefactive  organisms  are  present.  We  use  the  terms 
septicemia  and  sepsis  in  a  very  loose  way  to  mean  a  bacteremia  by  the  pus-cocci, 
when  the  Greek  original  means  putridity.  We  might  also  thus  use  the  term 
sapremia,  but  it  would  be  better  to  discard  all  three,  which,  however,  at  present  is 
impractical. 

When  a  puerpera  develops  fever,  which  by  exclusion  is  found  to  come  from  the 
genitals,  the  first  question  that  arises  is.  Is  there  anything  in  the  uterus?  If  there 
is  a  piece  of  placenta,  a  clot,  or  a  mass  of  membranes  in  the  uterus,  the  same  may  not 
become  infected  if  the  uterus  is  firmly  contracted  and  if  no  alien  bacteria  are  carried 
in  from  the  outside.  Should  it  become  infected,  the  symptoms  are  those  of  endo- 
metritis, and  there  is  always  more  or  less  reaction  in  the  endometrium. 

Another  danger  of  these  infected,  necrosing  bodies  lies  in  their  providing  a 
favorable  nidus  for  the  virulent  streptococcus,  in  developing  the  virulence  of  weak- 
ened cocci,  or  native  bacteria,  or  in  altering  the  subjacent  mucosa,  so  that  it  offers 
less  resistance  to  the  microorganisms  normally  present  in  the  vagina,  cervix,  and 
uterus.  Bacteremia  has  often  followed,  but  in  most  cases  the  disease  remains  local, 
and  there  is  no  marked  invasion  of  the  lymph-  and  blood-streams. 

Symptoms. — It  is  impossible  to  distinguish  this  condition  from  an  endometritis, 
since  the  symptoms  are  nearly  identical.  Lochiometra  and  lochiocolpos  are  char- 
acterized by  absence  of  the  lochia.  If  a  piece  of  membrane  or  placenta  has  been 
retained,  the  after-pains  often  continue  until  it  is  expelled,  after  which  also  the  fever 
and  rapid  pulse  subside.     Profuse  and  very  bloody  lochia  are  the  rule  if  portions  of 


840 


PATHOLOGY    OF   THE   PUERPERIUM 


the  placenta  are  retained,  and  repeated  hemorrhages  or  the  passage  of  clots  are  al- 
most pathognomonic.  The  uterus  is  large  and  soft  in  such  cases.  As  an  aid  to  the 
diagnosis  the  history  of  the  labor  is  useful,  since  the  placenta  may  have  shown  de- 
fects, or  the  prolonged  oozing  postpartmn  may  have  led  the  accoucheur  to  believe 
that  there  was  a  clot  in  the  uterus.  Since  uterovaginal  examinations  are  not  per- 
mitted, the  state  of  the  uterine  cavity  can  only  be  guessed  at.  A  rectal  exploration 
might  reveal  a  mass  in  the  vagina,  or  a  retroflexecl  or  anteflexed  uterus,  causing 
locliiostasis,  and  the  protrusion  from  the  vulva  of  a  shred  of  membrane  or  a  bit  of 
placenta  might  indicate  that  there  may  be  more  higher  up.  Treatment  will  be 
considered  later. 

Parametritis. — ]Mauriceau,  about  1760,  first  described  inflammations  of  the 


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Fig.  740. — Chart  of  a  Toxinemia. 
Retained  membranes.     No  local  treatment  except  removal  of  sutures. 


Dotted  lino  is  the  pulse. 


pelvic  connective  tissue,  and  Velpeau  associated  them  with  the  genital  organs, 
which  Doherty  proved  in  1843.  Virchow  applied  the  term  parametritis  to  these 
pelvic  phlegmons,  but  pelvic  cellulitis  is  a  better  one,  because  the  disease  is  very 
seldom  limited  to  the  neighborhood  of  the  uterus,  but  may  involve  the  connective 
tissue  from  the  vulva  to  the  kidney,  and,  further,  it  does  not  always  begin  around 
the  uterus.  Through  the  researches  of  Mattliews  Duncan,  W.  A.  P'reund,  and  A. 
von  Rosthom,  our  knowledge  of  pelvic  cellulitis  has  been  placed  on  firm  foundation. 
Causation. — As  in  the  other  puerperal  infections,  pelvic  cellulitis  is  caused  by 
bacteria,  and  these  gain  entrance  to  the  connective  tissue  in  various  ways  (Fig. 
747).  In  most  cases  the  atrium  of  infection  is  a  wound  of  the  cervix  or  lower  uterine 
segment,  but  the  injury  may  have  been  in  the  vagina  or  even  the  perineum.  Bac- 
teria may  break  through  the  granulation  bank  in  the  endometrium,  and,  passing 


CLINICAL   TYPES    OF    PUERPERAL    INFECTION 


841 


747. — Directions    Taken    by    the    Bacteria    to 
Reach  the  Pelvic  Connective  Tissue. 
A,    From  endometritis  through  uterine  wall;    B,  from 
cervix  tear;  C,  from  vaginal  tear  above   levator  ani;    D, 
from  perineal  tear;    E,  downward  from  peritonitis. 


thr()U<>;li  I  lie  uterine  \\:ill  !)>'  way  of  eilliei'  the  lymphatics  or  the  1)1(j(j(1-vo.ss('1s,  roach 
the  paranictriuni,  and,  (iiuilly,  they  may  wander  into  the  sul)jaeent  tis.suos  from  the 
l)erit(jncum  or  the  tubes,  which  may  be  infected. 

Nearly  always  it  is  the  Streptococcus  pyogenes  which  is  the  causative  organism, 
but  the  staphylococcus  hasl)een  found, 
also  the  colon  bacillus,  thouji;h  usually 
as  a  concomitant  infection,  and  even 
the  gonococcus  (Menge  and  Doderlein). 
Many  factors  favor  infection  of  the 
connective  tissue  in  the  i)elvis  after 
labor.  Besides  the  general  softening, 
t  he  edematous  imbibition  of  the  tissues, 
the  enlargement  of  the  connective-tis- 
sue spaces,  and  the  increased  vascu- 
larity due  to  pregnancy,  there  is  the 
direct  bruising  of  the  parts,  with  the 
bloody  and  serofibrinous  extravasa- 
tions. To  these  must  be  added  the 
inunediate  introduction  of  alien  and 
native  bacteria  through  lacerations  in-  ^'°- 
to  the  opened  spaces,  by  means  of  the 
hands,  instruments,  gauze,  etc. 

Pathology. — Cellulitis  in  the  pelvis 
differs  very  little  from  cellulitis  under  the  skin  or  elsewhere.     The  bacteria,  by  their 
presence  and  the  toxins  they  produce,  irritate  the  tissues,  a  protective  serum  is 
thrown  out  (inflammatory  edema),  leukocytes  hurry  to  the  scene,  the  binding  cells 

proliferate  and  form  fibrin,  all 
of  which  compose  an  exudate 
in  the  infected  area.  The  bac- 
teria pass  along  the  lines  of 
least  resistance,  and  these  are 
the  natural  planes  of  cleavage 
of  the  pelvic  connective  tissue, 
and  are  limited  by  firm  laj'ers 
of  fascia  and  by  the  organs  in 
the  pelvis.  The  infiammatorj^ 
exudates,  therefore,  following 
the  infection  will  extend  in  cer- 
tain directions,  passing  along 
the  planes  of  fascia,  and  sur- 
rounding and  embedding  the 
hollow  pelvic  organs.  Since 
the  inflammatory  reaction  is 
sometimes  excessive,  the 
amount  of  serum  and  fibrin 
and  cellular  infiltration  may 
overfill  the  tissue-spaces,  and 
the  exudate  itself  may  wander. 
On  the  other  hand,  the  bacteria 
may  select  an  unanatomic 
course,  for  example,  through  a  fascia  or  muscle,  and  then  the  inflammatory 
exudate  will  be  found  where  it  was  not  expected.  Yon  Rosthorn's  classification 
of  pelvic  exudates  is  the  most  practical:  '(1)  Lateral  horizontal  exudates  located 
in  the  bases  of  the  broad  ligaments,  with  a  tendency  to  spread  to  the  side  walls  of 


Fig.  748. — Parametritis  Puerperalis. 
Drawn  from  a  specimen  of  Dr.  Ries'.     Streptococci  in  the  tissues. 


842 


PATHOLOGY  OF  THE  PUEEPERIUM 


the  pelvis  and  around  the  cervix;  these  usually  come  from  cervix  tears;  (2)  high 
intraligamentous  infiltrations  beginning  near  the  cornua  uteri,  forming  tumors, 
rounded  above,  with  a  tendency  to  unfold  the  broad  ligaments  and  climb  up  into  the 
iliac  fossse;  these  usuallj^  come  from  endometritis;  (3)  exudates  in  the  retrocervical 
connective  tissue,  with  a  tendency  to  spread  either  posteriorly  along  the  uterosacral 
ligaments  or  sink  in  the  rectovaginal  septum;  (4)  exudates  in  the  precervical  tissues, 
and  spreading  toward  the  sides,  around  the  ureters;  (5)  exudates  anterior  to  the 
bladder,  behind  the  pubis,  with  the  tendency  to  rise  behind  the  recti  muscles,  even 
to  the  navel — "plastron  al^dominal"  of  the  French.  Several  of  these  forms  may 
be  combined.  The  most  common  is  the  lateral,  extending  from  the  side  of  the  uterus 
to  the  bony  pelvic  wall,  then  anteriorly  around  the  ureter,  raising  the  peritoneum 
up  and  appearing  above  Poupart's  ligament.  Rarer  distributions  are :  Posteriorly, 
to  the  sacrum  and  up  to  the  kidney,  or  even  to  the  diaphragm  and  through  it; 
laterally,  out  through  the  sciatic  foramen  into  the  thigh;  or  inside  the  infundibulo- 
pelvic  ligament  along  the  psoas,  involving  the  tissues  around  the  lumbar  plexus  of 
nerves. 

The  exudation  varies  in  extent  and  consistence,  depending  on  the  virulence 


Fig.  749. — Diagram  of  Cotirse  op  Infections  of  Pelvic 
Connective  Tissue. 


Fig.  750.- 


-Course  of  Infections  of  Pelvic  Connec- 
tive Tissue. 


of  the  germ  and  the  resistance  of  the  patient.  In  mild  cases  there  is  only  a  simple 
inflammatory  edema,  and  in  the  severest  cases  also  the  process  is  limited  to  a 
serous  and  poorly  cellular  infiltration,  the  bacteria  passing  quickly  through  the 
l^'mphatics  into  the  blood.  Most  often  there  is  adequate  reaction,  with  the  forma- 
tion of  large  exudates.  If  a  section  is  made  through  the  inflamed  tissues  at  the 
side  of  the  uterus,  the  lymph-vessels  will  be  found  thickened,  tortuous,  and  beaded, 
and  a  yello^^^sh  or  whitish  pus  exudes  from  numerous  fine  openings.  Around  them 
the  exudate  lies,  and  it  gives  the  surface  a  glistening,  glassy,  moist  appearance. 
Later,  white-cell  infiltration  and  fibrin  exudation  solidify  the  tissue  and  make  it 
opaque.  The  veins  are  often  thrombotic,  and  if  they  were  primarily  infected,  or 
even  if  they  become  so  secondarily,  the  thrombi  may  undergo  puriform  degenera- 
tion, the  debris  breaking  up  and  often  getting  into  the  circulating  blood  as  infected 
emboli.  The  arteries  are  usually  not  affected.  Later,  when  shrinking  of  the  scars 
occurs,  the  arteries  may  be  kinked,  the  same  being  true  of  the  veins,  and  varicosities 
may  develop,  or  chronic  venous  congestion,  with  its  noxious  results.  Implication 
of  the  ganglia  and  the  nerves  in  the  pelvis  results  in  their  partial  destruction,  but 
more  often  in  neuritis  and  perineuritis,  with  recovery  or  compromise  of  function. 


CLINICAL   TYPES    OF   PUERPERAL    INFECTION  843 

Th(>  pcritoiuiiiii  ol'  t  he  pcK  is  :il\\;iys  tiikcs  part  in  1  he  iiillaiiiiiial  ion;  t  lie  tubes  and 
ovaries  are  matted  to  the  broad  ligaments  or  the  uterus,  and  the  intestines  are  ad- 
herent to  the  pelvic  masses  of  exudate.  It  may  Ije  difficult  to  saj^  whether  the  para- 
metritis or  the  perimetritis  is  of  greater  moment. 

Nature  cures  these  cases  in  two  ways:  Either  tlie  <'xudates  are  realjsorlK'd  or 
they  suppurate.  In  the  latter  instance  the  pus  is  discharged  externalh'  or  encap- 
sulated, or  complete  resorption  occurs.  If  resolution  takes  place,  the  exuded 
fluids  are  absorbed,  phagocytes  attack  the  fil:)rin  and  detritus  (the  dead  leukocytes 
and  d(>ad  l)acteria),  and  digest  them  or  carry  them  off.  The  new-formed  connec- 
tive-tissue cells  make  the  scar  tissue,  and  filjrous  Ijands,  and  cicatricial  thickenings 
which  mark  the  site  of  the  inflammation.  These  cicatrices  distort  the  pelvic  or- 
gans, as  regards  position,  shape,  and  function.  The  uterus  is  sometimes  found 
drawn  over  to  one  side  of  the  pelvis,  and  moored  here  immovably;  or  it  may  be 
drawn  up  toward  the  sacrum  by  the  shortening  of  the  ut(^rosacral  ligaments — 
Schultze's  anteflexion, — or  it  may  be  twisted  on  itself.  Sometimes  the  neck  of  the 
bladder  is  pulled  open  by  the  retracting  scars,  causing  incontinence  or  "irritable 
jjladder."  Stricture  of  the  rectum  may  result.  Thickenings  in  the  fornices,  in 
the  uterine  ligaments,  with  displacements  of  the  uterus,  are  very  common  in  daily 
practice  and  indicate  the  frec{uency  of  mild  forms  of  pelvic  cellulitis  (Emmett). 

If  the  process  ends  by  suppuration,  necrotic  areas  appear  in  .various  parts  of 
the  exudate,  which  become  converted  into  pus.  The  Avhole  exudate  may  become 
one  abscess  or  several,  separated  by  septa.  Thus  the  entire  pelvis  may  be  riddled 
with  a])scesses.  Depending  on  the  location  of  the  exudate  and  its  proximity  to  one 
of  the  hollow  organs  of  the  pelvis,  pointing  will  occur,  and  unless  there  is  operative 
interference,  in  the  course  of  from  twenty  to  seventy  days  the  abscess  will  break 
into  the  rectum,  vagina,  bladder,  ureter,  sldn,  or  general  peritoneal  cavity.  Then, 
if  there  is  no  other  focus  of  suppuration,  the  cavity  closes  rapidly.  If  there  are 
other  foci,  these  may  undergo  the  same  process,  and  thus  the  patient  may  be  ill 
with  suppurating  cavities  for  months  and  even  years. 

These  latter  cases  and  the  immense  exudates  extending  to  the  navel  or  kidney 
are  very  rare  nowadaj's,  but  in  the  preantiseptic  time  they  were  common.  Some- 
times the  al^scess  does  not  open,  and  nature  cures  b}^  encapsulating  the  pus.  The 
wall  of  the  abscess  thickens  and  gets  firm  w^th  fibrous  tissue;  the  more  fluid  part 
of  the  pus  is  absorbed,  and  such  a  tmuor  may  persist  in  the  pelvis  for  years,  grad- 
ually shrinking  in  size.  I  watched  one  such  case  eight  years,  and  the  condition  had 
existed  for  six  years  before.  A  clinicallj'^  important  fact  is  that  the  germs  do  not 
always  lose  their  virulence,  but  may,  on  the  occasion  of  traumatism,  exposure,  ill 
health,  etc.,  break  out  with  renewed  fury  and  establish  a  general  bacteremia  (jNIartin 
and  Busse,  loc.  cit.,  p.  119).  Even  in  the  scars  from  exudates  which  supposedly 
had  been  reabsorbed  tiny  pus  cavities  containing  virulent  bacteria  may  later  be 
found,  a  point  of  immense  clinical  and  medicolegal  importance. 

Sy7npto»is. — In  the  mildest  forms,  traces  of  which  are  found  during  a  g3^leco- 
logic  examination  as  a  thickening  in  one  of  the  fornices,  or  a  displaced  uterus,  the 
symptoms  during  the  puerperium  are  hardly  noticeable.  A  slight  rise  of  tempera- 
ture, a  little  local  tenderness,  and  mild  febrile  symptoms,  which  are  usually  referred 
to  something  else  or  to  "milk  fever,"  may  not  even  call  the  attention  of  the  accou- 
cheur to  the  pelvis  at  the  time. 

With  the  severer  grades,  however,  there  are  marked  signs  of  disease.  The 
symptoms  usually  begin  on  the  third  or  fourth  clay.  If  the  fifth  day  has  passed 
without  symptoms,  according  to  Olshausen,  there  is  little  danger.  Still,  I  have  seen 
parametritis  begin  on  the  eighth  and  ninth  day.  These  cases  are  called  late  fever, 
and  are  sometimes  due  to  too  earl}'  getting  up,  which  starts  up  anew  an  umioticed 
parametritis,  or  the  movements  tear  open  some  small  wound  in  the  cervix,  or,  after 


844  PATHOLOGY  OF  THE  PUERPERIUM 

some  local  treatment  or  examination,  these  womids  are  reopened  and  infection 
enters. 

Nearl}'  always  the  symptoms  of  an  endometritis  precede  those  of  parametritis, 
and  an  acute  observer  may  be  able  to  determine  the  time  when  the  infection  passes 
the  bounds  of  the  uterus  and  strikes  into  the  broad  ligaments.  A  chill  or  chilli- 
ness, fever  of  103°  or  104°  F.,  pulse-rate  100  to  110,  and  marked  local  pain  are 
constant,  together  with  the  general  manifestations  of  the  febrile  state — headache, 
anorexia,  restlessness,  sleeplessness,  soreness  of  the  body.  All  movements,  cough- 
ing, sneezing,  etc.,  are  painful.  Nausea  and  vomiting  are  unusual,  but  do  occur, 
and  generally  indicate  that  the  peritoneum  is  involved  to  some  extent.  They  do 
not  persist  as  in  peritonitis.  The  general  impression  the  attendant  gets  is  that  the 
patient  is  not  seriously  ill.  Sometimes  the  parametritis  is  hidden  under  the  symp- 
toms of  a  general  sepsis.  The  fever  is  at  first  quite  continuous,  but  soon  becomes 
remittent,  and  later,  when  pus  has  formed,  it  may  be  intermittent.  Now,  repeated 
chills  occur,  and  sweats  accompany  the  defervescence.  Unless  the  pus  cavities  are 
freely  evacuated,  the  patient  may  pass  into  a  condition  called  by  the  older  writers 
''hectic,"  and  rasiy  die  of  exhaustion,  having  wasted  to  a  skeleton.  Rapid  dis- 
appearance of  the  symptoms  follows  on  proper  drainage  of  the  abscesses. 

If  absorption  of  the  exudate  takes  place,  the  temperature  gradually  subsides, 
the  local  symptoms  disappear  for  the  time,  but  later  symptoms  referable  to  some 
pelvic  displacement  make  themselves  apparent,  and  often  the  patient  becomes  an 
invalid  for  life. 

Resolution  may  require  only  ten  clays,  while  sometimes  it  may  be  sixty  days 
before  the  patient  can  safely  get  up.  The  severity  of  the  local  process  can  usually 
be  determined  by,  the  general  symptoms,  e.  g.,  temperature  and  pulse,  but  not  al- 
ways, as  sometimes  a  moderate  amount  of  exudation  causes  severe  symptoms,  while 
again  a  large  exudate  will  exist  vnth  only  mild  manifestations  of  disease. 

Locally  in  the  early  period  will  be  found  the  large,  soft,  tender  uterus  of  infec- 
tion, subinvolution,  and  at  either  side  of  the  uterus,  deep  in  the  flanks,  marked 
tenderness  on  pressure,  but,  relatively  to  peritonitis,  little  rigidity.  It  is  not  best 
to  make  a  vaginal  examination.  When  I  have  done  so  at  this  time  I  found  the 
whole  pelvis  hot  and  soft,  with  one  spot,  usually  the  lateral  fornix,  very  sensitive, 
and  an  ill-defined  thickening  present  in  this  region.  The  lochia  may  have  the 
appearance  of  the  lochia  from  endometritis.  If  the  infection  entered  at  the  site  of 
a  cervical  tear,  the  puerperal  discharges  may  not  be  much  altered.  Later  the  exu- 
date may  be  palpated  as  a  firm,  sometimes  almost  wood-like,  tumor,  at  the  side  of 
the  uterus  or  filling  the  pelvis  more  or  less,  embedding  the  pelvic  organs  as  one 
might  do  with  paraffin.  If  suppuration  occurs  in  the  mass,  the  numerous  tiny 
abscesses  fuse  together  into  a  large  one,  palpable  to  the  finger,  and  pointing  occurs. 
Vaginally,  the  soft  abscess  may  be  felt  bulging  down  one  of  the  fornices,  or  it  may 
better  be  felt  per  rectum.  Abdominally,  the  tumor  causes  a  prominence  above  one 
or  the  other  Poupart's  hgament,  the  skin  becomes  slightly  edematous,  reddens,  and, 
unless  the  accoucheur  anticipates  it,  the  tissues  break  do^\al  over  the  abscess  and 
the  pus  escapes  externall}^  Spontaneous  rupture  of  the  pus-sac  into  the  rectum, 
the  bladder,  or  the  vagina  seldom  occurs  before  the  third  week,  and,  through  the 
abdominal  wall,  still  later.  If  resorption  occurs,  the  tumor  hardens  and  shrinks, 
at  first  rapidly,  later  slowly,  requiring  three  to  twelve  weeks,  and  rarely  several 
years,  to  disappear. 

Pressure  of  the  exudate  on  the  various  hollow  viscera  in  the  pelvis,  and  com- 
munication of  the  infection  to  them,  are  accompanied  by  symptoms  appropriate  to 
each  organ.  Cystitis,  ureteropyelitis,  even  hydronephrosis  from  ureteral  obstruc- 
tion, with  uremia  and  death,  have  been  noted.  (Edema  bullosum  precedes  the 
opening  of  the  abscess  into  the  bladder.  Proctitis,  with  mucous  and  bloody  diar- 
rhea, often  precedes  the  discharge  of  the  pus  per  rectum.     Involvement  of  the 


CLINICAL   TYPES    OF    PUERPERAL    INFECTION 


845 


nerves  in  the  pcKis  cuuscs  nciii-aljiias,  and  ('\'cii  paralyses  of  the  muscles  in  the  legs. 
If  the  infection  takes  the  patii  alonji;  the  blood-vessels  to  the  thifi;h,  one  of  the  forms 
of  phlegmasia  alha  dolens  may  result  (q.  v.). 

Diagnosis. — At  first  it  may  not  be  easy  to  differentiate  this  inflammation  from 
others  in  the  pelvis,  though  the  history  of  cervical  injury,  the  pain  and  tenderness 
at  the  sides  of  the  uterus,  with  absence  of  peritonitic  symptoms  and  signs,  will 
render  such  a  suspicion  well  grounded.  When  the  tumor  develops,  the  diagnosis  is 
usually  easy  and  its  discussion  will  be  taken  up  later. 

The  prognosis  is  usually  good.  With  proper  treatment  the  patient  has  a  mild 
course  of  fever,  and  absorption  of  the  exudate  takes  place.  Even  after  the  forma- 
tion of  abscesses  the  ])rognosis  as  to  life  is  good,  as  the}'  either  break  or  are  incised 
and  then  heal.  In  the  larger  abscesses  the  prognosis  is  to  be  guarded,  as  they  some- 
times sujijHirate  for  months,  the  pelvis  becoming  riddled  with  sinuses,  and  the  pa- 
tient finally  dying  of  hectic  fever  and  exhaustion. 


Fig.  751. — Cradle  for  Hot-air  Treatment  of  Chroxic  Cellulitis. 

Made  of  tliin  sheet-iron  and  covered  with  asbestos.     A  bag  of  calcium  chlorid  is  hung  inside  while  in  use,  to    absorb 

moisture,  but  must  not  be  near  the  bulbs  (see  Gellhorn). 


The  prognosis  as  to  health  is  not  so  good,  because  only  too  often  the  women 
have  permanent  backache,  leukorrhea,  or  disturbed  pelvic  circulation — ch'smenor- 
rhea — and  symptoms  of  uterine  displacements.  The  scars  may  contract  and  cause 
pressure  on  the  nerves  (neuralgias  and  paralysis)  or  on  the  ureters,  producing 
hydronephrosis, — which  the  exudate  may  also  do, — or  traction  on  the  bladder, 
and  cause  tenesmus  and  incontinence,  or  on  the  rectum,  making  a  stricture.  The 
uterus  is  sometimes  draA^Ti  to  different  parts  of  the  pelvis  and  fixed,  or  it  is  walled 
up  in  thick  connective  tissue  and  atrophies. 

Treatment  of  Pelvic  Cellulitis. — Besides  the  treatment  applicable  to  all  puerperal  infected 
cases,  attention  is  to  be  directed  to  the  prevention  of  the  spread  of  the  infection  and  to  the  evacu- 
ation of  pelvic  abscess,  or  to  means  to  hasten  the  absorption  of  large  exudates.  Since  sitting  up 
and  getting  out  of  bed  are  known  to  cause  extension  of  the  disease,  manifested  bj'  chill,  increased 
pain,  and  fever,  the  patient  must  lie  quietly  on  her  back  during  the  acute  stages.  Vaginal  and 
intra-uterine  manipulations  are  unwise  and  harmful.  An  ice-bag,  a  hot-water  bag,  or  warm, 
moist  heat  may  be  applied.  Cathartics  are  sparingly  used,  and  if  enemata  are  required,  they  maj- 
not  exceed  six  ounces  in  amount.  Operation  is  contraindicated  in  the  acute  stages,  even  if  the 
exudates  ai"e  immense — reaching  above  the  navel.  If  the  symptoms — irregular  fever,  chills,  emaci- 
ation— point  to  suppuration  in  the  mass,  or  if  fluctuation  is  demonstrated,  the  abscess  is  to  be 
opened.     As  a  rule,  there  need  be  no  precipitation  in  this  matter,  experience  ha\Tng  shown  that 


846  PATHOLOGY  OF  THE  PUERPERIUM 

it  is  best  to  wait  until  the  attack  on  the  pus  cavity  has  become  easy  and  simple.  If  the  mass 
points  above  Poupart's  ligament,  one  may  wait  until  the  adhesion  of  the  dome  of  the  abscess  to 
the  abdominal  wall  is  firm  and  extensive,  thus  making  certain  that  the  general  peritoneal  cavity 
will  not  be  opened.  By  careful  dissection,  layer  bj^  layer,  the  tissues  are  reflected  until  the  infil- 
trated wall  of  the  abscess  is  reached.  A  small  opening  is  made  here,  part  of  the  pus  evacuated, 
and  the  finger  inserted.  A  gentle  exploration  is  made  to  determine  the  extent  of  the  cavity,  and 
also  whether  it  will  be  better  to  drain  per  vaginam  also.  If  the  lowest  part  of  the  abscess  lies 
beneath  the  level  of  the  cervix,  the  vagina  may  also  be  opened  from  below,  guided  by  the  finger 
in  the  pus-pocket.  It  is  well  to  avoid  manipulation  at  the  sides  of  the  uterus  at  the  bases  of  the 
broad  hgaments,  because  of  the  large  vessels  here,  and  in  general  to  move  the  fingers  about  as 
little  as  possible  to  preserve  the  peritoneum.  Tubular  drainage  through  one  or  both  open- 
ings is  employed.  Healing  is  remarkablj'  quick,  unless  the  operation  was  done  too  early,  when 
time  may  be  required  for  an  undiscovered  pus-pocket  to  break  into  the  operative  sinus.  If  the 
abscess  bulges  in  the  po.sterior  culdesac,  it  is  attacked  here.  If  the  abscess  bulges  down  one  of 
the  lateral  fornices,  it  should  be  attacked  behind,  as  near  in  the  middle  line  as  possible,  to  avoid 
injuring  the  m-eter  or  uterine  vessels  {vide  infra).  Since  most  cases  of  pelvic  cellulitis  heal  by 
absorption,  prolonged  expectancy  is  required.  When  amelioration  of  the  general  symptoms 
indicates  that  the  acuteness  of  the  local  process  has  subsided,  the  attendant  may  try  to  hasten  the 
absorption  of  the  exudates.  Hot  prolonged  vaginal  douches,  repeated  thrice  daily,  are  useful, 
also  the  hot-air  bath  of  the  pelvic  region,  recommended  by  Bier  and  Polano.  Such  an  apparatus 
is  easily  improvised  by  mounting  8  to  10  electric  lights  on  the  inside  of  a  cradle  lined  with  asbestos 
paper.  Gellhorn  describes  the  details  of  the  treatment,  which  can  be  heartily  recommended. 
The  patient  may  not  leave  her  bed  until  the  masses  have  almost  disappeared.  General  muscular 
tone  is  to  be  maintained  by  massage,  but  no  massage  is  given  the  pelvic  structures  for  several 
months  after  the  patient  is  up  and  about.  Then  massage,  gentle  at  first,  watching  the  effect, 
may  be  used  to  mobilize  the  uterus  and  tubes. 

Perimetritis. — Pelvic  peritonitis  accompanies  many  forms  of  local  puerperal 
infection,  as  parametritis,  endometritis,  uterine  abscess,  salpingitis.  Since  the 
inflammation  is  limited  to  the  pelvic  peritoneum,  we  may  conclude  that  the  infect- 
ing bacteria  are  of  low  virulence,  and,  as  a  rule,  the  staphylococcus,  the  gonococcus, 
and  saprophytes  are  usually  found.  Diplostreptococci  and  pneumxococci  have  been 
present,  and  the  Bacterium  coli  also,  either  alone  or  in  symbiosis  with  the  others. 
Less  often  have  the  Bacillus  aerogenes  capsulatus,  the  pyocyaneus,  and  anaerobes 
been  detected.  They  cause  fetid  exudate  and  sometimes  gas.  Streptococci  of  low 
virulence  maj^  cause  a  mild  peritonitis.  If  of  high  virulence,  they  quickly  invade 
the  whole  peritoneum,  and  may  be  more  quickly  fatal  than  even  a  bacteremia.  The 
immense  surface  of  the  peritoneum  absorbs  the  toxins  of  the  streptococci  so  rapidly 
that  the  heart  and  nervous  system  are  overcome  within  a  few  days  or  even  a  few 
hours  after  inoculation. 

Causation. — (1)  Traumatism,  as  where  the  uterus  is  much  squeezed  or  torn, 
may  have  a  mild  plastic  peritonitis  as  a  sequel,  and  the  most  dangerous  infections 
are  likely  to  follow  the  introduction  of  even  weak  bacteria  under  such  circumstances. 
In  cases  of  pressure  necrosis  of  the  soft  parts  between  the  head  and  the  bony  pelvis 
a  reactive  inflammation  usually  prevents  the  spread  of  the  inevitable  infection.  If 
a  careless  examiner  should  tear  the  surfaces  asunder,  or  if  alien  bacteria  are  intro- 
duced, a  rapidly  fatal  process  may  ensue.  (2)  Endometritis,  uterine  lymphangitis, 
pelvic  peritonitis,  a  sequence  demonstrated  by  Tonnele,  explain  most  of  the  cases, 
and  sometimes  the  bacteria  (streptococci)  may  be  demonstrated  on  their  way  in  the 
lymph-spaces  through  the  uterus  (Fig.  741);  (3)  a  parametritis  may  develop  from 
a  torn  cervix  or  vagina,  and  the  l^acteria,  without  meeting  a  reactive  inflammation 
in  the  broad  ligaments,  may  reach  the  peritoneum;  (4)  gonorrhea  may  cause,  in 
succession,  by  surface  extension,  endometritis,  salpingitis,  ovaritis,  pelvic  peri- 
tonitis, or  a  gonorrheal  pus-tube  may  burst  during  or  after  labor;  unless  the  strepto- 
coccus is  also  present,  such  infections  are  usually  mild,  with  a  strong  tendency  to 
localize;  (5)  rupture  of  an  appendiceal  abscess,  extension  of  a  perityphlitis  to  the 
pelvis,  or  the  bursting  of  a  collection  of  pus  anywhere  near  the  pelvis,  may  cause  a 
peritonitis  localized  to  this  region,  or  even  spreading  over  the  whole  serous  surface; 
(6)  the  bacteria  may  reach  the  peritoneum  from  the  veins  in  the  broad  ligaments  in 
cases  of  streptococcous  thrombophlebitis.  It  is  clear,  therefore,  that  infection  may 
spread  to  the  pelvic  peritoneal  cavity  in  several  ways — via  the  lymph-vessels, — the 


CLINICAL   TYPES    OF   PUERPERAL    INFECTION 


847 


Fig.  752. — Diagram  to  Show  Locations  of  Peritonitic  ErrrsioNS. 
Pus-tube  .^nd  Ovarian  Abscess  on  Left.  Peritubal  Effusion  on 
Right.     Intestines  Form  Part  of  Wall  of  Abscess. 


most  common, — ])y  surface  extension  uIouk  the  tubes,  and  via  tlio  1)1()0(1,  in  addition 
to  the  inoculation  of  tlic  sctous  sac  l)y  direct  moans,  the  introduction  of  the  bacteria 
by  tlio  hand  or  instruments,  or  th(^  rupture  of  infected  i)us-sacs. 

Pathology. — The  pathologic  findings  are  the  same  as  are  usual  in  surgical  peri- 
tonitis. The  peritoneum 
is  reddened,  the  surface 
lusterless,  the  ])owels  dis- 
teiuled,  adherent  to  each 
other,  with  deep-red 
streaks  on  them  where  the 
surfaces  do  not  lie  directly 
apposed,  and  covered  with 
long  strings  of  fibrinopus 
and  serous  exudate.  Be- 
tween the  matted  intes- 
tines a  seropus  is  found  in 
which  float  whitish-yellow 
flakes  of  fibrin,  or  the  ex- 
udate may  be  all  fibrin  and 
pus. 

In  streptococcic  infec- 
tions the  serous  membrane 
may  be  only  reddened, 
there  being  little  exudate 
and   only  few   shreds    of 

fibrin.  The  tendency  to  localize  is  not  marked.  Subperitoneal  cellulitis  also  marks 
the  streptococcic  infections,  and  since  it  is  impossible  to  drain  these  spaces,  opening 
the  peritoneal  cavity  offers  little  hope  of  cure.     Blood  may  tinge  the  exudate,  w^hich 

may  have  an  acrid,fpenetrating  odor, 
stinging  the  hand  immersed  in  it .  If 
the  infection  is  mild,  the  reaction  of 
the  serosa  may  limit  its  progress, 
which  nature  accomplishes  by 
throwing  out  a  coating  of  lymph 
which  binds  the  viscera  together. 
The  tubal  ostia  are  closed,  the  fim- 
briae being  matted  together.  The 
exudates  are  thus  confined  in 
pockets  bounded  by  adhesions,  and 
take  on  the  character  of  pus.  They 
may  break  into  neighboring  or- 
gans,— the  bladder,  vagina,  or  rec- 
tum,— and  the}'  may  creep  up  out 
of  the  pelvis,  usually  on  its  pos- 
terior surface,  toward  the  dia- 
phragm, the  way  being  laid  out 
by  an  advancing  line  of  fresh  ad- 
hesions which  prevent  the  spread 
of  the  infection  over  the  whole 
peritoneum.  Great  care  must  be 
exercised  in  palpating  such  cases, 
because  rough  pressure  may  rupture  the  adhesions,  flooding  the  peritoneal  cavity 
with  pus,  and  causing  death. 

The  usual  locations  for  these  collections  of  pus  are  in  Douglas'  culdesac,  and 


FiQ.  7.53. — Diagram  to  Show  Location  of  Peritonitic  Effu- 
sion. Abscess  in  Douglas'  Culdes.\c.  Intestines 
Form  Part  of  Wall  of  Abscess. 


848 


PATHOLOGY  OF  THE  PUERPERIUM 


high  up  at  each  side  of  the  uterus,  in  the  fold  between  the  infundibulopelvic  and 
broad  ligaments.  As  they  form  when  the  uterus  is  in  the  abdomen,  and  become  ad- 
herent at  the  leyel  at  which  they  form,  they  do  not  sink  with  the  uterus,  and,  there- 
fore, are  found  high  up.  This  distinguishes  them  from  parametritic  exudates, 
which  are  low,  nearer  the  vagina.  The  course  of  these  exudates  is  the  same  as  in 
parametritis — resolution,  absorption,  suppuration,  and  abscess.  The  latter  is  more 
common  than  in  parametritis.  The  former  takes  longer  than  in  parametritis,  and 
the  organs  are  left  more  deformed,  bound  down,  and  matted  together.  Frequently 
the  women  are  left  gynecologic  invalids,  and  are  almost  always  incurably  sterile, 
from  closure  of  the  tubes. 

If  the  infection  is  virulent,  the  streptococcus,  alone  or  in  symbiosis,  being  the 


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Dotted  line  is  the  pulse. 


cause,  its  spread  is  very  rapid,  involving  the  whole  lower  abdomen  within  a  few  days 
or  even  only  a  few  hours.  Seldom  is  there  time  for  the  peritonitis  to  become  uni- 
versal, because  the  patient  dies  from  the  inundation  of  the  system  by  toxins  rapidly 
formed,  and  absorbed  so  readily  from  the  immense  area  of  surface  of  the  peritoneum. 
The  exudate  in  cases  of  general  peritonitis  may  be  small  or  measure  several  quarts 
in  amount. 

If  the  infection  reached  the  peritoneum  from  the  endometrium,  it  may  be 
possible,  microscopically,  to  trace  the  bacteria  along  the  lymph-spaces.  At  the 
sides  of  the  uterus,  in  the  larger  lymph-vessels,  droplets  of  pus  may  be  found  on 
section,  and  the  peritoneum  over  the  uterus  shows  the  intensest  inflammation, 
redness,  and  fibrinopurulent  exudate. 

If  the  peritoneum  was  infected  by  way  of  the  tubes,  these  are  usually  dilated, 


CLINICAL   TYPKS    OF    PUERPERAL    INFKCTION  849 

forming  pus-sacs;  often  the  ovary  is  imolvod,  an  ovarian  abscess  resulting,  and 
nearly  always  the  ])ro<'('ss  is  mild,  hcinj!;  limit<'d  to  the  jx'h'is,  unless  inii)ro[)er  treat- 
ment transports  the  infection  hiji;her  up. 

Syniptonts. — lioth  local  and  general  symptoms  and  signs  depend  on  the  mode 
in  which  the  infection  reaches  the  jieritoneum.  The  bursting  of  a  pus-sac  is  almost 
always  attended  by  stormy  symptoms,  ^\  hi(  li  resemble  those  of  ruptured  ectopic 
jM'egnancy:  sharp,  severe  ])ain  at  tlu^  sit(i  of  th(;  a])s('ess,  with  tenderness,  both 
rai)idly  spreading  over  the  abdomen,  collapse,  followed  by  febrile  reacti(jn  and  the 
evidences  of  peritonitis  mentioned  below.  If  the  peritonitis  follows  a  rupture  of  the 
uterus,  it  resembles  in  all  respects  that  following  a  severe  operation.  Usually  the 
mode  of  entry  is  via  the  lymphatics  from  the  endometrium,  and,  therefore,  the 
symptoms  and  signs  of  endometritis  precede  those  of  peritonitis.  (Sec  Endometri- 
tis.) As  soon  as  the  peritoneum  becomes  involved  pain  becomes  a  prominent  symp- 
tom, localized  at  first  in  the  uterus  and  lower  abdomen,  spreading,  in  the  bad  cases, 
all  over  the  belly.  Vomiting  is  almost  a  constant  occurrence,  preceded  and  ac- 
companied by  continuous  nausea  and  sometimes  by  singultus.  The  vomit  is  at 
first  watery,  then  bilious,  and  at  last  stercoral  in  character,  and  the  action  is  sudden 
and  expulsive,  so  that  sometimes  the  bed  may  be  soiled  before  the  nurse  can  hand 
the  basin.  It  brings  no  relief  from  the  intense  nausea.  Constipation  is  the  rule  at 
first,  and  flatus  is  not  passed,  peristalsis  being  paralyzed.  This  paralytic  ileus  leads 
to  immense  alxlominal  distention.  The  decomposition  of  the  intestinal  contents 
(by  the  Bacillus  coli,  the  perfringens,  pseudotetanus,  and  others)  leads  to  an  auto- 
intoxication, which  contributes  much  to  the  fatal  ending.  Later  in  the  disease  the 
l)owels  sometimes  loosen,  and  exhausting,  foul  diarrheas  are  observed.  Thirst  is 
excessive,  restlessness  is  distressing,  but  usually  the  mind  is  clear  until  near  the  end, 
when  either  delirium  or  coma  supervenes,  or — and  this  is  most  ominous — a  state  of 
well-being — euphoria — begins. 

Examination  shows  the  patient  on  her  back,  with  the  knees  dra^^^l  up,  both 
to  relax-  the  muscles  and  to  take  the  weight  of  the  bed-clothes  off  the  belly.  Her 
expression  is  anxious,  her  color  at  first  reddened,  later  pale  and  gray  or  subicteric. 
The  face  at  first  presents  a  febrile  aspect,  but  later  this  is  replaced  by  one  of  col- 
lapse— sunlvcn  eyes,  cold,  pointed  nose,  cool  forehead  bedewed  -with  clammy  sweat 
— in  short,  the  typical  "facies  Hippocratica."  Owing  to  the  constant  loss  of  body 
fluids  and  the  inability  to  replace  them,  the  tongue  soon  becomes  drj'  and  l)rown, 
with  fetor  ex  ore  and  fuliginous  gums;  the  urine  is  reduced  in  amount  and  con- 
tains albumin,  casts,  indican,  and  often  the  bacterium  causing  the  peritonitis. 
This  finding  shows  that  most  fatal  cases  are  really  septicemias.  The  temperature 
during  and  after  the  usual  initial  chill  is  raised, — often  as  high  as  105°  F., — the 
pulse  becomes  very  rapid,  and,  at  the  same  time,  of  a  peculiar  snappy  character, 
and  later,  when  the  toxins  paralyze  the  vagus  and  heart  muscle,  micountable  or 
filiform.  Respiration  is  quickened  and  costal,  first  because  of  the  toxinemia,  and, 
second,  because  of  the  immense  tympany  which  anchors  the  diaphragm  high,  and, 
third,  ])ecause  of  the  pain  in  the  belh'.  Dilatation  of  the  veins  in  the  splanchnic 
area  causes  symptoms  of  shock. 

Rales  are  usually  heard  over  the  lower  part  of  the  lungs,  and  friction-sounds, 
if  the  patient  lives  long  enough  to  develop  a  pleuritis  also.  The  first  sound  of  the 
heart  early  loses  its  booming  quality,  the  toxins  affecting  the  muscle.  Friction  may 
be  heard  over  the  liver,  Ijut  hardly  ever  over  the  lower  al^domen.  Gurgling  is  ab- 
sent (aperistalsis) ,  but  metallic  tinkling  may  be  found.  The  belly  is  tympanitic 
over  its  lower  part  at  first,  and,  as  the  infection  spreads,  it  may  be  immensely 
distended.  The  walls  are  usually  very  rigid  (defense  musculaire)  and  markedlj- 
tender.  Deep  pressure  may  sometimes  be  borne  ^^^thout  complaint,  but  sudden 
lifting  of  the  hand  causes  pain.  Remarkably,  but  true,  some  cases  of  peritonitis — 
and  these  are  usually  due  to  pure  streptococcous  infection — show  very  little  tender- 
54 


850  PATHOLOGY    OF   THE    PUERPERIUM 

ness,  hardly  any  rigidity,  and  are  attended  by  little  pain.  It  seems  that  the  toxins 
produced  are  so  caustic  that  they  benumb  the  nerve-endings,  or  they  quickly  bring 
about  general  toxinemia  and  bacteremia,  with  insignificant  local  reaction.  In  such 
cases  of  latent  peritonitis  a  diagnosis  of  peritonitis  may  not  be  possible  during  life. 

If  the  infection  is  virulent,  the  symi^toms  grow  worse  rapidly,  the  temperature 
keeps  high  until  shortly  before  death,  when  it  drops,  the  pulse  mounting  in  fre- 
quency, the  two  curves  crossing  on  the  chart — the  ''cross  of  death";  collapse 
follows,  and  edema  of  the  lungs  or  exhaustion  closes  the  scene. 

If  the  patient  is  able  to  withstand  the  onslaught  of  the  infection,  the  symptoms 
and  signs  are  all  milder  from  the  very  first  and  are  limited  to  the  pelvis.  Very  soon 
signs  of  localization  become  apparent — the  pain  begins  to  subside,  the  vomiting 
ceases,  the  bowels  begin  to  act,  the  movements  having  natural  color  and  odor,  the 
general  findings  improve — the  pulse  particularly,  by  slowing,  indicating  the  turn  for 
the  better.  It  is  not  safe  to  examine  these  cases  bimanually  for  several  weeks,  that 
is,  until  the  exudates  are  bound  off  by  firm  adhesions  and  resolution  in  them  is 
begun.  It  may  now  be  possible  to  find  a  fluctuating  tumor  in  the  culdesac  or  high 
up,  at  either  or  both  sides  of  the  uterus.  Great  care  must  be  exercised  in  palpating 
these  peritonitic  collections.  I  have  seen  two  deaths  result  directly  from  the  burst- 
ing of  such  abscesses  into  the  hitherto  protected  general  peritoneal  cavity.  Should 
such  an  accident  occur,  the  belly  must  at  once  be  opened  and  drainage  above  and 
below  established. 

If  the  patient  recovers,  the  pelvic  organs  and  intestines  are  matted  together, 
the  uterus  cUstorted  and  displaced,  the  tubes  kinked  or  occluded,  the  ovaries  are 
involved  in  a  mesh  of  adhesions  and  develop  a  tendency  to  become  cystic,  and  the 
pelvic  circulation,  as  in  parametritis,  is  disturbed.  If  a  pyosalpinx  or  ovarian  ab- 
scess is  the  residuum,  the  recovery  is  never  complete.  As  a  resultof  all  these  changes 
the  woman  usually  dates  life-long  invalidism  from  her  confinement,  her  symptoms 
being  pain  in  the  pelvis  and  back,  bearing  down,  inability  to  do  her  duties, 
neurasthenia,  sterility,  dyspareunia,  dysmenorrhea,  menorrhagia,  leukorrhea,  and 
the  signs  of  pelvic  congestion.  Mild  cases  of  perimetritis — so  mild  as  to  escape 
the  notice  of  all  but  the  acute  observer — may  leave  such  traces,  and  a  goodly  pro- 
portion of  the  gynecologist's  clientele  is  of  this  class. 

Diagnosis. — It  is  not  always  possible  to  differentiate  between  a  parametritis 
and  a  perimetritis  in  the  early  stages — indeed,  they  often  occur  together.  Chill  and 
high  fever  are  common  to  both,  but  the  chill  is  usually  more  pronounced  in  the 
cellulitis,  t)ut  the  general  impression  is  of  a  less  severe  illness.  Nausea,  singultus, 
and  vomiting,  with  prostration,  rapid  pulse,  excessive  local  pain  and  tenderness,  with 
increasing  and  spreading  abdominal  rigidity,  point  to  peritonitis.  The  exudate  in 
parametritis  is  usually  low  down  and  unilateral;  that  of  peritonitis  is  higher  up  and 
more  often  posteriorly  than  at  the  side;  the  cellulitis  shows  a  brawny,  hard  infil- 
trate, which  softens  late;  the  perimetritic  exudation  is  soft  from,  the  start.  The 
shape  of  the  pelvic  tumor  gives  useful  indications.  In  cellulitis  the  infiltrations 
follow  the  layers  of  fascia  and  the  ligaments;  in  peritonitis,  the  peritoneal  pockets 
are  first  filled  with  the  exudates,  Douglas'  culdesac,  and  the  regions  of  the  ovaries. 
Pyosalpinx  and  ovarian  abscess  usually  cannot  be  palpated  out  of  the  pelvic  in- 
flammatory masses  in  the  early  stages.  After  a  few  weeks  the  parametritic  infil- 
trates are  absorbed,  and  then  one  may  be  able  to  outline  the  structures.  The 
aspirating  needle  may  be  used  to  discover  the  nature  of  fluid  in  the  peritoneal 
cavity. 

Prognosis. — This  should  always  be  withheld  in  the  early  part  of  the  illness,  be- 
cause we  are  usually  in  ignorance  of  the  nature  of  the  infecting  bacterium  and  of  the 
road  it  takes  to  the  peritoneum.  Streptococcic  infections  are  particularly  fatal: 
they  seldom  localize,  and  the  absorption  of  the  toxins  is  so  rapid  that  the  heart 
muscle  and  nervous  system  are  quickly  overcome.     Staphylococcic,  gonococcic, 


CLINICAL   TYPES    OF    PUERPERAL    INFECTION 


851 


and  colon  infections  arc  miicli  more  favoral)lc.  All  depends  (jii  tlie  ability  of  the 
peritoneum  to  wall  off  the  advancing  bacteria  by  the  layer  of  leukocytes,  the  throw- 
ing out  of  lymph,  and  matting  of  the  pelvic  viscera  together.  Symptoms  and 
signs  which  indicate  such  a  process  justify  us  in  giving  a  favorable  prognosis.  The 
pulse  gives  us  the  most  reliable  information  of  what  is  going  on  in  the  peritoneum; 
next,  the  general  condition  of  the  patient.  Low  blood-i)ressurc  is  of  bad  omen. 
Slowing  of  tlie  pulse  is  a  good  sign. 

Treatment  of  Peritonitis. — At  the  heginninp;  it  may  not  be  possible  to  rlifferentiate  a  peritoni- 
tis from  a  cellulitis,  and  the  treatment,  therefore,  will  be  the  same  for  both.  If  the  case  starts 
out  as  a  violent,  acute  puerperal  jK-ritonitis,  very  little  can  be  expected  from  any  treatment. 
Simply  opening;  the  abdomen  in  the  midline  above  the  pubis,  or  posterior  colpotomy,  will  not  do 
much  harm.  If  such  an  incision  reveals  a  ruptured  uterus  or  a  burst  pus-sac  (pu.s-tube,  appendi- 
citis, etc.),  appropriate  treatment  is  made;  otherwise  several  soft -rubber  drainage-tubes  are  placed 


Fig.  755. — Opening  Abscess  in  Culdesac. 


radiall}^  in  the  abdomen,  one  reaching  to  the  culdesac,  and  a  large  moist  dressing  is  applied.  Some 
operators  irrigate  the  peritoneal  cavity  with  normal  salt  solution,  but  most  men  are  opposed  to 
this,  as  well  as  to  eventration,  because  it  shocks  the  patient  too  much.  Lately  the  injection  of 
100  to  300  c.c.  of  a  1  per  cent,  solution  of  camphor  in  oil  has  been  recommended.  If  the  course 
of  the  disease  is  milder, — more  chronic, — more  may  be  expected  of  operation,  and  it  is  these  cases 
which  give  the  better  statistics — for  example,  Bumm,  50  per  cent.;  Leopold,  23  per  cent.;  Jean- 
nin,  .50  per  cent,  mortality.  The  gonococcus,  the  staphylococcus,  or  a  mild  streptococcus  are 
usually  found  here.  My  own  experience  with  operation  in  acute  diffusing  puerperal  peritonitis 
shows  only  one  recovery'  in  10  women  drained.  When  there  is  a  tendencj'  to  locahzation,  it  is 
safer  to  wait  until  the  abscess  has  formed  and  then  drain  it,  usually  from  below. 

The  vagina  is  exposed  by  short,  broad  specula,  the  cer\-ix  steadied,  but  not  pulled  douTi, 
and  with  a  vulsellum  forceps  the  posterior  fornix  is  incised  cleanly  with  a  sharp  scissors  or  scal- 
pel, the  tissue  to  be  cut  being  held  by  long  tissue  forceps,  and  the  opening  enlarged  b\'  stretching 
with  an  S-inch  artery  clamp.  The  sac  })iay  not  he  punched  into — -every  eflfort  must  be  taken  to 
avoid  increasing  its  tension,  because  a  delicate  adhesion  in  its  roof  may  give  waj'  and  pus  will  es- 
cape above  into  the  general  peritoneum,  an  accident  which  even  the  immediate  laparotomj-  may 
not  prevent  being  fatal.  After  the  pus  is  evacuated  one  or  two  fingers  may  be  passed  into  the 
ca\aty,  and  gentle  palpation  of  the  walls  made,  but  it  is  unwise  to  try  to  isolate  a  pus-tube  unless 
it  is  within  easy  reach,  when  it  may  be  drained  through  the  same  opening.     An  ovarian  abscess 


852 


PATHOLOGY  OF  THE  PUERPERIUM 


is  treated  similarly.  It  is  hazardous  to  remove  the  pus-sacs  in  the  acute  stages.  It  is  better  to 
reUeve  the  danger  by  vaginal  drainage,  if  necessary,  and  postpone  the  radical  operation  for  several 
montlis  until  the  pus  has  become  sterile.  If  ceUotomy  is  imperative,  the  sac  may  be  fixed  to  the 
abdominal  wall  and  opened  three  days  later  with  the  Paquelin  cautery.  The  drainage-tube 
should  be  left  in  place  for  a  day  after  it  has  ceased  to  drain,  and  the  opening  kept  open  a  few  days 
longer  with  a  bit  of  gauze.  Irrigations  are  unnecessary  and  harmful.  The  patient  is  kept  in  the 
Fowler  position  for  a  few  days.  In  the  very  chronic  pelvic  sinuses  vaccine  therapy  may  be  useful. 
Vaginal  douches  to  hasten  the  absorption  of  exudates  and  the  hot-air  bath  may  be  used  in 
chronic  cases,  but  are  not  so  successful  as  in  parametritis.  Massage  may  be  employed  in  the 
latest  stages. 

Bacteremia  is  an  acute  infectious  disease,  due  to  the  entrance  into  the  blood  of 
microbes,  usually  the  Streptococcus  pyogenes,  but  sometimes  of  other  cocci  and 


Via.  757. — Uterine  Lymphanoitis, 
Above  is  a  ohirnp  of  streptocoooi  tuken  from  the  lymphs/tic. 

bacteria,  and  their  toxins,  which  produce  a  dissolution  of  the  blood,  degenerative 
changes  in  the  organs,  and  the  symptoms  of  a  rapid  intoxication.  The  terms  ''septi- 
cemia" and  "sepsis,"  from  the  Greek  arj\}/Ls,  meaning  decay,  have  gained  such 
general  usage  as  applied  to  all  forms  of  severe  infection  that  they  will  probably  be 
retained.  Septicemia  is  synonymous  with  bacteremia,  which  term  should  replace 
it.  The  essential  quality  of  these  infections  is  the  invasion  of  the  blood-stream  by 
the  bacteria.  Most  often  the  streptococcus  is  causative,  but  the  pneumococcus, 
the  staphylococcus,  the  Bacillus  pyocyaneus,  the  gonococcus,  the  Bacillus  aerogenes 
capsulatus,  and  others  have  been  found.     Entrance  to  the  blood  is  gained  in  two 


Fio.  750. — Purely   Diagrammatic.     Course  of  Lymphatic  (Right  Side,  Green)  and 
\'ascular  (Left  Side,  Red)  Bacteremias. 


CLINICAL   TYPES    OF    PUERPERAL    INFECTION  853 

ways — via  the  lymphatics,  the  most  usual,  and  \'ia  the  Mood-vessels,  particularly 
the  veins,  and  sonietinu^s  in  both  ways  at  the  same  tinu;.  Dif'i'erinfi;  clinical  pictures 
are  produced,  depentling  on  the  mode  of  invasion,  and  it  is  often  possible  to  desig- 
nate the  symptoms  appertaining  to  each  form,  .lust  as  often  the  pictures  are  in- 
distinct, partaking  of  the  characters  of  the  two  affections.  The  lymphatic  form  of 
bacteremia  usually  develops  from  an  endometritis,  the  bacteria  passing  along  the 
lymph-spaces  of  the  uterus  and  broad  ligaments  into  the  blood,  or  out  onto  the  sur- 
face of  the  peritoneum,  causing  peritonitis,  pleuritis,  etc.  The  vascular  form  of 
bacteremia  begins  as  a  metrophlebitis,  usually  at  the  placental  site,  with  thromboses 
in  the  veins.  From  these  infected  thrombi  the  bacteria  get  into  and  multiply  in 
the  blood,  locating  in  distant  organs, — the  eye,  the  brain,  the  cord,  the  joints,  the 
valves  of  the  heart,  etc., — in  short,  a  true  bacteremia  develops.  In  such  cases  the 
local  symptoms  may  be  insignificant.  A  slower  form  of  general  infection  occurs  in 
the  metrophlebitic  cases.  The  thrombi  suppurate, — a  condition  not  common  with 
the  streptococcus, — and  bits  of  infected  fibrin  or  microscopic  droplets  of  pus,  or 


WaUoj. 


Fig.  758. — Infected  Thrombus  from  Case  of  Tubal  Pregnancy. 
Methylene-blue  stain. 

even  larger  pieces  of  thrombus,  may  break  off  and  be  swirled  away  by  the  blood- 
stream to  the  lungs,  the  kidneys,  the  brain,  etc.,  where  they  set  up  new  foci  of  sup- 
puration. This  last  disease  has  been  named  pyemia,  but  there  is  almost  never  any 
"pus  in  the  blood."  Von  Herff  has  suggested  the  term  "metastatic  bacteremia" 
for  this  affection.  Often  it  begins  as  a  septicemia,  developing  the  characters  of  a 
pyemia  later. 

Pathology  of  SejHicemia. — A  bacteremia  may  follow  an  insignificant  lesion  lo- 
cated at  any  part  of  the  genital  tract.  Even  a  frenulum  tear  may  allow  the  virulent 
streptococcus  rapid  access  to  the  blood.  Again,  the  resistance  of  the  patient  may 
be  broken  down  only  after  a  long  fight  or  after  ill-advised  local  treatment — that  is, 
a  process  that  was  limited  to  the  surface  is  allowed  to  become  invasive.  An  ex- 
ample of  this  is  the  severe  bacteremia  which  usually  follows  curetage  in  cases  of 
streptococcic  endometritis. 

In  the  lymphatic  varieties  of  septicemia  the  findings  at  autopsy  are  quite 
typical:    (1)  Endometritis  gangrenosa,  or  metritis  desiccans,  often  the  whole  tract 


854 


PATHOLOGY  OF  THE  PUERPERIUM 


being  covered  by  a  grayish,  sloughing,  diphtheroid  exudate.  (2)  Parametritis  and 
lymphangitis,  the  lymph-vessels  at  the  sides  of  the  uterus  being  filled  with  purulent 
fluid  which  exudes  from  the  cut  surface;  the  connective  tissue  may  be  infiltrated 
and  edematous,  and  this  cellulitis  may  spread  so  fast  and  far  as  to  justify  the  name 
Virchow  gave  it — erysipelas  puerperalis  malignum  internum.  The  changes  in  the 
parametria  may  be  simply  a  serous  infectious  edema,  or  necrosis  may  occur — a  real 
phlegmon.  (3)  Pelvic  peritonitis,  then  general  peritonitis.  (4)  If  the  patient  lasts 
long  enough,  pleuritis  and  pericarditis.  (5)  Gastritis  submucosa — gastritis,  enter- 
itis, and  colitis.  (6)  General  pathology  of  acute  in- 
fectious disease — swollen  spleen,  fatty  degeneration 
and  cloudy  swelling  of  muscles,  and  especially  of  the 
heart,  liver,  and  kidneys.  Bacteria  in  immense 
numbers  are  found  in  the  minute  capillaries  and 
lymphatics  of  these  organs.  (7)  The  findings  of 
the  metastases  in  the  lungs,  heart,  brain,  joints, 
connective  tissue,  and  so  on. 

In  the  vascular  forms  of  bacteremia  the  lym- 
phatics are  not  involved  at  all,  or  to  a  decidedly 
less  extent.  The  veins  of  the  placental  site  are 
filled  with  large  thrombi,  which  are  swarming  with 
bacteria.  The  bacteria  erode  the  endothelium  of 
the  vessel;  fibrin  is  deposited  on  the  surfaces;  the 
lumen  is  occluded,  and  the  process  advances  through 
the  venous  plexuses  of  the  broad  ligament  into  the 
spermatic  and  iliac  veins,  even  to  the  cava.  From 
the  surface  of  these  thrombi  bacteria  are  liberated 
in  the  blood-stream,  and  if  they  are  strong  enough 
to  multiply  in  it,  a  fatal  bacteremia  will  result.  If 
the  bacteria  are  less  virulent  or  of  a  more  pyogenic 
character,  the  process  is  more  chronic,  the  thrombi 
undergo  purif orm  softening,  and  solid  bits  or  drop- 
lets of  pus  break  loose,  and,  floated  by  the  blood- 
stream, lodge  in  distant  portions  of  the  body,  set- 
ting up  new  foci  of  suppuration.  This  condition 
has  been  called  pyemia,  and  will  be  considered 
directly. 

Symptoms. — A  period  of  incubation  of  from  one 
to  three  days  usually  precedes  the  outbreak  of  the 
severe  symptoms.  In  rare  cases  threatening  pro- 
dromes appear  within  a  few  hours  after  the  inocula- 
tion, and  the  woman  gets  very  sick  and  may  die  be- 
fore thirty-six  hours  have  passed  (Fig.  759) .  Ordin- 
arily, the  prodromal  stage  is  manifested  by  the  signs 
and  symptoms  of  the  local  process  from  the  site  of 
which  the  ])acteria  gained  access  to  the  blood.  The 
reader  is  referred  to  the  chapters  on  Endometritis,  Parametritis,  etc.,  for  these 
symptoms.  It  is  often — indeed,  usually  — impossible  to  determine  when  and  how 
the  germs  get  into  the  blood.  Schottmiiller,  using  anaerobic  methods,  has  been 
able  to  cultivate  the  streptococcus  from  the  blood  in  many  cases  where  the  diag- 
nosis of  a  purely  local  process  had  been  made.  That  a  serious  bacteremia  exists 
will  be  apparent  from  the  following  syndrome,  though  it  must  be  admitted  that 
the  absorption  of  toxins  in  large  amounts  will  produce  the  same  conditions. 

A  severe  chill,  lasting  from  five  to  thirty  minutes,  ushers  in  the  affection;    the 
temperature  rises  rapidly  to  103°  or  104°  F.,  and  the  pulse  jumps  at  once  above 


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Fig.    759. — Acute   Bacteremia. 

Forehead  presentation.    Forceps,  etc.    Low 

est  line  is  temperature,  dotted,  the  pulse. 


CLINICAL    TYPKS    OF    PUERPEUAL    INFECTION  855 

120,  soon  attaining  a  tV('(|Ucii('y  Ix'twccn  this  and  100.  At  first  l)ouii<linp^,  it  soon 
hccoincs  soft  and  coniiircssihlc,  the  toxnis  wcukcninfi;  the  licart  muscle.  Owiiij^  to 
the  destruction  of  the  red  blood-ccjrpuscles  the  oxygen-carrying  jxjwer  of  the  blood 
is  diminished,  the  patient  exhibits  a  marked  pallor,  and  the  respirations  are  hurried. 
In  som(>  respects  the  disease  resembles  acute  leukemia.  Tympany  and  peritonitis 
st  ill  further  compromise  the  breathing.  Very  early  in  the  attack  malai.se  is  decided 
— the  woman  appears  as  if  stricken  down,  is  apprehensive  of  a  dangerous  illness, 
even  of  impenthng  death,  the  change  being  sudden  and  significant.  Headache  and 
sleeplessness  are  constantly  complained  of — the  latter,  in  the  absence  of  sufficient 
cause,  being  particularly  ominous.  While  the  mind  may  remain  clear  until  near  the 
end,  this  is  unusual— mild  delirium,  delirium  in  somnolence,  and  often  maniax-al 
outbursts  characterize  the  last  clays.  Acute  endocarditis  is  almost  always  marked 
by  delirium. 

Symptoms  of  peritonitis — nausea,  vomiting,  pain,  etc. — very  soon  begin,  and 
the  facies  Hippocratica  shows  that  the  fatal  termination  is  not  distant.  The  lochia 
are  usually  i)rofuse  and  putrid,  the  result  of  a  gangrenous  endometritis,  though 
sometimes  the  lochia  are  scant.  The  odor  is  not  marked,  being  pungent  to  the 
nostril.  The  puerperal  wounds  become  necrotic.  Signs  of  peritonitis — tenderness, 
tympany,  spreading  rigidity,  ileus,  etc. — begin,  and  if  the  patient  lives,  become 
marked,  and  th(>  picture  becomes  one  of  virulent  peritonitis.  While  the  tempera- 
ture goes  down,  the  pulse  rises  higher,  and  the  tongue  becomes  dry  and  fuliginous. 
A  peculiar  fruity  odor — sweet,  sickening — may  be  noticed  about  the  patient.  After 
three  or  four  clays  the  patient  feels  easier,  but  the  objective  signs  are  Avorse.  Her 
body  is  cold,  sometimes  even  the  trunk,  and  bedewed  with  a  cold  sweat;  she  is  of  a 
yellowish  color,  Avhile  the  translucent  parts,  for  example,  nose  and  ears,  are  a  leaden 
gray.  Consciousness  is  sometimes  retained  until  a  few  hours  before  death,  w'hich 
usually  occurs  in  coma,  preceded  by  edema  of  the  lungs.  Oftener,  the  course  is 
marked  by  delirium,  and  in  cases  where  the  liver  is  much  involved,  the  sjTnptoms 
may  resemlile  those  of  acute  yellow  atrophy  of  the  liver  {q.  v.).  If  the  patient  lives 
long  enough,  a  pleuritis  develops. 

The  disease  lasts  for  from  two  to  ten  days.  It  is  especially  virulent  if  it  be- 
gins during  labor,  when  the  course  is  usually  short  and  violent — "foudroyante,"  as 
the  French  say.  Eruptions  on  the  skin  resembling  scarlatina  occasionally  occur. 
This  has  nothing  in  common  with  true  scarlatina,  though  the  puerpera,  like  every 
one,  may  contract  this  disease.  It  may  be  difficult  to  make  the  differential  diag- 
nosis. Pustular  and  vesicular  eruptions  (containing  the  infecting  organism)  are 
very  rare,  as  also  are  petechise  and  hemorrhages  in  the  skin,  all  of  which  denote  a 
very  dangerous  form  of  the  malad3^  A  marbling  of  the  skin  which  shows  the 
com*se  of  the  superficial  veins  is  of  bad  omen — it  indicates  general  hemolysis.  An 
erysipelatous  inflammation  may  begin  at  the  vulva  and  invade  a  large  part  of  the 
trunk  and  legs.  Albuminuria  is  the  rule,  with  casts,  kidney  epithelium,  and  the 
causative  bacterium.  Sometimes  severe  diarrheas,  fetid  and  acrid,  still  further 
reduce  the  strength  of  the  patient.  Thyroiditis  is  not  a  rare  complication.  Ex- 
amination of  the  Ijlood  reveals  the  streptococcus  or  other  organism  in  the  majority 
of  the  cases,  especially  if  the  bacteremia  is  of  vascular  origin.  In  the  l^^llphatic 
forms  the  toxins  from  the  parametrium  and  peritoneum  may  kill  the  patient,  \nXh. 
little  invasion  of  luxcteria  in  the  blood.  Leukocytosis  is  usually  present,  but  its 
absence  does  not  signify  much  {vide  infra).  There  is  a  hemogiobinemia  and  an 
increase  of  the  polynuclears  and  mononuclears,  with  a  decrease  of  the  eosinopliiles 
and  of  the  reds. 

If  the  patient  is  al^le  to  overcome  the  attack  of  the  bacteria,  it  is  evidenced  bj' 
a  degree  of  mildness  of  the  symptoms  and  a  protracted  course  of  the  disease.  The 
initial  chill  is  occasionally  repeated,  but  rareh'  more  than  once;  the  temperature 
shows  greater  remissions,  the  pulse  keeps  a  lower  level,  the  patient  feels  some  im- 


856  PATHOLOGY  OF  THE  PUERPERIUM 

provement  in  her  condition,  sleeps  more,  her  skin  becomes  covered  with  a  warm 
perspiration,  the  peritoneal  symptoms  subside  or  do  not  even  appear,  the  kidneys 
act  more  freely',  the  bowel  movements  become  normal,  and  the  disease  terminates, 
usually  rapidly,  by  lysis. 

If  embolic  processes  are  lit  up,  the  symptoms  and  signs  are  those  peculiar  to  the 
organ  and  location  of  the  new  inflammations.  One  way  that  acute  bacteremias 
terminate — and  this  is  true  of  the  vascular  variety — is  by  passing  over  into  a  sub- 
acute or  chronic  state  of  pyemia.  Some  authors  call  these  conditions  septicopyemia. 
The  diagnosis,  prognosis,  and  treatment  will  be  discussed  later. 

Septic  Endocarditis. — This  usually  complicates  the  severer  bacteremias,  or 
septicopyemia,  but  may  occur  after  a  mild  local  affection,  or,  rarely,  Avithout  dem- 
onstrable local  lesions.  The  bacteria  settle  on  the  valves,  oftenest  of  the  left 
heart,  causing  ulceration  of  same.  The  disease  is  marked  by  the  presence  of  miliary 
embolic  abscesses  in  the  brain,  liver,  kidneys,  etc.  An  endocardium  that  is  already 
diseased  is  more  prone  to  infection,  and  chlorosis  seems  to  favor  it,  too. 

Symptoms. — Severe  rigor,  high  and  continuous  fever,  very  rapid  pulse,  cerebral 
symptoms,  muttering  delirium,  stupor,  or  even  acute  delirious  mania,  and,  later, 
sjTiiptoms  of  meningitis;  retinal  hemorrhages  in  80  per  cent.  (Litten);  diarrhea; 
hemorrhages  under  the  skin;  scarlatiniform  eruptions  or  blisters.  The  disease 
lasts  from  two  to  twenty-eight  days,  and  often  simulates  typhoid,  presenting  roseola, 
enlarged  spleen,  and  typhoid  tongue.  The  heart-findings  are  usually  equivocal. 
Sometimes  sudden  death  occurs. 

The  diagnosis  is  not  easy  in  the  absence  of  a  local  cause  for  the  high  fever  and 
the  rapid  pulse.  Severe  sickness,  marked  nervous  symptoms,  retinal  hemorrhages, 
repeated  chills  without  determinable  emboli,  indicate  a  severe  bacteremia. 

The  -prognosis  is  bad.     The  treatment  is  symptomatic. 

Pyemia,  septicopyemia,  metastatic  bacteremia,  are  all  names  for  a  chronic  form 
of  sepsis  characterized  by  repeated  chills,  high  fever  with  deep  remissions  and  inter- 
missions, and  marked  tendency  to  metastatic  pus-formation.  The  essential  path- 
ology of  this  form  of  infection  is  a  metrophlebitis  with  extension  along  the  veins  of 
the  broad  ligaments  into  the  spermatic,  the  hypogastric,  and  the  iliac  veins,  even 
to  the  vena  cava,  attended  by  the  formation  of  thrombi,  from  which  bacteria,  bits 
of  fibrin,  and  droplets  of  pus  are  released  and  carried  away  in  the  blood-stream,  to 
find  lodgment  in  distant  organs,  there  setting  up  purulent  processes.  The  thrombi 
in  these  infections  are  large,  and  undergo  puriform  degeneration,  while  in  the  acute 
bacteriemia  they  are  not  so  extensive  and  do  not  break  down,  but  supply  myriads  of 
germs  to  the  blood.  These  thrombi  are  found  mainly  in  the  spermatic  vessels  if  the 
infection,  as  is  usual,  gained  entrance  at  the  placental  site  in  the  fundus.  If  the 
main  infection  is  in  the  lower  part  of  the  uterus,  or  if  the  placental  site  was  low 
(placenta  praevia),  the  uterine  veins  first,  and  then  the  hypogastric  and  internal 
iliac  or  the  femoral  are  involved,  causing  one  form  of  phlegmasia  alba  dolens  (Fig. 
756).  There  is  sometimes  a  periphlebitis  around  the  veins  in  the.  broad  ligaments, 
and  from  this  a  peritonitis  or  a  parametritis  may  develop,  which  extends  upward  or 
down  the  thigh,  the  latter  causing  another  fonn  of  phlegmasia  alba  dolens  (g.  v.). 
The  uterus  will  show  the  changes  resulting  from  the  attack  of  the  bacteria, — either 
an  endometritis  or  a  phlebitis,- — and  involution  will  be  retarded.  Sometimes  in- 
volution is  normal,  the  disease  being  located  only  at  the  placental  site,  which  shows 
large  and  infected  thrombi.  The  bacteria  involved  are  again  frequently  strepto- 
cocci of  a  low  grade  of  virulence  or  the  pyococci,  but  the  others  mentioned  above 
may  also  be  causative. 

Symptoms. — Often  the  symptoms  of  a  local  infection,  especially  that  of  endo- 
metritis, precede  the  development  of  pyemia,  and  this  process  may  have  subsided 
and  the  patient  already  have  been  called  convalescent  when  the  first  chill  announces 
a  new  complication.     Again  the  puerpera  may  have  had  an  apparently  normal 


CLINICAL   TYPES    OF    PUERPERAL    INFECTION 


857 


l)U(Ti)<'riiim,  only  a  slislit  cvcnin};  tciniK'r.ihin'  or  rise  of  i)ul.s<-  apprising  the  acute 
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declare  the  disease.     1  have  seen  this  as  late  as  three  weeks  after  delivery.     The 


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initial  chill  is  constant,  lasts  ten  to  forty  minutes,  and  is  followed  by  high  fever, — 
even  106°  F., — fast  pulse,  and  defervescence  is  accompanied  by  a  profuse  sweat. 
Subnomial  temperature, — 95°  F., — even  collapse,  may  ensue.     Another  rigor  may 


858  PATHOLOGY    OF   THE    PUERPERIUM 

occur  within  a  few  hours  or  the  next  day,  and  these  are  repeated  daily  for  a  varia- 
ble length  of  time.  One  of  my  cases  had  more  than  100  chills.  The  severest  forms 
of  infection  have  the  fewest  number  of  chills,  and  the  number  of  rigors  cannot  be 
foretold.  It  is  believed  that  each  one  indicates  that  a  bit  of  thrombus  has  broken 
off,  or  at  least  that  the  blood  has  gained  a  new  supply  of  bacteria  or  toxins.  The 
bacteria  are  usually  most  easily  found  in  the  blood  during  the  chill  (Warnekros). 
It  is  impossible  to  locate  the  embolism  of  every  chill.  The  temperature  is 
very  irregular;  the  pulse-curve  follows  that  of  the  fever,  unless  an  embolism  occurs 
in  a  vital  organ  (Fig.  760).  Leukocytosis  is  the  rule.  The  course  of  the  disease 
is  very  chronic,  lasting  from  three  weeks  to  three  months,  or  even  as  long  as  a 
year.  At  first  the  general  condition  is  little  affected,  but  sooner  or  later  the  blood 
suffers,  the  strength  wanes,  and  a  hectic  condition  and  inanition  develop.  The 
skin  becomes  waxy-gray,  the  pulse  weak  and  rapid,  bed-sores  develop,  and  the 
patient  may  die  of  exhaustion  in  four  to  twelve  weeks  without  metastases  devel- 
oping. Metastases  are  the  rule,  however,  and  they  may  protract  the  course  of  the 
disease  as  long  as  eight  months.     The  most  common  metastases  are: 

(a)  Lungs. — Emboli  here  are  indicated  by  pain  in  the  chest,  cough,  bloody, 
sometimes  purulent,  expectoration,  dyspnea,  and  the  signs  and  symptoms  of  pleur- 
isy, abscess,  or  pneumonia.  Later,  gangrene  of  the  lung  may  occur.  If  the  em- 
bolus is  large,  it  may  plug  one  of  the  larger  pulmonary  vessels  and  cause  sudden 
death.  If  the  embolus  is  exceedingly  small,  it  may  pass  through  the  large  pul- 
monary capillaries  and  lodge  in  the  brain,  kidneys,  etc.  If  the  foramen  ovale  is 
patent,  the  emboli  may  pass  directly  into  the  greater  circulation. 

(6)  Joints. — When  the  joints  are  affected,  the  usual  signs  of  arthritis  are  present. 
Suppuration  and  complete  disorganization  do  not  always  follow;  sometimes  a 
serous  effusion  is  the  only  finding,  and  it  is  reabsorbed,  but  may  leave  adhesions, 
contractures,  and  partial  disability.  The  knee  is  most  often  affected,  and  the  large 
joints  usually,  but  not  one  is  exempt. 

(c)  Subcutaneous  tissue  anywhere  may  be  the  seat  of  an  abscess,  which  is  shown 
by  the  usual  signs.  Fochier  noticed  that  these  abscesses  seemed  to  have  a  curative 
effect,  and  he  induced  them  artificially  as  a  therapeutic  measure. 

{d)  Kidneys. — Albuminuria  is  constant  in  the  bad  cases.  Emboli  here  are 
shown  by  pain,  bloody  urine,  and  the  usual  course  of  a  pyonephrosis. 

(e)  Eyes. — Two  forms  occur.  Retinal  hemorrhages,  common  with  acute  endo- 
carditis, and  panophthalmitis,  with  complete  disintegration  of  the  eyeball. 

(/)  Thyroiditis,  Parotitis. — Metastases  of  the  kidney,  eye,  and  thyroid  are 
of  very  evil  omen,  but  are  not  absolutely  fatal.     Meningitis  is  always  fatal. 

If  the  veins  of  the  pelvis  are  much  involved,  edema  of  the  legs  is  noticed,  and 
the  abdominal  wall  veins  enlarge  for  the  collateral  circulation.  Ascites  may  be  pres- 
ent. On  the  other  hand,  all  three  may  be  absent,  with  very  extensive  thrombosis. 
Gangrene  of  the  flesh  of  the  calves  and  posterior  aspects  of  the  thighs,  leaving  deep 
and  eroding  bed-sores,  occurs  in  very  chronic  cases,  and  the  puerpera  will  be  made  a 
bed-  or  chair-ridden  invalid  for  life. 

The  diagnosis  at  first  may  be  in  doubt,  but  soon  the  repeated  chills,  the  zigzag 
temperature-chart,  and  the  local  findings  will  clear  the  situation.  Vaginally,  the 
uterus  may  be  normal,  but  usually  it  is  enlarged  and  slightly  tender.  At  one  or 
both  sides  the  fornices  may  be  found  swollen  and  sensitive;  indeed,  the  thrombosed 
veins  may  sometimes  be  felt  as  solid,  worm-shaped  cords.  Deep  pressure  at  the 
sides  of  the  uterus  from  the  belly  always  elicits  tenderness,  and  the  same  may  be 
present  under  Poupart's  ligaments.  Prognosis  and  treatment  will  be  considered 
later. 

Phlegmasia  Alba  Dolens. — This  is  a  term  rather  loosely  applied  to  several 
different  pathologic  conditions.  Literally  it  means  a  painful  white  inflammation, 
and  is  applied  to  such  occurring  in  the  legs  and  thighs,  although  equally  applicable 


CLINICAL   TYPES    OF    PUERPERAL    INFECTION  859 

U)  tlu'  same  condition  occurring  in  the  arms.     'Jlic  following  forms  arc  observed  in 
practice: 

(1)  Simple  thrombosis  of  llic  saphenous  and  femoral  veins  or  of  th(^  ihae,  with 
edema  of  the  extremity  begiiming  at  the  foot  and  exten<hng  to  the  trunk,  but  not 
onto  it,  attended  by  very  slight  fever,  little  pain,  and,  in  general,  very  mild  symptoms. 
The  skin  is  cool,  translucent,  and  mottled,  or  marbled  with  distenderl  veins.  Punc- 
ture would  show  a  thin  serum.  These  cases  have  been  called  mechanical  thrombo- 
ses, and  have  been  explained  by  the  stasis  of  the  blood  in  the  pelvic  and  crural  veins 
during  pregnancy  and  the  puerperium,  the  long  rest  in  the  recumbent  posture,  the 
anemia,  the  hyperinosis  of  pregnancy,  marasmus,  etc.,  but  the  author  believes  that 
they  are  always  due  to  a  mild  infection,  and  that  it  is  a  rapidly  advancing  endo- 
phlebitis.  The  origin  of  this  infection  may  be  remote  from  the  site  of  th(!  throm- 
bosis, and  may  have  healed,  examples  of  which,  from  my  own  observation,  are  ulcer 
of  the  ankle  and  infected  perineum.  At  an  autopsy  in  Vienna  on  a  woman  who  died 
of  pulmonary  embolism  after  a  simple  perineorrhaphy  the  pelvic  and  femoral  veins 
were  found  filled  with  clots,  and  thcnr  origin  could  Ije  traced  to  the  infected  wound  in 
the  perincaim.  Many  cases  of  sudden  death  from  em})olism  are  preceded  by  mild 
febrile  symptoms,  rapid  pulse,  or  local  symptoms  which  indicate  that  disease  of  some 
kind  exists  in  the  pelvis.  Excepting  these  accidents,  the  course  of  the  thrombosis  is 
not  alarming;  the  fever  keeps  a  low  level,  the  general  health  is  good,  appetite  and 
sleep  are  ])ut  little  disturbed,  and  recovery  takes  place  in  from  two  to  six  weeks. 
The  disease  usually  begins  after  the  eighth  day  of  the  puerperium,  and  is  caused  by 
an  organism  of  low  virulence — either  an  attenuated  streptococcus  or  the  staphylo- 
coccus, even  sometimes  by  the  bacteria  which  normally  grow  as  saprophytes  in  the 
genitals.     This  form  of  phlegmasia  occurs  not  seldom  after  myoma  operations. 

(2)  ThrombophlelDitis  of  the  pelvic  and  crural  veins  may  be  the  outward  exten- 
sion of  the  infected  uterine  veins,  being  only  a  part  of  a  pyemic  process,  to  which  ref- 
erence has  already  been  made,  and  it  may  also  occur  apparently  alone.  In  thefonner 
case  the  symptoms  and  signs  of  endometritis  or  pelvic  inflammation  precede  the  pain 
and  sw^elling  of  the  leg;  in  the  latter  case  the  initial  chill  is  followed  at  once  bj'  the 
localization  in  the  extremity.  Often  the  intrapelvic  symj^toms  of  the  early  puer- 
perium are  overlooked.  Usually  after  the  eighth  day,  and  perhaps  as  late  as  the 
twentieth,  the  puerpera  experiences  pain  in  the  groin,  and  at  the  same  time  in  the 
calf  of  the  leg.  The  pain  is  so  great  that  the  leg  is  immovable.  The  swelling  is 
noticed  first  in  Scarpa's  triangle  and  in  the  labium  vulvae  of  the  affected  side.  The 
groin  is  the  site  of  the  greatest  pain,  and  sometimes  it  is  possible  to  feel  the  throm- 
bosed veins  under  Poupart's  ligament.  The  upper  thigh  is  sometimes  swollen  to 
twice  its  natural  size,  has  a  white,  opalescent,  or  somewhat  yellowish  tint,  feels  hot 
to  the  touch,  is  exceedingly  sensitive,  and  pits  with  difficulty  on  pressure.  Within 
a  few  hours  or  days  the  whole  limb  is  involved,  but  sometimes  the  lower  leg  and  foot 
seem  rather  to  be  edematous,  and  not  infiltrated  with  lymph.  W.  A.  Freund  has 
differentiated  by  puncture  the  lymph  of  the  upper  thigh  from  the  serum  of  the  lower 
leg.  The  milk-white  appearance  of  the  liml)  gave  the  disease  the  popular  appella- 
tion, "milk-leg" — indeed,  the  ancients  Ijelieved  it  was,  in  reality,  a  milk  metastasis. 

At  the  beginning  a  chill  may  or  may  not  occur,  but  fever  is  always  present,  to- 
gether ^\^th  the  symptoms  of  severe  illness — i.  e.,  of  infection,  of  a  pyemic  process. 
Both  limbs  may  be  involved  at  once  or  one  after  the  other.  The  fever  pursues  an  ir- 
regular course,  with  marked  remissions;  the  pulse  is  usually  high,  and  the  course  of 
the  disease  is  very  protracted,  especially  if  one  limb  is  involved  after  the  other.  Weeks 
or  months  may  elapse  before  the  signs  of  inflammation  and  obstruction  of  the  veins 
disappear,  and  the  general  health  may  suffer  very  much.  Bed-sores  are  prone  to 
form  over  the  sacrum  and  the  heels.  Even  long  after  the  recovery  edema  of  the 
foot  "\\all  appear  when  the  patient  is  much  on  her  feet.  In  bad  cases  the  inflamma- 
tion passes  over  to  the  arteries;  thrombosis  occurs  here  too,  and  gangrene  of  the 


860  PATHOLOGY  OF  THE  PUERPERIUM 

extremity  results.  If  many  of  the  veins  of  the  leg  become  occluded,  the  circulation, 
may  be  stopped,  with  the  same  result.  Arterial  thrombosis  may  also  result  from 
emboh  from  the  valves — endocarditis.  Immediate  amputation  is  demanded  when 
the  diagnosis  of  gangrene  is  made;  delay  means  death,  and  even  amputation  may 
not  save.  Portions  of  the  calves  and  thighs  may  slough  off  from  pressure  and  poor 
circulation.     Treatment  is  based  on  surgical  principles. 

Pathologically^  in  these  cases  one  finds  the  pelvic  veins  full  of  firm  thrombi, 
and  the  inflammation  has  crept  out  through  the  pampiniform  plexus  to  the  obturator 
vein,  or  even  through  the  hypogastric,  to  the  common  iliac,  and  then  backward  to 
the  femoral.  In  addition  to  the  endophlebitis  and  phlebitis,  there  is  a  marked  peri- 
phleliitis.  The  connective  tissue  around  the  veins  is  infiltrated  with  a  gelatinous, 
mucoid  material  ( "phlegma"),  and  the  lymphatics  which  accompany  the  veins  are 
filled  and  occluded  by  the  same  material.  Whether  or  not  there  is  a  lymphangitis 
or  simply  a  lymphatic  stasis  with  coagulation  of  the  lymph  has  not  been  settled — 
probably  both  exist.  This  lymphatic  process  accompanies  the  inflammation  of  the 
veins  as  the  latter  spreads  out  of  the  pelvis  and  down  the  leg.  Incision  into  such 
a  leg  shows  the  cellular  tissue  solid  ^vith  coagulated  lymph — the  same  in  the  lym- 
phatics. The  large  veins  are  filled  with  thrombi,  partly  solid,  partly  puriform  de- 
generated. The  phlebitis  may  be  primary,  or  secondary  to  a  pelvic  cellulitis,  and 
the  process  may  be  reversed;  a  phlebitis  may  lead  to  a  cellulitis,  and,  owing  to  the 
proximity  of  the  peritoneum,  to  a  local  peritonitis.  The  clinical  picture  may  then 
be  indistinct,  combining  symptoms  and  signs  of  the  three  conditions. 

(3)  Pelveocrural  Cellulitis. — In  this  form  of  phlegmasia  the  condition  is  one  of 
extension  of  a  cellulitis  from  the  pelvis.  This  cellulitis  differs  from  the  form  de- 
scribed under  Parametritis  in  the  rapidity  of  its  spread,  its  tendency  to  attack  the 
subcutaneous  cellular  tissue,  the  lateness  of  suppuration,  if  at  all,  and  the  severity  of 
its  effect  on  the  general  system.  It  resembles  the  malignant  infections  of  the  arm, 
and  is,  like  them,  almost  always  caused  by  a  virulent  strain  of  streptococci.  The 
infection  may  leave  the  pelvis  either  above  or  below,  and  the  resulting  inflammation 
of  the  upper  thigh  will  appear  first  over  Poupart's  hgament  or  in  the  nates.  Swell- 
ing, pain,  heat,  and  redness  characterize  this  form  of  phlegmasia,  and  it  often  is  but 
part  of  a  general  septicemia.  Very  often,  in  addition,  thrombosis  occurs  in  the 
crural  veins,  and  then  the  lower  part  of  the  affected  extremity  swells  up  with  edema, 
and  the  picture  resembles  the  ordinary  phlegmasia  alba  dolens  more.  It  may  at 
first  be  difficult  to  distinguish  between  the  two  forms,  but  the  fact  that  the  inflamma- 
tion with  the  swelling  began  in  the  upper  part  of  the  thigh  first  and  the  edema  of  the 
foot  came  a  considerable  time  later, — an  observation  clearly  made  by  Levret  in 
1766, — and  the  demonstration  of  a  pelvic  cellulitis,  will  aid  a  good  deal  in  the  differ- 
entiation. Blisters  and  pustules  occur  with  both  forms.  Necrosis  and  abscess  are 
rare  with  the  purely  phlebitic  phlegmasia,  and  commoner  with  the  cellulitis.  The 
course  of  this  kind  of  phlegmasia  is  rapid  and  usually  fatal,  the  inflammation 
involving  both  limbs,  and  the  bacteremia  being  pronounced.  If  healing  is  to 
take  place,  the  infection  ceases  to  spread  and  the  general  symptoms  ameliorate. 
Abscess  formation  is  a  favorable  sign  unless  the  whole  limb  becomes  studded  with 
areas  of  necrosis.  Such  cases  are  protracted  and  serious.  The  diagnosis  is  easy, 
as  a  rule.  Sometimes  it  may  be  necessary  to  shut  out  neuritis  or  parametritis, 
when  the  thrombosis  is  deep  seated  and  edema  not  yet  begun. 

Treatment. — Prevention.  Extreme  asepsis  in  the  conduct  of  all  obstetric  cases 
will  effectually  prevent  the  vast  majority  of  all  the  forms  of  phlegmasia  alba  dolens. 
The  milder  thromboses,  phlegmasia  of  the  type  first  described,  may  now  and  again 
occur  with  faultless  technic,  but  these  are  also  ascribable  to  infection,  probably 
endogenous  in  origin,  though  many  authors  Ixdieve  th(!y  are  due  to  stasis  of  the 
blood  in  the  veins,  prolonged  rest  in  the  horizontal  position,  and  alteration  of  the 
blood.     To  forestall   such   thromboses  many   authors,   especially  the   Germans, 


CLINICAL   TYPES    OF    PUERPERAL    INFECTION 


861 


rocomiiiciid  that  the  j)U('ri)('ra  \)v  <i;ott<'ii  out  of  bed  us  soon  as  possible  after  labor — 
on  the  seeond  or  tliird  day.  This  is  said  to  improve  tiie  circulation  and  {)revent 
thronil)i  from  forminfj;.  1  am  not  stronfi;l\-  in  sympathy  with  such  a  practice,  but 
give  the  puerpera  much  more  freedom  in  bed  than  formerly.  (See  Time  of  Getting 
Up,  p.  326.) 

Aside  from  the  general  rules  applicable  to  all  forms  of  puerperal  infection,  which 
will  be  discussed  later,  the  treatment  of  plilebitis  and  thrombosis  ref|uires  special 
precautions.  The  dangers  are  embolism  and  Ijcd-sores.  Good  nursing  is  of  prime 
importance.  Moving  the  patient  and  the  affected  limb  is  restricted  to  a  minimum, 
and  is  done  slowly  and  with  the  greatest  care.  In  addition  to  the  cradle  showTi  in 
Fig.  761,  a  symphysiotomy  Ijcd  (Fig.  815)  may  Ixi  employed.  The  limb  is  to  be 
elevatctl  slightly  to  aid  the  return  circulation,  which  may  be  done  as  in  Fig.  761, 
or  by  means  of  a  few  pillows.  For  a  few  hours  each  day  the  leg  should  lie  flat,  the 
change  l)eing  made  guardedly.  The  pad  to  protect  the  heel  is  to  be  placed  under 
the  tendo  Achillis,  and  the  bed-clothes  are  to  l)e  supported  by  a  cradle  of  hoops  or 
by  the  top  of  the  box  shown  in  the  illustration.     Drop-foot  may  be  prevented 


Fig.  761. — Phlegmasia  Cradle. 
Adhesive  strap  is  to  support  the  ball  of  the  foot     The  board  is  well  padded. 


by  an  adhesive  strap  running  from  the  sole  or  the  big  toe  to  the  side  of  the 
box.  The  padding  in  the  box  is  best  made  of  eiderdown,  and  is  to  be  fre- 
quently aired,  and  changed  whenever  soiled.  After  from  four  to  eight  weeks  the 
clot  may  be  considered  firm  enough,  and  the  patient  given  a  little  more  freedom, 
but  it  is  ])est  to  keep  her  in  bed  for  at  least  two  weeks  after  the  temperature  has  be- 
come normal.  jMassage  of  the  liml)  is  not  permitted  for  several  months  after  the 
patient  is  about.  I  never  use  ointments,  bandaging,  or  applications  of  wet  dressings 
to  the  limb — they  disturb  the  parts  too  much.  At  most,  when  there  is  great  pain 
in  the  groin,  a  light  ice-bag  or  a  warm-water  bag  is  applied.  Care  is  required  to 
avoid  freezing  and  l)urning,  both  of  which  are  more  likely  to  occur  when  the  circu- 
lation is  poor.  Morphin  may  be  used  for  pain.  It  is  important  to  keep  up  the 
nourishment.  Later,  when  the  patient  gets  up,  the  foot  may  become  edematous. 
A  rubber  stocking  may  sometimes  be  worn  with  comfort.  In  a  subsequent  puer- 
perium  the  thrombosis  maj'  recur.  In  the  event  of  pulmonary  embolism  the  at- 
tendant is  powerless.  Trendelenburg  and  others  have  opened  the  pulmonary  artery 
and  removed  the  clots,  but  all  the  patients  have  died.  One  died  five  days  later  from 
infection  of  the  wound,  and  thus,  perhaps,  might  have  been  saved. 


862  PATHOLOGY  OF  THE  PUERPERIUM 

Intramural  Uterine  Abscess. — More  commonly  than  is  reported,  a  uterine 
lymphangitis  or  phlebitis  results  in  an  abscess  within  the  muscular  wall.  Such 
abscesses  may  be  single  or  multiple,  seem  to  prefer  the  cornua  as  sites,  and  may  be 
the  only  local  cause  for  the  general  symptoms,  or  may  be  only  a  part  of  an  extensive 
local  infectious  process,  as  pelvic  peritonitis,  cellulitis,  pyosalpinx,  phlebitis.  These 
abscesses  may  break  into  neighboring  organs — the  bladder,  the  peritoneum,  the 
parametrium,  the  sigmoid,  or  the  rectum;  they  may  break  into  the  cavity  of  the 
uterus,  giving  rise  to  a  sudden  discharge  of  pus  per  vaginam,  which  simulates  that 
of  a  pyosalpinx,  or  they  may  be  absorbed  or  inspissated.  The  course  of  the  uterine 
abscess  is  chronic.  The  symptoms  of  the  acute  stage  of  the  infection  subside,  and 
the  accoucheur's  attention  is  drawn  to  this  condition  by  the  persistence  of  the  fever, 
etc.  Examination  shows  the  uterus  enlarged,  and,  at  some  point,  a  soft,  fluctuating 
tumor  is  palpable.  In  my  own  case  the  abscess  was  felt  in  the  right  uterine  cornu 
posteriorly,  through  an  incision  made  to  evacuate  pus  in  the  culdesac.  The  patient 
recovered,  the  abscess  either  draining  spontaneously  or  having  become  quiescent, 
and  she  has  been  sterile  since.  A  soft  or  suppurating  fibroid  will  give  all  the  symp- 
toms and  signs  of  uterine  abscess.  An  exploratory  laparotomy  may  be  necessary  to 
confirm  the  diagnosis.  Treatment  is  surgical.  If  the  symptoms  persist,  the  abscess 
is  attacked  by  laparotomy,  but  drained  if  possible  from  below,  otherwise  from  above, 
walling  off  the  general  peritoneal  cavity  with  gauze  and  by  fixing  the  omentum  to 
the  uterus.  A  drainage-tube  may  be  inserted  into  the  abscess  and  led  out  of  the 
belly,  being  fastened  in  place  with  sutures  (Barrows).  If  the  uterus  is  riddled  with 
abscesses,  hysterectomy  and  free  vaginal  drainage  are  indicated. 

Specific  Infections. — Gonorrhea. — A  large  number — easily  15  per  cent. — of  the 
patients  of  our  public  maternities  enter  with  a  latent  gonorrhea.  In  private  prac- 
tice the  number  will  perhaps  not  exceed  10  per  cent.  Since,  with  modern  aseptic 
methods,  fever  is  becoming  so  rare,  we  conclude  that  the  gonococcus  does  not  play 
a  very  important  role  in  puerperal  infection.  Acute  gonorrhea  is  much  more  likely 
to  spread  than  the  chronic  and  to  become  serious,  both  as  regards  the  mother  and 
also  the  baby,  its  eyes,  navel,  etc.  When  the  disease  is  latent,  the  surfaces  are 
usually  free  from  the  organisms,  the  gonococci  resting  in  the  crypts  of  the  vulva,  the 
urethra,  Skene's  tubules,  the  ducts  of  BarthoHn's  glands,  and  sometimes  the  cervical 
glands.  If  the  tubes  are  already  infected,  temporary  or  permanent  sterility  results. 
Causes  which  we  do  not  understand  effect  an  increase  of  virulence  of  these  cocci; 
then  they  spread  all  over  the  surface  of  the  parts,  even  to  the  uterine  cavity,  up 
through  and  out  of  the  tubes  onto  the  pelvic  peritoneum  and  ovaries,  causing  pyo- 
salpinx, ovarian  abscess,  and  pelvic  peritonitis.  This  extension  on  the  surface  is 
the  rule  mth  gonorrhea,  but  in  exceptional  cases  the  bacteria  burrow  into  the 
cellular  tissue,  causing  cellulitis,  with  or  without  abscess,  or  into  the  veins,  causing 
phlebitis,  phlegmasia,  metastases,  gonitis,  endocarditis,  even  general  bacteremia — 
gonococcemia.  It  is  usual  to  find  a  mixed  infection  in  these  conditions,  but  there 
is  no  doubt  but  that  the  gonococcus  alone  can  cause  them. 

Symptoms. — There  is  nothing  characteristic  about  gonorrheal  infections.  Usu- 
ally the  fever  begins  later  in  the  puerperium  than  the  other  infections,  because  it 
requires  some  time  for  the  cocci  to  attain  full  virulence  and  to  pass  up  through  the 
uterus  to  the  tubes  and  peritoneum.  Pelvic  peritonitis  beginning  after  the  seventh 
day  is  almost  always  gonorrheal.  Involvement  of  a  single  joint, — the  knee  or  the 
wrist, — of  a  very  chronic  nature,  is  often  gonorrheal;  indeed,  pregnancy  and  the 
puerperium  are  the  most  potent  predisposing  causes  of  gonorrheal  "rheumatism." 
With  the  rare  exceptions  mentioned  the  symptoms  are  mild,  and  apply  to  the  part 
of  the  pelvic  anatomy  which  is  affected.  The  course  of  the  cases  is  usually  pro- 
tracted, which  is  especially  true  of  pyosalpinges  and  ovarian  abscesses.  A  collec- 
tion of  pus  in  the  culdesac  may  be  opened  when  it  bulges  toward  the  vagina  or  the 
rectum,  and  healing  is  then  rapid.     Deforming  scars  and  adhesions  always  follow 


CLINICAL   TYPES    OF    PUERPERAL    INFECTION  863 

gonococcal  infections,  and  sterility  is  tlu;  usual  result.  The  diagnosis  may  seldom 
))e  made  from  the  cHnieal  course.  The  finding  of  the  gonococcus  in  large  numbers 
(rarely  in  pure  culture)  in  the  lochia  will  indicate  the  cause  of  the  symptoms,  but 
not  positively,  because  the  streptococcus,  the  pyococcus,  or  the  Bacterium  coli  in 
symbiosis  may  be  at  the  root  of  the  real  illness.  The  prognosis  as  to  life  is  good,  as 
to  health,  dubious.  The  women  almost  never  fully  recover  if  the  infection  passes 
beyond  the  uterus.  After  many  years  the  tuljcs  may  Ijecome  ])atulous,  and  even 
pregnancy  sujx'rvene,  ])ut,  as  a  rule,  the  women  remain  tlieir  life  long  gynecologic 
invalids  and  often  require  capital  operations  to  restore  even  partial  health. 

Treatment  is  based  on  general  principles.  Local  treatment  is  absolutely  con- 
traindicated  in  the  acute  stage.  Prolonged  rest  in  bed  is  imperative.  Only  after 
the  fever  has  Ix^en  absent  a  week  may  the  puerpera  get  up.  If  an  internal  examina- 
tion is  to  be  made,  it  is  done  very  gently.  If  an  al:)scess  is  felt  in  the  culdesac,  it  is 
to  be  opened,  but  not  before  the  surrounding  adhesions  are  very  firm.  The  tubular 
drain  may  be  removed  when  the  discharge  has  nearly  ceased — usually  at  the  end  of 
ten  days;  then  a  bit  of  gauze  is  kept  in  the  vaginal  opening  for  a  few  days.  Irriga- 
tions of  the  pus-sac  are  never  made.  Pyosalpinges  should  not  l)e  removed,  either 
vaginally  or  abdominally,  for  a  year  at  least,  and  even  then  only  for  specially  in- 
sistent indications.  If  the  pyosalpinx  is  due  to  a  streptococcous  infection,  several 
years  may  elapse  before  its  removal  is  positively  safe. 

Tetanus. — Nowadays  tetanus  is  the  rarest  of  all  infections  in  the  puerperium,  but  when 
it  does  occur,  it  is  of  a  most  virulent  type.  Pathology,  symptoms,  diagnosis,  and  treatment  do 
not  differ  from  those  of  surgical  tetanus.  Prophylaxis  in  maternities  requires  special  severity,  be- 
cause, to  judge  from  the  experience  of  one  European  hospital,  when  the  disease  is  once  introduced, 
all  ordinary  means  of  eradicating  it  may  fail.  If,  therefore,  one  case  should  occur  in  a  lying-in 
hospital,  the  patient  had  better  be  removed  at  once  from  this  institution,  and  all  the  rooms  she 
occupied  be  disinfected  in  the  most  thorough  manner  and  left  exposed  to  the  elements  for  at  least 
a  week.  All  instruments  and  utensils  that  came  in  contact  with  the  patient  should  be  doubly 
sterilized,  and  all  the  women  exposed  to  the  infection  given  an  immunizing  dose  of  antitoxin. 

Diphtheria. — This  is  rare  in  the  puerperium,  and  the  disease  differs  in  no  way,  except  local- 
ization, from  tliat  observed  in  the  throat.  The  membrane,  unhke  that  of  the  streptococcus,  shows 
a  marked  tendency  to  spread  all  over  the  parturient  canal,  and  usually  leaves  no  scars.  General 
symptoms  of  toxinemia  are  in  evidence,  and  if  the  streptococcus  is  associated,  a  severe  septi- 
cemia may  ensue.  Over  40  cases  of  puerperal  diphtheria  are  on  record.  I  had  one.  Smears  and 
cultures  should  be  taken  from  every  puerperal  fever  case  in  order  to  discover  diphtheria.  Treat- 
ment with  antitoxin  in  maximal  doses  is  indicated,  but  no  local  treatment  at  all. 

Literature 

Barrows:  Amer.  Jour.  Obstet.,  April,  1911. — Gellhorn:  Amer.  Jour.  Obstet.,  July,  1909,  p.  31. — Kroemer:  "Phlegmasia 
Alba  Dolens,"  Arch.  f.  Gyn.,  1910,  vol.  xcii,  2,  p.  537. — Sampson:  Amer.  Jour.  Obstet.,  IMarch,  1910.  Gives 
literature  on  Uterine  Absces.s. — Schottmtiller:  Centralbl.  f.  Gyn.,  December,  1910,  No.  52,  p.  1674. — Thyroid- 
itis: Ann.  de  Gyn.  et  d'Obst.,  February,  1910.  Literature. —  Warnekros:  Arch.  f.  Gyn.,  June,  1912,  vol.  xcvii, 
H.  1,  p.  73. 


.  CHAPTER  LXV 
DIAGNOSIS  OF  PUERPERAL  INFECTION 

Most  cases  of  fever  in  child-bed  are  cases  of  child-bed  fever,  but  this  fact  must 
not  lead  the  accoucheur  into  carelessness  in  his  treatment  of  feverish  puerperse. 
Several  times  I  have  found  the  attendant  giving  intra-uterine  douches  when  the 
patient  was  suffering  from  tonsillitis.  In  my  own  experience  the  following  diseases 
have  been  mistaken  for  puerperal  infection:  typhoid  fever,  acute  miliary  tubercu- 
losis, meningitis,  acute  yellow  atrophy  of  the  liver,  tonsillitis,  pneumonia,  la  grippe, 
tubercular  peritonitis,  appendicitis,  cholecystitis,  ureteropyelitis,  and  mastitis.  In 
practice,  therefore,  while  puerperal  infection  is  the  first  to  be  thought  of  when  the 
puerpera  sickens,  the  patient  should  be  subjected  to  a  complete  and  careful  physical 
examination,  and,  by  a  process  of  exclusion,  the  diagnosis  reached  that  the  disease  has 
taken  its  origin  in  the  genitals.  It  is  wise  to  repeat  the  general  examination  at  in- 
tervals of  three  or  four  days  to  avoid  surprises,  and  early  to  recognize  complications. 

After  it  is  certain  that  the  case  is  one  of  infection,  these  questions  are  to  be 
answered,  all  being  essential  to  prognosis  and  treatment:  (1)  What  is  the  anatomic 
location  of  the  infection?  (2)  In  what  direction  is  it  spreading  and  how  far?  (3) 
Is  the  infection  more  general  than  local,  or  more  local  than  general?  (4)  What 
bacterium  is  causative?     (5)  Is  there  anything  in  the  uterus? 

Ad  1 :  A  study  of  the  history  of  the  labor  may  indicate  at  once  the  site  of  the 
infection,  for  example,  if  the  delivery  was  instrumental,  with  extensive  injury  to  the 
cervix,  the  usual  result  of  infection  is  a  cervicitis  followed  by  parametritis  or  peri- 
tonitis. Perineorrhaphies  may  suppurate.  Manual  removal  of  the  placenta  is 
often  followed  by  endometritis  and  bacteremia,  curetage  postpartum  by  bacteremia 
via  the  lymphatics,  with  or  without  peritonitis,  and  so  on.  In  addition  to  the 
history  the  site  of  pain  and  other  local  symptoms  may  point  to  the  anatomic  struc- 
ture involved.  Early  in  the  puerperium  it  is  dangerous  to  make  an  internal  ex- 
amination, and,  further,  the  information  gained  is  slight.  Specular  examinations 
are  not  recommended.  All  these  manipulations  tear  open  the  puerperal  wounds, 
reinoculate  the  tissues,  and  carry  the  infection  to  parts  higher  in  the  parturient  canal. 
Inspection  of  the  vulva,  aided  by  separating  the  labia  to  get  a  good  view  of  the 
introitus,  will  give  useful  information,  the  condition  of  the  puerperal  wounds  being 
a  good  index  of  what. is  going  on  higher  up.  (See  Endometritis.)  Parametritis 
and  pelvic  peritonitis  are  usually  easily  distinguishable — if  not  at  first,  then  later 
in  their  course. 

Ad  2 :  Ordinarily  the  spread  of  the  infection  can  be  traced  from  day  to  day  by 
the  clinical  course  of  the  disease.  Metastases  in  various  parts  of  the  body  give 
symptoms  characteristic  to  the  part  affected. 

Ad  3 :  The  determination  whether  the  infection  is  limited  to  the  uterus  or  has 
already  invaded  the  blood  is  not  easy — indeed,  as  was  already  stated,  Schottmiiller 
has  proved  that  in  many  cases,  formerly  considered  local  diseases,  that  is,  toxinemic 
only,  a  hemolytic  anaerobic  streptococcus  may  be  cultivated  from  the  blood.  For- 
merly sterility  of  the  blood  was  considered  evidence  that  the  infectious  process  was 
entirely  local.  Now,  unless  anaerobic,  as  well  as  aerobic,  methods  and  the  utmost 
variety  of  culture-media  are  used,  sterility  of  the  Ijlood  may  not  be  regarded  as 
evidence  that  the  bacteria  are  restricted  to  the  genitals.  In  many  cases  the  strep- 
tococcus has  been  found  culturally  in  the  blood,  the  staphylococcus  also,  as  well  as 

864 


DIAGNOSIS    OF    PUERPERAL    INFECTION 


865 


other  bacteria  previously  mentioned,  and  wlien  they  are  found  easily,  by  the  or- 
dinary methods  or  in  lar<;c  nunii;ers,  one  may  conclude  that  a  bacteremia  exists. 
For  the  technic  of  the  bacteriologic  study  of  the  blood  the  reader  is  referred  to  ap- 
propriate text-books.  Clinically,  the  accoucheur  may  not  l)e  able  positively  to 
decide  from  the  symptoms  whether  he  has  a  purely  local  infection  with  toxinemia,  or 
whether  the  blood  is  also  being  disijrganized  by  the  bacteria,  but  in  general  the 
severity  of  the  illness  is  a  fair  guide.  Continuous  high  temperature,  very  rapid 
pulse,  severe  prostration,  etc.,  point  to  bacteremia. 

Ad  4:  It  is  usually  possible  to  determine  what  germ  is  causative — at  lea.st  the 
on(>  taking  th(>  leading  role.  Investigation  has  shown  that  the  streptococcus  pyo- 
genes is  the  conunonest,  and  since  some  of  its  strains  are  very  virulent  and  others 
less  so,  it  is  needful  to  discover  which  one  is  active  in  the  particular  case.  Un- 
fortunately, we  are  not  able  to  do  this.  Tests  of  the  virulence  of  cultures  of  strepto- 
cocci on  the  lower  animals  are  unreliable  because  the  latter  do  not  react  as  do  the 
humans.  Long  chains  of  stn^ptococci  do  not  incUcate  high  virulence,  but  only  that 
the  culture-medium  is  favorable  to  such  growi:h.  Hemolysis  in  cultures  (on  blood- 
agar,  for  example)  has  been  proved  to  occur  with  many  kinds  of  streptococci,  though 
it  almost  always  betokens  a  virulent  strain,  and,  on  the  other  hand,  anhemolytic 


Fig.  702. — Two  Forms  of  Pipet  with  which  to  0BT.^.1N  Lochia. 

a,  b:  Little's  pipet,  a  bent  tube  threaded  with  a  rubber  band  tied  at  the  end  of  the  thread,  which,  when  drawn  through, 

makes  suction. 


streptococci  may  be  very  virulent  (Zangemeister) .  Fromme's  lecithin-bouillon 
test  also  has  proved  fallacious,  and  thus  the  work  of  Schottmiiller,  i\Iau,  and  Zange- 
meister has  borne  little  fruit.  In  order  to  find  out  the  causative  bacteria  it  is 
necessary  to  make  exhaustive  studies  of  the  blood,  as  well  as  of  the  lochia.  A  small 
quantity  of  the  lochia  is  ol)tained  from  the  deeper  portion  of  the  vagina  by  means  of 
a  simple  pipet,  and  cultures  made  in  all  the  kno^^^l  bacteriologic  media,  both  anae- 
robic as  well  as  aerobic  (Fig.  762).  Smears  are  also  examined.  The  best  stain  is 
Loffler's  methylene-blue. 

Just  because  one  identifies  certain  bacteria  in  the  lochia  does  not  permit  the 
deduction  that  the  infection  results  from  that  particular  organism.  If  it  is  found  in 
large  num]:)ers,  in  pure  culture,  or  overshadowing  all  the  others,  the  conclusion  that 
it  is  causative  may  be  hazarded,  and  if,  in  addition,  the  same  organism  is  found  in 
the  blood,  the  diagnosis  becomes  positive.  Regarding  the  streptococcus,  Kronig 
believes  that  this  simple  test  will  enable  one  to  be  positive.  If  a  small  amount  of 
lochia,  inoculated  on  blood-agar,  gives  rise  to  very  numerous  hemohi:ic  colonies, 
the  puerpera  is  suffering  from  puerperal  infection.  If  a  finer  reagent  is  used,  such 
as  grape-sugar  bouillon,  streptococci  will  grow  in  80  per  cent,  of  even  normal  puer- 
perae,  and  the  test  is  less  valuable. 
55 


866 


PATHOLOGY  OF  THE  PUERPERIUM 


The  gonococcus  is  easy  to  recognize  in  the  lochia,  and  when  present  in  large 
numbers  or  pure  culture,  may  be  held  responsible  for  the  clinical  picture.  Still,  the 
accoucheur  must  bear  in  mind  that  the  gonococcus  is  frequently  associated  with  the 
streptococcus  and  the  staphylococcus,  and  that  all,  or  at  least  a  goodly  part  of,  the 
disease  may  be  due  to  the  latter.  Further,  gonococci  may  appear  in  the  lochia  of  an 
apparently  healthy  puerpera,  and  their  presence  may  be  proved  by  clinical  experi- 
ence— i.  €.,  gonorrheal  ophthalmia  neonatorum,  the  mother  remaining  well.  The 
discovery  of  true  tetanus  bacilli  has  not  yet  been  made  except  in  tetanus.  In  one 
case  seen  by  the  writer  in  consultation  diphtheria  bacilli  were  obtained  by  a  com- 
petent bacteriologist  when  neither  the  appearance  of  the  genitals  nor  the  clinical 
course  suggested  diphtheria.  In  the  differential  diagnosis  of  puerperal  infections 
from  other  diseases  accompanied  by  fever  the  bacteriologic  investigation  of  the 


■^, 


••^^iX'''f^,  V 


^fn.r''      "  ■■'■■ 


/i'*     ^       .'■■'i-^f  (^ "-■ ■-"    -i 


Pus-cell 


Decidual 
cells 


;  'Jrri 


H 


Fig.  763. — Lochia  in  Puerperal  Septicemia.     Streptococcus  Infection. 
Fuchsin  stain. 

lochia  gives  only  conditional  information.  For  example,  if  the  diagnosis  lies  be- 
tween miliary  tuberculosis  and  sepsis,  the  finding  of  streptococci  in  the  lochia  would 
not  be  enough  to  fix  the  diagnosis  of  sepsis.  Much  more  information  would  be 
gotten  from  the  blood  examination.  Here  the  streptococcus,  the  finding  of  the 
tubercle  bacillus,  the  typhoid  bacillus,  and  the  pneumococcus  give  us  dependable 
information. 

Having  pursued  the  investigation  of  the  case  along  the  four  lines  indicated,  the 
accoucheur  may  usually  make  a  satisfactory  diagnosis.  In  actual  practice  other 
questions  arise.  One  of  the  most  common  is — (5)  "Is  there  anything  in  the  uterus?" 
This  has  been  discussed  on  p.  839.  If  the  answer  cannot  be  positively  made,  the 
case  is  treated  as  if  there  were  nothing  in  the  uterus — contrary  to  older  teachings. 
Another  duty  of  the  attendant  is  the  diagnosis  of  the  condition  of  the  vital  organs  of 


DIAGNOSIS    OF    PUERPERAL   INFECTION 


867 


the  body,  the  state  of  the  liver,  of  the  kidiic.Ns,  of  I  he  lun^^,  of  tin;  heart,  of  the 
blood — these  must  all  he  watched  to  discover  how  they  are  witlistanding  the  attack 
of  the  toxins  aiul  bacteria. 

If  the  case  becomes  chroiii<-,  an  internal  examination  is  to  be  made  to  find  any 
localized  suppuration,  as  i)elveocellulitic  abscess,  perimetritic  exudates,  pyosalpinx, 
ovarian  abscess,  intranuiral  uterine  abscess,  infected  myoma,  etc. 

A  word  of  caution  may  be  permitted  here.  In  all  infected  cases  the  utmost 
gentleness  is  to  be  practised  in  palpating  the  pelvic  structures.  Only  too  easily  is 
the  infectious  process  carried  into  regions  hitherto  protected,  and  also  a  collection  of 
jius  may  be  ])roken  into  the  general  peritoneal  cavity,  which  usuall}'  results  fatally, 
in  spite  of  immediate  laparotomy  and  free  drainage  abov(!  and  below. 

The  differential  diagnosis  should  consider — (1)  All  the  pelvic  inflammations. 


/ ' 


■  -  • 


Fig.  764. — Lochi.v — Saprophytic  Infection. 


one  from  the  other,  and  from  inflamed  tumors  (myomata,  cysts,  etc.) ;  (2)  the  separa- 
tion of  pelvic  infections  from  those  of  the  urinary  system,  especially  ureteropj'elitis; 
(3)  the  cUfferentiation  from  inflammations  of  other  organs  in  the  belly,  e.  g.,  the 
gall-bladder,  the  appendix;  and  (4)  from  all  general  diseases — t^iDhoid,  malaria, 
tuberculosis,  etc.  Obviousl}',  in  a  treatise  of  this  size  a  presentment  of  all  these 
subjects  is  impossible.     Api)ropriate  text-books  must  be  consulted. 

In  considering  pyrexia  during  the  i^uerperium,  mention  must  be  made  of 
"nervous"  temperature.  Many  accoucheurs  and  nearly  all  nurses  beheve  that  a 
puerpera  may  develop  fever  from  nervous  shock  or  excitement,  but  such  an  oc- 
currence has  never  come  under  my  personal  observation.  In  the  dispensaiy  ser\'ice 
of  the  Chicago  L^^ng-in  Hospital  a  woman  on  the  fifth  day  after  delivery,  as  the 
result  of  anger  against  her  husband  who  drank  up  their  small  store  of  money,  and 


868 


PATHOLOGY  OF  THE  PUERPERIUM 


anxiety  for  her  children,  who  were  without  food,  became  intensely  wrought  up  and 
developed  a  temperature  of  105°  F,  The  nurse  brought  food  for  her  and  her  chil- 
dren, and  the  fever  subsided  Avithin  six  hours.  No  other  cause  was  demonstrable. 
Granting  this  possibility,  it  must,  however,  be  emphasized  that  pyrexia  from  ner- 
vousness is  of  greatest  rarity.     Infection  is  almost  always  the  actual  cause. 

Prognosis  of  Puerperal  Infection. — Statistics,  usually  deceptive,  are  particularly 
fallacious  in  puerperal  infection.  The  disease  is  so  protean  in  its  manifestations 
that  it  is  next  to  impossible  to  group  cases  similar  enough  to  make  general  deduc- 
tions from — to  say  nothing  of  reducing  them  to  figures.  Experience,  however,  will 
permit  the  attendant  to  give  a  good  or  a  bad  prognosis,  and  if  he  has  made  a  com- 
plete diagnosis,  as  outlined  in  the  previous  section,  much  difficulty  will  be  overcome. 

Infection  varies  in  gravity  with  the  anatomic  part  involved,  the  direction  of  its 


Fig.  765. — Lochia — Gonorrheal  Infection. 


spread,  the  degree  of  invasion  of  the  blood,  and  the  nature  of  the  infecting  organism. 
Vulvitis  and  vaginitis  are  usually  not  serious — only  rarely  does  the  infection  break 
through  the  natural  Imrriers  and  get  into  the  blood  or  travel  up  to  the  peritoneum, 
and  this,  with  the  Streptococcus  pyogenes.  Endometritis  is  more  dangerous, 
but  here,  too,  the  large  majority  of  cases  recover,  although  the  streptococcus 
may  be  causative,  unless  improper  treatment  is  instituted.  Putrid  endometritis, 
even  when  there  is  considerable  decaying  material,  heals  rapidly  if  drainage  is  good. 
Lochiometra,  responsiljle  for  many  "one-day  fevers,"  is  easily  relieved  by  treat- 
ment and  almost  invariably  has  a  good  prognosis.  Parametritis,  with  the  exception 
of  the  form  called  erysipelas  internum  puerperale,  which  is  really  but  a  part  of  a 
septicemia,  has  a  good  prognosis.  Even  if  the  whole  connective-tissue  framework 
of  the  pelvis  is  involved,  the  prognosis  is  good  as  to  life,  because  if  an  abscess  does 


DIAGNOSIS    OF    PUERPERAL    INFECTION  869 

not  I'urni,  nature  usually  absorbs  tlie  exudates,  and,  furtlier,  the  bacteria  involved 
are  rarely  of  a  virulent  type.  Perimetritis  is  more  serious,  because  at  the  start  one 
cannot  say  if  the  disease  will  remain  limited  to  the  pelvis.  If  the  clinical  evidence 
early  in  the  disease  seems  to  indicate  such  limitation,  the  pnj^nosis  is  good  and  re- 
covery is  the  rule,  since  the  bacteria  are  not  likely  to  be  virulent  (often  the  gono- 
coccus)  and  the  resistance  of  the  woman  is  shown  to  be  strong.  General  periton- 
itis is  almost  always  fatal.  Very  few  cases  of  streptococcus  infection  recover,  but 
even  here  hope  should  be  by  no  means  abandoned.  Bacteremia  or  general  septicemia 
is,  in  thretMjuarters  of  the  cases,  fatal.  Septicopyemia  or  metastatic  l^acteremia 
is  not  so  dangerous.  Bunmi  complains  of  a  high  mortality, — 80  per  cent., — but  my 
own  experience  has  been  more  favorable — almost  30  per  cent.  These  forms  of  inflam- 
mation show  that  nature  is  more  or  less  successful  in  localizing  the  infection.  Indeed, 
in  all  cases  where  the  accoucheur  detects  a  tendency  at  limitation  a  good  prognosis 
may  be  given.  Spreading  infections  and  invasion  of  the  blood-stream  and  of  the 
peritoneal  cavity  are  always  serious.  Phlegmasia  alba  dolens  is  usually  a  favorable 
outcome  of  a  puerperal  infection.  The  large  majority  of  cases  recover,  unless  it  be 
the  form  of  crural  cellulitis,  which  is  often  fatal. 

Much  depends  on  the  causative  organism.  Tetanus  is  the  most  fatal  of  all, 
hardly  any  of  the  women  recovering  from  it.  Gonorrhea  is  the  least  dangerous  of 
the  pus  cocci.  Saprophytic  infections  are  so  varied  that  we  cannot  generalize — 
indeed,  some  of  the  bacteria  formerly  held  to  be  saprophytic  have  recently  been 
found  to  possess  invasive  qualities,  for  example,  the  Streptococcus  putridus. 
Others  have  long  been  known  to  possess  them — for  example,  the  Bacterium  coli, 
the  gas  bacihus,  etc.  Since  the  Streptococcus  pyogenes  causes  most  of  the  serious 
infections,  its  demonstration  in  pure  culture,  or  as  the  dominant  organism  in  the 
lochia,  carries  considerable  prognostic  importance.  Unfortunately,  it  is  not  easy 
to  determine,  as  was  already  shown,  whether  the  streptococcus  is  of  the  virulent 
type,  and,  further,  unless  the  bacteriologic  examination  is  made  early  in  the  puer- 
perium,  the  organisms  may  have  disappeared  from  the  vagina.  Symbiosis  usually 
clouds  the  prognosis. 

In  judging  the  severity  of  any  particular  case  the  above  information  is  first 
considered;  next,  the  apparent  severity  of  the  clinical  manifestations.  If  the  in- 
fection occurs  early  in  labor,  develops  before  it  is  finished,  and  does  not  subside  im- 
mediately, the  uterus  is  emptied — the  disease  is  serious.  If  the  fever  begins  within 
thirty-six  or  forty-eight  hours  after  delivery,  the  same  is  true.  A  single  chill  at  the 
beginning  of  the  disease  is  of  only  moderate  significance,  but  a  second  chill,  or  a 
chill  occurring  after  a  preliminary  run  of  fever,  indicates  graver  disease,  since  these 
symptoms  betoken  advancing  infection.  Repeated  chills  m  pyemia  are  not  a  fatal 
symptom,  though  very  distressing  and  somewhat  ominous.  One  of  my  cases  had 
over  100  chills  and  recovered.  Continuous  high  fever  from  the  start  is  an  unfavor- 
able symptom,  as  is  extreme  prostration,  both  usually  indicating  a  liacteremia. 
Remittent  fever  is  less  serious.  Rapid  pulse  is  also  bad — a  sign  of  grave  toxinemia; 
indeed,  the  pulse  is  a  better  indicator  of  the  gravity  of  the  case  than  the  temperature. 
If  the  pulse  remains  around  100,  the  woman  will  rarely  die.  If  it  goes  above  140, 
the  prognosis  becomes  dubious.  A  good  pulse  with  volume  and  force  usually  means 
recovery,  but  if  it  rapidl>'  increases  in  rate  while  diminishing  in  power,  one  may  de- 
cide that  the  heart  muscle  is  degenerating  under  the  poisoning.  A  sinking  tem- 
perature with  a  running  pulse  almost  alwaj's  presages  death,  and  since,  on  the 
graphic  charts,  their  lines  cross,  it  has  been  called  the  cross  of  death.  Restful  sleep, 
a  warm,  moist  skin,  and  appetite  are  good  symptoms.  The  advent  of  septic  endo- 
carditis or  of  septic  pneumonia  or  pleuritis  immediately  darkens  the  outlook.  De- 
lirium and  even  the  typhoid  state  are  not  necessarily  bad,  but  ominous.  The  gen- 
eral impression  on  the  accoucheur  of  the  severity  of  the  illness,  and  the  feeling  of  the 
patient  herself,  help  a  great  deal  in  making  the  decision,  but  in  regard  to  the  latter 


870  PATHOLOGY  OF  THE  PUERPERIUM 

I  must  say  that  sometimes  very  severe  and  even  fatal  cases  show  remarkable  eu- 
phoria. This  is  most  common  in  peritonitis  toward  the  end :  the  woman  feels  well, 
wishes  food,  and  desires  to  get  up,  but  the  Hippocratic  facies,  the  collapse,  the 
thready  pulse  in  a  clammy,  icy  wrist,  show  that  death  is  not  far  distant. 

Unfortunately,  the  laborious  researches  of  von  Rosthorn,  Arneth,  Burkhard, 
von  Herff,  and  others  on  the  morphology  of  the  blood  have  produced  no  really  use- 
ful results  so  far  as  prognosis  is  concerned.  Destruction  of  the  red  blood-corpuscles 
is  the  rule,  which  accounts  for  the  pallor  of  the  women  and  also  for  the  icterus  of 
some  cases  of  infection.  In  severe  toxinemias  or  bacteremias  the  reds  may  sink  to 
less  than  2,000,000.  Poikilocytosis  and  nucleated  reds  appear  in  the  worst  infec- 
tions. Leukocytosis  is  the  rule,  but  is  of  no  prognostic  significance.  There  is  a 
physiologic  leukocytosis  in  the  puerperium  which  may  reach  29,000.  Absence  of 
leukocytosis  shows  lessened  reaction  of  the  puerpera  to  the  attack  of  the  bacteria, 
but  I  have  seen  recovery  take  place  from  severe  infection  with  a  leukocytosis  that  did 
not  exceed  8000.  It  was  hoped  that  the  differential  count  would  give  useful  data. 
In  health,  according  to  Tiirck,  the  relations  of  the  whites  are  about  as  follows:  Poly- 
morphonuclears, 65  to  75  per  cent. ;  lymphocytes,  20  to  25  per  cent. ;  mononuclears, 
3  to  5  per  cent. ;  eosinophiles,  2  to  3  per  cent.  According  to  Arneth,  increase  of  the 
pol>miorphonuclears  indicates  an  effective  reaction  against  the  invaders,  because 
these  leukocytes,  being  older,  have  strongest  phagocytic  power.  Decrease  in  the 
polynuclears  and  increase  in  the  mononuclears  and  neutrophiles,  with  two  or  three 
nuclei,  show  that  the  bacteria  are  using  up  the  former,  while  the  blood-making 
organs  are  filling  the  ranks  with  young  leukocytes.  The  eosinophiles  disappear 
early  in  the  disease.  Reappearance  of  the  eosinophiles  and  increase  of  the  poly- 
morphonuclears may  be  regarded  as  a  sign  of  improvement.  How  far  these  state- 
ments apply  in  practice  is  yet  to  be  determined. 

When  bacteria  are  demonstrated  in  the  blood,  the  prognosis  is  bad,  but  not 
necessarily  fatal.  Lenhartz  reports  17  per  cent,  of  recoveries,  and  Canon  25  per 
cent,  where  such  were  found.  If  they  are  numerous  and  easily  discovered  by  our 
ordinary  cultural  methods,  and  if  they  are  found  in  all  the  examinations,  the  prog- 
nosis is  worse  than  if  they  are  few  in  number  and  discovered  only  once  in  numerous 
tests.  The  hemolytic  aerobic  Streptococcus  pyogenes  is  very  fatal,  also  the  staphy- 
lococcus (which  seems  to  be  exceptionally  virulent  when  it  invades  the  blood),  the 
Bacterium  coli,  and  the  Bacillus  aerogenes  capsulatus. 

Finally,  in  making  the  prognosis,  the  state  of  the  woman's  previous  constitu- 
tion must  be  debated.  Much  depends  on  the  general  health  of  the  woman — heart, 
lung,  and  renal  and  hepatic  affections  often  seriously  diminishing  her  chances  of 
recovery. 

Albuminuria  appearing  and  increasing  is  of  bad  omen,  also  the  presence  of 
granular  and  epithelial  casts.  Women  exhausted  by  profuse  hemorrhage,  by  the 
toxemias  of  pregnancy,  by  the  shock  of  severe  and  contusing  operations,  debilitated 
by  alcohol,  syphilis,  tuberculosis,  and  the  acute  diseases — all  are  poor  subjects  for 
an  added  infection. 

Mortality  of  Puerperal  Infection. — In  1!)0!),  in  the  registered  area  of  the  United  States, 
which  coinpri.sed  only  5.^.3  per  cent,  of  the  total  population,  7791  women  died  in  childbirth,  and 
of  these,  3.540  died  of  "puerperal  septicemia."  In  1910,  in  the  registered  area,  which  comprised 
58.3  per  cent,  of  the  total  population,  84.5.")  died  in  childbirth,  and  of  these,  4122  died  frcnn  infection. 
These  figures  are  taken  from  tlie  mortality  statistics  of  th(>  United  States  Bureau  of  the  Census. 
If  the  same  proportion  of  deaths  exists  in  tlie  non-registcreil  area,  it  is  safe  to  say  that  every  year 
there  are  lost,  in  the  United  States,  over  6000  mothers  from  child-bed  fever.  In  reality  the  num- 
bers are  much  larger.  There  is  no  floubt  that  women  ha\-e  died  from  sepsis,  and  the  death  reported 
as  due  to  other  causes,  cither  through  mistaken  diagnosis  or  deliberate  concealment.  I  do  not  fear 
to  hazard  the  statement  that  8000  women  die  annually  in  the  United  States  from  child-bed  infec- 
tions. ^\'hen  one  considers  that  the  majority  of  cases  of  puerperal  infection  get  well,  the  conclusion 
is  inevitable  that  the  disease  is  still — in  these  modern  aseptic  and  antiseptic  times — very  prevalent. 

In  England  and  Wales,  exclusive  of  Ireland  and  Scotland,  between  1500  and  2000  women 
die  annually  from  puerperal  sepsis,  and  2200  to  2900  from  the  accidents  of  labor,  but  Sir  WiUiam 


DIAGNOSIS   OF   PUERPERAL   INFECTION  871 

J.  Sinclair  assorts  tluit  llio  septic  iiioiialily  |)r()l)alily  varies  hetweciu  :i(J()()  and  oOOO  per  year. 
Routh  l)elievcs  that  tli(>last  few  years  show  sli}j;lil  iniprovenieiit.  In  Ireland  0.li27  per  cent,  of  puer- 
pera'  die  from  iiii'ectioii  (Hoxall,  190:^).  In  Ciennany  about  ."jOOO  women  are  lost  each  year  from 
infection,  and  fully  as  many  mor(>  from  ac<'idents  of  childhirth.  Von  HerlT  recently  called  atten- 
tion to  a  sli^iht  but  persistent — and  deplorable — risinfi  of  the  mortality  from  sej)sis,  which  he 
ascribes  to  the  lack  of  aseptic  practice  hij  lite  pl/ij.sicidn.s  and  increase  of  obstetric  operatinfj. 

"Without  d()ui)t — and  to  our  discredit  must  it  be  said — t(jday  one  woman  in  -lOO  frivinn  birth 
to  a  child  dies  from  puerperal  infection,  a  humanly  prevental)le  di.sease.  In  the  maternities  fatal 
sepsis  has  been  reduced  almost  to  the  vanishin<f-point.  A  sharp  distinction  must  be  made  between 
the  cases  delivered  in  the  hospital  and  treated  exclusively  by  its  officers,  and  those  cared  for  out- 
side, before  admission  to  the  institution.  With  this  separation  of  the  figures  some  maternities 
show  the  absence  of  fatality  in  successive  thousands  of  cases. 

Von  HerlT,  in  I'.KXl,  reported  that  in  Basel,  up  to  that  date,  GOOO  cases  had  been  delivered 
without  a  sinjile  d(>ath,  due  to  infection  having  been  acquired  in  tlie  hospital.  Lea  quotes  Ahlfeld, 
of  INIarljurjz;,  as  having  iiad  8000  cases  with  one  death,  the  infection  having  been  acfjuired  in  the 
hospital,  but  the  i)atient  had  examined  her.self.  In  the  Rotunda  Maternity,  Dublin,  20(10  women 
were  delivered  without  mortality  from  infection  caused  in  the  hospital,  and  Dr.  Boxall  gives  the 
record  of  the  York  Road  Lying-in  Hospital,  with  8373  deliveries  without  death  from  infection, 
ascribable  to  the  hospital  care.  This  is  by  far  the  best  work  yet  reported,  and  is  a  glorious  ac- 
complishment. All  these  institutions  report  deaths  from  infection,  but  after  careful  analysis  of 
the  circumstances  declare  tliat  the  cause  of  the  disease  lay  beyond  their  power  of  prevention. 
The  Chicago  Lying-in  Hospital  has  had  2193  cases  without  fatality  from  infection  acquired  in 
tlie  hospital.  One  woman  died  from  peritonitis  caused  by  the  rupture  of  a  gonorrheal  pyosalpinx 
during  normal  labor,  and  another  from  the  rupture  of  a  recto-uterine  abscess  during  operative 
delivery.  These  figures  speak  with  stunning  force  against  the  theory  of  autoinfection  in  its 
strictest  sense.  It  is  a  sad  statement  to  have  to  make  that  the  mortality  in  private  practice 
is  comparatively  much  higher  than  that  of  the  maternities. 

What  can  be  done  by  the  use  of  an  aseptic  technic  is  shown  by  the  results  of  the  obstetric 
dispensaries — institutions  that  care  for  the  poor  of  our  large  cities  in  their  own  homes.  Less 
favorable  conditions  could  hardly  be  imagined  than  those  in  which  such  obstetric  cases  are 
treated,  yet  the  results  challenge  our  admiration.  Lea  says  that  in  the  out-clinic  of  Queen 
Charlotte's  Lying-in  Hospital,  London,  in  1907-08,  416-5  women  were  delivered  without  a  death 
from  infection.  In  the  first  7000  cases  of  the  Chicago  Lying-in  Hospital — the  dispensary  service 
— one  woman  died  from  infection,  and  there  was  a  series  of  3990  cases  without  death  from  any 
cause — that  is,  of  cases  handled  exclusively  by  the  dispensary  staff.  In  the  total  of  16,000  cases 
treated  (exclusively)  to  date,  seven  women  have  died  from  infection.  In  three  cases  the  dis- 
pensary staff  was  probably  to  blame,  though  possibly  one  of  the  deaths  could  have  been  avoided 
had  the  patient  not  fallen  into  other  hands  later;  two  of  the  women  had  had  sexual  intercourse 
a  few  hours  before  labor,  in  one  case  the  act  having  ruptured  the  bag  of  waters,  one  was  an 
eclamptic  and  one  woman  had  fever  of  102°  F.  when  the  physicians  arrived  at  her  bed-side.  It 
was  103°  F.  on  the  completion  of  labor,  and  did  not  improve  before  removal  to  a  hospital,  in 
wliich  she  died.  Another  woman  died  of  acute  peritonitis,  the  cause  being  indeterminable. 
Thus  here  are  1(),000  cases,  with  an  institutional  mortality  of  1  in  4000. 

Morbidity  of  Puerperal  Infection. — It  is  safe  to  say  that  for  every  woman  who  dies  from 
puerperal  infection  five  others  suffer  from  it,  but  it  is  impossible  to  prove  the  statement.  The 
morbidity  as  regards  infection  is  the  best  available  test  of  the  efficiency  of  a  maternitj^'s  technic. 
Statistics  from  a  large  number  of  maternities  collected  by  von  Herff  and  Lea  show  that  6  to  30 
per  cent,  of  puerpera>  ha\"e  fever  postpartum,  but  it  is  unwise  and  unjust  to  make  comparisons 
between  these  institutions,  because — (1)  There  is  no  generally  accepted  standard  of  what  consti- 
tutes "fever";  (2)  some  hospitals  take  the  temperature  in  the  a.xilla,  some  in  the  mouth,  and  a 
few  in  the  rectum;  (3)  some  hospitals  have  trained,  intelligent  nurses,  some  midwives,  more  or 
less  intelligent  and  conscientious;  (4j  some  hospitals  have  four-hour  temperature  readings,  others 
only  A.  M.  antl  p.  M.;  (5)  many  thermometers  are  inaccurate  (I  myself  ha\'e  noted  inaccuracies  of 
over  1°  F.);  (6)  some  authors  omit  the  common  initial  elevation  of  temperature  to  100°  or  even 
101°  F.  that  follows  dcliverj^  and  subsides  within  twenty-four  liours,  while  others  include  it;  (7) 
it  is  impossible  always  to  separate  the  cases  due  to  infection  from  those  due  to  other  non-puerperal 
causes — the  statistics,  therefore,  will  always  have  a  subjccti\'c  or  personal  bias;  (S)  some  mater- 
nities get  gooil  material,  others  the  most  unfavorable — for  example,  women  debilitated  by  priva- 
tion or  constitutional  disease,  heart,  pulmonary,  or  other  visceral  lesions,  gonorrhea,  etc. 

It  is  highly  desirable  that  obstetric  authorities  come  to  agreement  on  a  standard  of  puerperal 
morbidity.  Important  information  could  then  be  obtained  as  to  the  relative  values  of  various 
methods  of  treatment,  of  the  use  antl  the  non-use  of  rubber  gloves,  of  the  vaginal  antiseptic  douche, 
of  external  disinfection,  etc.  Not  until  such  a  standard  is  adopted  maj'  reliable  conclusions  be 
drawn  from  present  statistical  information,  and  for  this  reason  the  statistics  are  here  omitted. 
The  British  Medical  Association  recommended  as  standard — "The  puerperal  morbidity  should 
include  all  fatal  cases  and  also  all  cases  in  which  temperature  exceeds  100°  F.  on  any  two  of  the 
bidaily  reatlings  from  the  end  of  the  first  to  the  eighth  day  after  dehvery."  German  authorities 
adopt  38°  C,  or  100°  F .,  as  the  noi-mal  limit.  In  my  own  practice  every  temperature  above  99.5° 
F.  taken  with  a  certificated  thermometer,  in  the  mouth,  is  regarded  as  morbid;  indeed,  any  rise 
above  99°  F.  is  viewed  with  suspicion,  and  the  rise  which  so  often  follows  labor  is  also  ascribed  to  an 
infection  and  is  not  held  to  be  a  "fibrin  ferment  fever."  In  my  opinion  this  postpartum  fever  is  due 
to  the  inoculation  of  the  puerperal  wounds  with  the  bacteria  ever  present  in  the  parturient  canal. 

From  my  own  experience  in  private  practice,  in  practice  in  the  maternity  wards  of  general 
hospitals,  in  a  special  maternity  hospital,  and  in  consultation;    from  my  knowledge  of  the  results 


872  PATHOLOGY  OF  THE  PUERPERIUM 

of  my  colleagues  who  treat  cases  parallel  to  mine  in  the  same  institutions,  and  from  my  observation 
of  the  work  done  in  maternities  at  home  and  abroad;  from  my  studies  of  the  statistical  tables  of 
several  countries  and  of  a  large  number  of  institutions,  details  of  which  it  is  naturally  impossible 
to  present  here,  I  have  come  to  the  following  conclusions:  Puerperal  infection  is  still  very  preva- 
lent— indeed,  it  is  perpetually  endemic;  it  kills  1  in  400  women  dehvered  of  full- term  children; 
it  leaves  as  incurable  invalids  at  least  ten  times  this  number;  it  is  more  frequent  in  private  prac- 
tice than  in  maternity  practice;  it  is  more  frequent  in  maternities  that  forrn  an  integral  part  of  a 
general  hospital  than  it  is  in  private  practice;  it  is  least  frequent  in  the  special  maternity  hospital, 
even  when  the  latter  accepts  infected  cases  (the  danger  of  infection  is  so  well  recognized  that 
transmission  of  the  disease  to  others  is  prevented) ;  it  is  more  frequent  in  maternities  used  for  the 
teaching  of  students  than  in  those  not  so  used,  or  where  only  midwives  or  nurses  are  taught;  it 
is  more  frequent  in  January,  February,  and  March,  the  time  when  the  general  health  of  the  people 
is  below  par,  when  fresh  air  and  sunshine  are  at  the  minimum;  it  is  more  frequent  during  the 
prevalence  of  la  grippe,  colds  in  the  head,  pneumonia,  scarlet  fever,  erysipelas,  bacteremia  from 
other  causes  (a  fact  proved  by  Galabin  for  England  and  Wales) ;  it  is  more  common  among  the 
dehcately  bred  well-to-do  than  among  the  poor,  who,  through  ages  of  squalor  and  filth,  have 
developed  immunities,  which  the  other,  in  their  protected  hves,  do  not  possess.  Medical  practices 
which  are  without  bad  result  among  the  poor  would,  if  apphed  to  the  finely  bred  woman,  produce 
effects  horrible  to  contemplate;  it  is  more  frequent  in  the  country  than  in  the  city,  perhaps  because 
so  many  births  occur  in  the  maternities ;  it  is  still  carried  about  on  the  person  of  the  accoucheur, 
as  a  rhinitis  or  pharyngitis,  for  example,  and,  in  those  times  when  it  seems  that  an  epidemic  influence 
is  at  work,  the  cause  may  be  sought  in  the  inefficiency  of  the  means  ordinarily  practised  for  its 
prevention  in  the  presence  of  numerous  alien  bacteria.  For  example,  a  certain  practitioner,  fairly 
careful  and  thorough  in  his  aseptic  technic,  may  for  years  have  no  infections.  Suddenly,  when 
there  is  a  prevalence  of  streptococcal  infections,  rhinitis,  sinusitis,  mastoids,  etc.,  he  has  a  succession 
of  septic  cases.  This  means  that  his  ordinary  methods  of  prevention  are  not  efficient  enough  in 
the  presence  of  extra  danger. 

It  is  impossible  to  learn  the  number  of  deaths  that  occur  long  after  parturition,  but  indirectly 
from  its  action,  from  operations  done  to  relieve  the  effects  of  puerperal  infection,  or  from  disease 
of  the  heart,  lungs,  liver,  and  kidneys,  which  took  its  origin  in  a  puerperal  process.  Counting 
such  deaths  would  swell  the  mortality  figures  decidedly.  Likewise  it  is  impossible  to  measure 
the  invalidism  suffered  by  these  unfortunate  women. 

Literature 

Boxall:  Puerperal  Morbidity,  1903.  Sherratt  and  Hughes,  London. — Heynemann:  "Phagocytosis  in  the  Lochia," 
Arch.  f.  Gyn.,  1911,  vol.  xciii,  H.  1. — Lea:  Puerperal  Infection,  Oxford  Medical  Publications,  1910.— Rouih: 
Jour.  Obst.  and  Gyn.,  Brit.  Empire,  October,  1911,  p.  165. — Sinclair,  Sir  W.  J.:  The  Life  of  Semmelweis. 


CHAPTER  LXVI 
TREATMENT  OF  PUERPERAL  INFECTION 

Prophylaxis  plays  the  transcendently  important  role  in  this  disease.  So  much 
can  he  done  by  prevention  and  so  little  by  treatment  that  our  efforts  shoukl  be 
concentrated  on  asepsis  and  on  a  physiologic  conduct  of  labor. 

IMuch,  in  a  preventive  line,  can  be  done  during  pregnancy  to  get  the  woman 
into  perfect  condition  for  the  trial  of  labor.  Local  diseases,  vulvitis,  intertrigo, 
vaginitis,  bartholinitis,  cervicitis,  etc.,  are  to  be  cured  as  long  as  possible  before 
labor  supervenes.  Appendicitis  cases  are  to  be  operated  on  early.  If  not  operated 
on,  care  is  to  be  taken  during  la})or  not  to  rupture  a  possible  pus-sac.  The  same 
may  be  said  of  salpingitis,  but  the  diagnosis  of  the  latter  is  harder  to  make.  Sup- 
puration of  the  ear  or  of  the  head  sinuses,  etc.,  should  all  receive  appropriate  treat- 
ment. The  patient  is  to  be  instructed  in  the  principles  of  local  cleanliness,  and 
coitus  and  self-examination  in  the  latter  months  should  be  expressl}'  forbidden. 
The  gravida  should  not  visit  sick  puerperse  and  should  not  expose  herself  to  contagi- 
ous diseases.  In  the  unavoidable  presence  of  one  of  the  above  conditions,  and  dur- 
ing the  prevalence  of  colds  in  the  head,  grippal,  streptococcal,  and  other  infections, 
the  precautions  to  be  followed  during  labor  are  to  be  redoubled.  For  the  sake  of 
completion  may  be  mentioned  the  prophylactic  use  of  antistreptococcus  serum  in 
cases  where  postpartum  infection  is  feared.  Polano,  in  60  cases,  and  Zangemeister, 
in  his  experiments,  could  find  no  good  in  this  measure  of  immunization.  In  the 
prevention  of  tetanus  prophylactic  injection  of  antitetanic  serum  is  useful,  as  was 
shown  by  the  epidemic  in  Prague. 

The  reader  is  referred  to  the  chapter  devoted  to  the  Conduct  of  Labor  for  the 
details  of  the  methods  of  prevention.  Here  only  the  governing  principles  enun- 
ciated by  Crede  may  be  reiterated:  (1)  Limit,  as  far  as  possible,  the  puerperal 
ivounds.  (2)  Prevent  the  injection  of  the  necessary  puerperal  wounds.  Every  puerpera 
is  a  wounded  woman.  It  is  good  surgery  to  limit  the  operative  wound  and  to 
avoid  injuring  the  tissues,  and  the  same  is  true  of  obstetrics.  A  few  concise 
directions  will  indicate  how  this  may  be  done. 

Ad  1 :  Limit  the  number  of  internal  examinations  to  an  irreducible  minimum, 
and  make  them  very  gentl}',  so  as  not  to  tear  the  softened  mucous  membrane.  Con- 
duct the  laljor,  so  far  as  possible,  by  external  examination.  The  state  of  the  cervix 
and  the  possible  prolapse  of  the  cord  are  the  only  points  in  labor  indeterminable  by 
external  examination.  The  author  conducts  the  majority  of  normal  labors  with 
one  internal  examination,  often  without  any  at  all,  and  rarely  with  two  or  three. 

Do  not  rupture  the  bag  of  waters  until  there  is  strict  indication  for  it,  and  let 
one  condition  be  a  completely  dilated  os.  The  membranes  dilate  the  cervix  with 
the  least  trauma,  and  also  mechanically  prevent  the  access  of  germs  to  the  uterus. 

Avoid  all  measures  to  shorten  the  time  of  normal  labor,  as  manual  dilatation 
of  the  cervix,  of  the  perineum,  or  having  the  woman  bear  do'^ni  before  the  head  has 
slipped  through  the  cervix.  Do  not  give  ergot  until  the  placenta  has  been  delivered. 
Outside  of  its  noxious  action  on  the  child,  it  increases  the  frequency  of  operative 
interference.  Do  not  apply  forceps  until  there  is  an  honest,  scientific  indication 
for  their  use.  Do  not  use  douches,  especially  hot  ones  or  antiseptic  ones,  in  normal 
labors.  These  rob  the  vagina  and  cervix  of  their  epithelium  and  their  natural 
protecting  secretions.     Prevent  perineal  and  vaginal  tears,  as  far  as  possible,  which 

S73 


87-1  PATHOLOGY  OF  THE  PUERPERIUM 

means  a  patient  conduct  of  the  second  stage,  but  do  not  allow  the  other  extreme  of 
practice,  and  permit  the  head  to  pound  for  hours  on  a  rigid  perineum  until  the 
vitality  of  the  tissues  is  lost  and  they  are  bruised  and  infiltrated  with  blood.  Early 
episiotomj^  and  forceps  are  more  scientific  procedures. 

The  third  stage  should  be  conducted  as  physiologically  as  possible.  Interfer- 
ence should  be  instituted  only  on  strict  indication — above  all,  manual  removal  of 
the  placenta  should  be  attempted  only  when  hemorrhage  occurs  or  the  organ  is 
pathologicall}^  adherent.  Great  care  is  to  be  exerted  to  obtain  the  placenta  and 
the  membranes  complete,  as  retained  portions  of  either  furnish  pabulum  for  the 
organisms  naturally  in  the  vagina,  and  they  retard  involution,  which,  when  nor- 
mall}^  progressing,  offers  a  barrier  to  infection.  The  uterus  should  not  be  bruised 
by  too  early,  too  frequent,  and  too  strong  attempts  at  Crede  expression  of  the  pla- 
centa, or  too  much  and  too  forcible  massage. 

The  placenta  and  membranes  should  be  carefully  inspected,  to  determine  if 
pieces  of  the  former  or  shreds  of  the  latter  are  missing.  Such  an  examination  con- 
sumes fully  five  minutes,  and  should  never  be  neglected.  It  is  the  keystone  of 
the  treatment  of  the  patient  should  fever  arise  subsequently.  The  cases  in  which 
it  is  impossible  to  determine  this  point  are  rare.  If  a  piece  of  placenta  is  missing, 
it  must  be  removed  at  the  time  of  labor.  If  a  piece  of  membrane  less  than  one-half 
of  the  whole  remains  in  the  uterus,  I  usually  do  not  go  in  after  it.  If  the  uterus 
balloons  out  with  blood,  or  if  there  is  external  hemorrhage,  the  cause  is  frequently 
found  to  be  such  a  piece  of  membrane  wrapping  up  a  blood-clot.  Removal  is  then 
indicated.  See  that  the  uterus  is  free  from  blood-clots,  hard,  and  firmly  contracted 
before  you  leave  the  house. 

After  every  operative  delivery,  and  after  every  breech  delivery,  and  in  all  cases 
where  there  has  been  a  very  rapid  dilatation  of  the  cervix,  examine  the  whole 
uterovaginal  tract  for  lacerations.  You  must  know,  without  the  least  suspicion  of 
a  doubt,  whether  or  not  there  is  a  perforating  injury  of  the  parturient  canal;  you 
must  determine  exactly  the  number  and  extent  of  the  puerperal  wounds.  This 
advice  is  not  given  for  normal  labors,  but  for  operative  and  abnormal  ones. 

Repair  all  lacerations  of  the  perineum  that  are  deeper  than  one-half  inch. 
A  large  number  of  cases  of  infection  originate  in  the  perineal  wound.  It  is  pref- 
erable to  do  this  after  the  delivery  of  the  placenta,  as  the  parts  are  not  obstructed 
by  flowing  blood,  the  tissues  are  not  so  swollen  and  stretched,  and  one  can  so 
arrange  the  patient  that  better  work  may  be  done.  Then,  too,  if  one  sews  the 
laceration  before  the  placenta  is  delivered,  the  proper  conduct  of  the  third  stage  is 
neglected,  and  also  the  placenta  will,  as  it  passes  over  the  wound,  force  blood 
between  the  stitches,  which  will  prevent  proper  healing.  The  one  consideration 
of  saving  the  accoucheur's  time  should  not  weigh  against  the  above  disadvantages. 

Before  introducing  the  hand  into  the  uterus,  in  any  manipulation,  I  wash 
out  the  introitus  and  the  vagina  with  bichlorid  and  lysol  solutions  on  cotton 
pledgets.  This  is  done  to  avoid  carrying  higher,  or  into  the  uterus,  particles  of 
feces,  etc.,  which  may  have  reached  the  vagina  through  the  various  manipulations 
connected  with  an  operative  delivery. 

When  a  purulent  vaginitis  complicates  labor,  1  per  cent,  lysol  douches  may  be 
given  with  a  view  to  limiting  the  amount  of  pus  ground  into  the  puerperal  wounds 
by  natural  and  operative  processes  and  of  preventing  ophthalmia  neonatorum. 

After  the  puerpera  has  been  cared  for  on  the  lines  just  indicated,  the  parturi- 
ent canal  is  to  be  left  severely  alone.  Make  no  internal  examinations,  give  no 
douches — practise  only  external,  vulvar,  antisepsis.  Only  after  the  puerperal 
wounds  are  well  healed  may  an  internal  or  specular  examination  be  safely  made. 
The  single  indication  for  douches,  in  my  opinion,  is  hemorrhage. 

Ad  2:  Prevention  of  the  infection  of  the  unavoidable  puerperal  wounds  com- 
prises the  principles  and  practice  of  asepsis  and  antisepsis,  and  here,  after  referring 


TREATMENT   OF    PUERPERAL    INFECTION  875 

to  Chapter  XX,  p.  273,  iiothiiiji;  more  need  he  said  on  lliis  suhjcct.  Such  a  technic 
sliould  !)(•  part  ot"  the  \('n'  hody  and  soul  of  the  accoucheur. 

Curative  Treatment. — Few  subjects  in  medicine  present  such  diversity  of 
opinion  as  this  one,  and,  too,  owing  to  the  latest  discoveries  in  bacteriology,  in  the 
action  of  bacteria  and  in  innnunology,  our  ideas  of  treatment  have  undergone 
radical  changes.  In  general,  it  may  l)e  said  that  the  polyi)ragmasia  of  lormer 
times  has  given  way  to  a  more  physiologic  treatment;  that  we  now  rely  more  on 
aiding  and  stimulating  nature's  own  methods  of  combating  the  disease.  The 
discussion  of  this  subject  may  be  divided  into  four  parts, — local,  general,  specific, 
and  surgical  measures, — but  l)efore  considering  these,  the  author  wishes  to  describe 
the  routine  treatment  he  carries  out  in  such  cases. 

When  the  careful  general  medical  examination  has  excluded  all  other  causes 
for  the  illness  and  a  diagnosis  of  puerperal  infection  is  made,  the  woman  is  isolated 
in  the  lightest,  airiest  room  available,  and  put  at  complete  physical  and  mental  rest, 
which  means  that  a  good  obstetric  nurse  is  put  in  charge  of  her.  If  too  poor  to 
ol)tain  proper  care  at  home,  she  is  sent  to  the  best  hospital  within  her  means.  A 
brisk  cathartic  is  administered  (calomel,  followed  by  a  saline  or  castor  oil) ;  provi- 
sion is  made  for  a  generous  semisolid  diet,  with  much  fluid;  an  ice-bag,  or,  if  the 
patient  jirefers  it,  a  warm-water  bag,  is  laid  over  the  uterus;  and  ergot  and  hydras- 
tis  (15  minims  of  the  fiuidextract  of  each)  given  by  mouth  thrice  daily.  A  little  of 
the  lochia  is  sent  to  a  laboratory  for  bacteriologic  analysis.  Sutures  in  the  peri- 
neum and  cervix  are  removed  at  once,  to  provide  free  drainage,  and  the  gaping 
wounds  swabbed  with  pure  tincture  of  iodin,  but  this  is  the  extent  of  the  local 
treatment.  Developments  are  then  awaited.  Even  if  it  is  certain  that  there  is 
something  in  the  uterine  cavity,  the  uterus  is  not  invaded.  The  patient  may  be 
propped  up  a  little  to  favor  drainage,  but  curetage,  ecouvillonage  (brushing  out  the 
uterus),  douches,  packing,  etc.,  are  not  employed.  The  sole  indication  for  such 
treatment  is  hemorrhage  from  the  uterus.  If  the  woman  does  not  show  immediate  im- 
provement, the  various  specific  remedies  are  considered  (vide  infra) .  When  the  course 
of  the  disease  becomes  chronic,  the  patient  is  carefully  watched  for  signs  of  localiza- 
tion of  the  infection,  and  in  a  very  few  cases  this  point  is  attacked  by  operation. 

This  policy  of  non-interference — this  nihilism  with  respect  to  active  local  and 
general  measures — is  the  result  of  my  experience  in  the  Dispensary  Service  of  the 
Chicago  Lying-in  Hospital.  In  the  last  seventeen  years  15,784  women  were  deliv- 
ered at  term.  Of  these,  about  10  per  cent,  had  fever  over  100°  F.  In  only  one  case 
was  the  uterine  cavity  invaded  and  a  douche  given;  in  the  others  we  followed  the 
plan  above  outlined,  and  only  7  women  died  of  infection,  but  2  of  these  died  under 
questionable  treatment  in  other  hands.  In  none  of  the  5  cases  did  the  subseciucnt 
course  show  that  the  event  might  have  been  different  had  a  more  active  policy  been 
followed.  With  the  thoughtful  clinician  the  article  of  Mermaim  (Arch.  f.  Gyn., 
1907,  vol.  iv)  carries  great  weight.  jMermann,  in  330  cases  of  fever  of  all  grades  of 
severity,  and  treated  purely  expectantly,  lost  only  7  women.  In  30  of  the  cases  the 
disease  was  critical,  and,  even  using  these  only  for  comparison,  the  results  compare 
favorably  with  all  other  methods  of  treatment.  On  the  other  hand,  I  can  recall  nu- 
merous cases  where,  before  adopting  the  above  methods,  I  caused  severe  illness  by 
active  local  treatment,  and  I  am  not  sure  ])ut  what  some  of  the  women  died  because 
of  the  curetage,  pelvic  drainage,  etc.,  intended  for  their  relief.  This  has  been  the 
experience  of  my  colleagues,  working  in  the  same  hospitals  with  me,  and  whose  re- 
sults I  have  been  ahlc  to  follow. 

Local  Treatment. — The  local  treatment  of  infection  is  the  attempt  to  remove 
the  offending  bacteria  and  their  toxins,  to  take  away  their  palmlum, — clots,  mem- 
branes, placental  fragments,  decidua, — and  to  destroy  those  liacteria  and  neutralize 
those  toxins  which  remain  in  the  genital  canal  after  the  mechanical  cleansing.  The 
idea  is  excellent — if  it  were  onlv  safer  to  carry  it  out. 


876  PATHOLOGY  OF  THE  PUERPERIUM 

In  the  hope  of  accomplishing  these  purposes  the  following  methods  are  prac- 
tised : 

(1)  Intra-uterine  douches  of  normal  salt  solution  or  of  antiseptic  solutions, 
such  as  bichlorid  of  mercury,  lysol,  carbolic  acid,  alcohol,  iodin,  etc.,  if  the  attendant 
believes  that  such  remedies  have  real  bactericidal  action  on  germs  already  inside 
the  living  tissues.  Harvey  knew  about  douches,  but  Ruleau,  in  1704,  first  used 
them  for  fetid  lochia.  They  enjoyed  the  greatest  vogue  in  the  years  1881  to  1900, 
often  being  given  in  normal  puerperse  as  a  routine,  but  lately  have  lost,  in  large 
part,  the  confidence  of  the  accoucheurs.  The  objections  to  the  uterine  douche  are 
— (a)  It  is  inefficient,  the  bacteria  being  beyond  reach  within  fifteen  minutes  after 
they  are  inoculated;  (6)  it  is  painful,  sometimes  violent  uterine  action  being  set 
up,  and  if  (c),  as  sometimes  happens,  part  of  the  liquid  escapes  through  the  tubes 
into  the  peritoneal  cavity,  syncope,  vomiting,  and  peritonitis  may  result;  (d)  the 
nervous  shock  sometimes  causes  syncope,  even  convulsions  and  coma  (Bar);  (e) 
the  antiseptic  employed  may  be  directly  poisonous,  over  50  cases  of  bichlorid  and 
as  many  more  from  carbolic-acid  poisoning  being  on  record,  the  chemical  being  ab- 
sorbed by  the  uterus,  or  gaining  entrance  to  the  blood  through  the  sinuses  (I  know  of 
two  which  have  not  been  recorded) ;  (/)  air-embolism;  (g)  perforation  of  the  uterus; 
(A)  profuse  hemorrhage;  (i)  chill  and  fever — the  infection  having  been  reinocu- 
lated  by  the  douche;  (j)  sudden  death,  which  is  usually  from  air-embolism,  but  may 
be  due  to  cardiac  paralysis;  (k)  the  infection  may  be  carried  up  higher  in  the  par- 
turient canal,  heretofore  unaffected. 

Continuous  irrigation  of  the  uterus  was  recommended  in  1877  by  Schiicking. 
It  had  some  vogue,  and  until  very  recently  was  occasionally  practised,  but  is  now 
abandoned. 

(2)  Swabbing  out  the  uterus  with  gauze  wound  around  a  long  dressing  forceps, 
with  or  ^\athout  antiseptic  or  caustic  solutions.  Alcohol,  carbolic  acid,  iodin,  and 
combinations  of  these  have  been  used.  Pincus  steams  out  the  uterine  cavity  with 
live  steam,  but  has  had  hardly  any  imitators,  and  these  not  a  second  time.  If  it 
were  possible  to  isolate  the  causative  bacteria  of  the  infection,  theoretically  it  might 
be  a  promising  procedure  to  pack  the  uterine  cavity  with  gauze  soaked  in  a  bacterin 
or  immune  body. 

(3)  Brushing  the  surface  of  the  endometrium  with  a  round  brush,  similar  to 
those  which  are  used  for  cleansing  bottles  (ecouvillonage) .  Introduced  by  Doleris, 
it  was  quite  popular  with  French  accoucheurs,  and  is  recommended  by  Lea  as  safe 
and  efficient.  The  Germans  do  not  use  the  brush,  nor  do  American  obstetricians. 
I  regard  it  as  dangerous,  but  perhaps  not  so  much  so  as  the  curet. 

(4)  Curage,  or  digital  removal  of  the  contents  of  the  uterus,  is  recormnended 
by  a  large  number  of  authorities  here  and  abroad,  among  whom  a  few  may  be 
mentioned:  Whittridge  Williams,  Hirst,  Galabin,  Jellett,  Sinclair,  Bumm,  Chrobak, 
Ahlfold,  Schauta,  Bar,  Pinard,  and  Pestalozza.  Some  recommend  aseptic  or  anti- 
septic douches  before  and  after  operation,  or  packing  the  uterus  with  sterile  or 
antiseptic  gauze. 

(o)  Curetage. — This  operation,  introduced  in  1850  l^y  Recamier,  who  invented 
the  curet  for  the  purpose,  has  obtained  a  very  generalized  employment.  Some 
operators  use  a  blunt,  others  the  sharp,  curet;  some  use  the  instrument  as  a  routine 
practice  as  soon  as  fcl)rile  symptoms  appear;  others  use  it  only  if  the  finger  fails  to 
r^Tnove  firmly  adherent  masses;  some  repeat  the  operation  once  or  oftener;  some 
pack  the  uterus  with  antiseptic  gauze  at  the  completion  of  the  operation;  others 
do  this  only  in  the  event  of  severe  hemorrhage,  etc.  The  operation  has  always  had 
opponents,  prominently  among  the  earliest  of  whom  may  be  mentioned  Karl 
Schroder,  and  lately  many  authorities  are  arrayed  against  the  practice — Whittridge 
Williams,  Noble,  Cragin,  Edgar,  Watkins,  Ries,  Bumm,  Leopold,  Fehling,  Kronig, 
Veit,  Olshausen,  and  others,  some  of  whom  formerly  advised  the  procedure.     The 


TREATMENT    OF    PUERPERAL    INFECTION  877 

dangci's  of  curctugc — imd  these  ure  present  wit  h  Unlli  Id  in  if  and  sliurp  instruments — 
and  with  curage  witli  the  finger  are:  (^0  ''''i<'  delicate  hank  of  leukocytes,  the  wall 
nature  tlirows  up  to  limit  the  spreaxl  of  the  bacteria,  is  broken  through  at  innumer- 
al)le  places,  and  the  bacteria  literally  ground  into  the  lymph-spaces  and  the  ven- 
ous lumina — it  is  a  thorough  vaccination  or  inoculation  of  the  uterine;  tissues,  and 
resembles  raking  the  soil  after  strewing  it  with  seed;  (6)  curetage,  no  matter  how 
expertly  done,  cannot  remove  all  the  diseased  tissues.  The  ))acteria,  within  fifteen 
minutes  after  inoculation,  are  already  out  of  its  reach,  and,  further,  at  autopsy  in 
cases  where  the  curet  had  been  used  invaria])ly  parts  of  the  endometrium  could  be 
jiroved  never  to  have  t)een  touched  by  the  instrument;  indeed,  even  the  whole 
placenta  has  been  found;  (c)  perforation  of  the  uterus  is  a  common  occurrence,  and 
almost  always  fatal  from  peritonitis;  even  the  greatest  gentleness  may  not  prevent 
such  an  accitlent,  bccau.se  in  some  cases  the  muscle  is  as  soft  as  butter;  (d)  hemor- 
rhage from  the  reoi)ened  i)lacental  sinuses,  even  air-embolism,  has  been  reported; 
{(■)  the  freshly  united  wounds  arc  torn  open  and  new  ones  created,  into  all  of  which 
infection  is  ground;  (/)  a  pyosalpinx  or  other  pus-sac  may  be  ruptured  by  the  man- 
ipulations. It  seems  about  as  reasonable  to  curet  the  nose  and  throat  in  eases  of 
diphtheria  as  to  curet  the  uterus  for  sepsis. 

(6)  Emptying  the  uterus  with  polypus  forceps  is  a  very  dangerous  procedure, 
because  parts  of  the  uterine  muscle,  even  the  intestine  and  omentum,  have  been 
pulled  out  under  the  impression  that  ovular  remnants  were  being  removed.  The 
forceps  may  be  used  only  to  remove  pieces  of  tissue  floating  freely  in  the  uterine 
cavity. 

(7)  Drainage  of  the  uterus  with  rubber  or  glass  tubes  is  the  practice  of  some 
French,  Italian,  and  American  accoucheurs. 

(8)  Packing  the  uterus  with  gauze,  or  draining  it  with  the  same,  may  be 
employed  to  stop  hemorrhage  after  the  operations  just  considered,  and  they  are 
employed  by  some  as  directly  antiseptic  measures.  The  technic  of  these  operations 
does  not  differ  from  those  performed  in  the  treatment  of  abortion,  to  which  the 
reader  is  referred  for  details. 

For  the  last  five  years  I  have  practically  dispensed  with  local  treatment  in 
puerperal  infection,  being  convinced  that  it  does  much  more  harm  than  good. 
Only  if  the  woman  is  having  uterine  hemorrhages  do  I  interfere,  and  then,  l)y  pack- 
ing the  uterus  with  2  per  cent,  iodoform  gauze  to  stop  the  flow  and  aid  the  expulsion 
of  the  retained  masses  causing  it.  This  packing  is  repeated,  if  needed,  daily  for 
several  days.  Often  the  foreign  matter  comes  away  when  the  gauze  is  removed, 
and  usually  the  temperature  comes  dowm,  the  patient's  general  condition  improving. 
Only  after  the  local  barriers  are  considered  strong  enough  and  involution  of  the 
uterus  well  advanced  is  the  removal  of  the  retained  material  attempted.  This  is  safe 
only  after  the  temperature  has  been  normal  two  or  more  weeks.  One  waits  as  long 
as  possible.  Nature  often  does  wonders.  Most  authorities  do  not  take  this  radical 
position.  Bumm,  Williams,  Hirst,  the  French,  and  many  advise  a  primary  palpa- 
tion of  the  uterine  cavity  with  the  finger  and  the  immediate  removal  of  its  contents, 
but  they  all  emphasize  the  danger  of  the  procedure  when  the  infection  is  strepto- 
coccal, urging  that  it  then  be  omitted.  It  has  already  been  proved  that  it  is  impos- 
sible to  say — certainly,  at  the  first  examination — whether  a  given  infection  is,  or  is 
not,  streptococcal,  and,  further,  before  the  streptococcus  can  be  demonstrated  the 
infection  is  through  the  uterine  wall  and  beyond.  On  the  other  hand,  if  the  infec- 
tion is  saprophytic,  but  little  danger  need  be  apprehended  from  it,  and  it  is  safe  to 
wait  a  few  days  to  see  what  course  the  disease  will  take.  Winter,  of  Konigsberg, 
Mermann  (loc.  cit.),  Saft,  and  Baumm,  of  Breslau,  Watkins,  and  Ries,  of  Chicago, 
are  opposed  to  local  treatment,  and  Crede,  of  Leipsic,  shortly  before  his  death, 
strongly  emphasized  its  dangers,  advising  its  total  discontinuance.  It  is  gratifying 
to  note  that  one  voice  after  another  is  being  raised  against  douches,  curetage, 


878  PATHOLOGY   OF   THE    PUERPERIUM 

curage,  and  other  local  interferences  with  the  processes  of  healing  adopted  by  nature, 
and  the  author  hopes  that  the  curet  will  soon  be  recognized  as  a  criminal  instru- 
ment in  simple  puerperal  infection,  and  that  the  other  operations  will  be  reduced 
to  the  one  indication — to  stop  hemorrhage.  (For  the  treatment  of  pus  collections 
see  Pelvic  Peritonitis.) 

General  Treatment. — Everything  that  will  improve  the  woman's  general  health 
will  help  her  throw  off  the  disease,  and  the  attendant  should  count  no  effort  lost 
that  will  increase  her  resisting  powers.  Fresh  air  is  important,  and  I  have  employed 
the  outdoor  treatment  with  good  results,  though  not  so  good  as  expected.  Sleep 
is  a  prime  necessity,  and  if  procuring  mental  and  physical  quiet  dp  not  bring  it, 
morphin  maj^  be  used.  Alorphin  is  also  given  for  pain.  Pain  is  depressing  and 
fatiguing.  In  a  maternity  the  sick  woman  should  be  isolated — first,  because  of  the 
danger,  recognized  by  practically  all  authorities,  of  her  being  the  beginning  of  an 
epidemic  of  puerperal  infection,  and,  second,  to  insure  her  quiet.  Visitors  are 
excluded,  and  every  one  about  the  house  should  bear  a  cheerful  mien.  Nursing 
the  child  is  stopped,  first,  because  the  mother  needs  all  her  reserve  force  to  combat 
the  infection;  second,  the  acts  of  nursing  are  disturbing  and  tiring,  and,  third,  the 
child  may  be  infected.  In  those  cases  where,  contrary  to  orders,  nursing  has  been 
continued,  the  child  does  not  always  suffer  from  the  poor  quality  of  the  milk, 
though  it  often  does. 

For  the  Jever,  as  a  rule,  nothing  need  be  done.  If  continuously  high,  cool 
sponging,  cool  packs,  or  the  cool  bath  may  be  used — rarely  the  bath,  because  it 
involves  too  much  exertion  for  the  patient,  and  a  weak  heart  may  go  default; 
further,  in  parametritis  and  perimetritis  the  patient  may  not  be  moved  much. 
Antipyretics  are  contraindicated.  Medicines  are  very  sparingly  used.  Of  tonics, 
quinin  is  the  best,  in  two-  or  three-grain  doses.  Hexamethylenamin  is  given  if 
there  are  signs  or  fears  that  the  urinary  tract  may  be  involved  in  the  mfection. 
Drugging  is  avoided,  so  far  as  possible,  first,  because  it  does  little  good,  and,  second, 
because  it  spoils  the  stomach,  the  most  important  ally  of  defense.  Alcohol, 
formerly  considered  almost  specific  in  all  kinds  of  infections,  has  lost  favor.  At 
most  the  sj'stem  can  utilize  J^  ounce  a  day,  and  there  is  no  objection  to  giving  this 
amount  in  the  form  of  eggnog  or  a  wine  to  stimulate  a  flagging  appetite. 

The  Bowels. — In  prolonged  cases  an  occasional  laxative  is  ordered,  and,  as  was 
said,  a  brisk  cathartic  forms  part  of  the  routine  treatment  at  the  beginning  of  the 
disease.  Diarrhea  may  be  one  of  nature's  methods  of  ridding  the  system  of  toxins, 
and  is  not  interfered  ^^^th  unless  pronounced,  and  when  it  begins  to  exhaust  the 
patient.  When  the  diarrhea  is  too  marked,  charcoal  and  salol  may  be  tried,  but 
magnesia  usta,  in  dram  doses  every  three  hours,  may  do  better.  Opium  and  starch 
enemata  may  be  necessary.  Vomiting  is  always  a  bad  symptom,  and  if  bilious, 
almost  always  means  a  fatal  ending.  Food  by  the  mouth  is  withheld  for  a  while 
and  rectal  feeding  instituted — saline  solution  with  3  drams  of  grape-sugar  added  to 
each  quart,  by  the  drop  method.  If  the  vomiting  persists,  the  stomach  may  be 
washed  out.  It  is  surprising  how  much  greenish-black  fluid  is  removed,  and  the 
patient  usually  feels  much  relief  for  several  hours.  Later,  against  peritonitic 
vomiting,  we  stand  powerless  and  dismayed.  When  food  cannot  be  administered 
by  the  stomach  and  the  rectum  proves  too  irritable,  it  has  been  recommended  to 
sew  the  intestine  to  a  tiny  opening  in  the  upper  linea  alba  and  inject  predigested 
foods  through  the  fistula  into  the  bowel.  Success  rarely  follows  such  operations, 
because  the  women  do  not  die  from  starvation,  but  from  toxinemia. 

Meleorisrn  in  peritonitis  is  a  troublesome  condition.  Overfeeding  and  cathartics 
are  to  be  avoided  and  enemata  given.  Milk  and  molasses,  of  each  one  pint,  form 
a  very  efficient  enema  in  causing  flatus  to  pass.  Physostigmin  salicylate,  -jnr 
grain,  may  be  given  every  four  hours  for  four  doses,  but  in  my  experience  it  has 
failefl  to  relieve  the  distention.  The  rectal  tube  gives  some  relief.  If  the  stomach 
is  dilated,  the  patient  is  to  lie  on  the  abdomen  and  the  foot  of  the  bed  is  raised,  or 


TREATMENT   OF    PUERPERAL    INFECTION  879 

the  stomach  is  washed  out — a  sovcici^n  rcniccly.  In  the  rarest  eases  the  bowel  may 
be  punctured  and  the  <!;afs  removed  tlirou^li  a  fine  needle,  a  procedure  I  have  never 
had  occasion  to  practise.  The  small  intestine  may  be  opened  through  a  tiny  incision 
near  the  navel  and  clrained.  In  one  case  it  seemed  to  me  that  the  electric  vibrator, 
allowed  to  play  on  the  belly,  stimulated  peristalsis. 

For  the  chills,  the  patient  is  covered  warmly  and  given  a  hot  drink.  If  the 
chill  is  prolonged,  /;  grain  morphin  is  given  hypodermically. 

Attention  is  given  the  heart,  and  all  exertion  of  the  patient  is  forbidden  in 
order  to  spare  its  strength.  Cardiac  stimulants  are  withheld  until  absolutely 
needed.  ]\Iy  experience  with  digitalis,  etc.,  and  strychnin  has  been  disappointing. 
For  the  syncopal  attacks  connnon  in  severe  bacteremias  an  abundance  of  fresh  air 
and  pure  oxygen  are  useful. 

Special  attention  is  directed  to  the  diet,  and  an  abundance  of  sugar  and  pro- 
teins is  provided — less  of  fat.  Milk,  buttermilk,  matzoon,  kumiss,  eggs,  jellies, 
cereals,  sugar,  ice-cream,  and  gelatin  in  all  forms  are  permissible. 

Finally,  the  mental  state  of  the  patient  should  be  treated.  She  should  be 
buoyed  up  with  the  hope  and  assurance  that  she  will  recover — indeed,  speaking 
from  experience,  I  can  say  that  even  the  apparently  hopeless  cases  sometimes  get 
well,  and  I  am  convinced  that  the  mind  of  the  patient  has  considerable  to  do  with 
her  struggle  with  the  infection. 

Specific  Treatment. — Since  the  bacteria  are  beyond  the  reach  of  the  antiseptic 
douche  and  the  curet,  we  try  to  get  at  them  and  to  neutralize  or  remove  their 
poisons  by  way  of  the  blood.  We  try  to  do  this  in  two  ways — first,  by  direct  anti- 
septic or  bactericidal  action;  second,  by  stimulating  the  antilmcterial  and  antitoxic 
power  of  the  blood,  as  well  as  we  know  these  forces.  Some  of  the  remedies  to  be 
mentioned  partake  of  both  these  qualities.  In  the  first  class  may  be  listed  iron, 
mercury,  quinin,  alcohol,  ioclin,  silver,  and  a  host  of  others.  Mercury  in  the  form 
of  inunctions  was  recommended  by  Fehling  thirty  years  ago,  and  as  intravenous 
injection,  by  Kesmarsky,  in  1894  (Barsony).  One-fourth  grain  of  bichlorid 
dissolved  in  three  ounces  of  water  is  given  in  the  median  basilic  vein  daily.  Neph- 
ritis is  a  contraindication.  My  associate,  Dr.  Stowe,  at  my  suggestion,  employed 
it  in  34  cases,  but  without  decided  benefit,  though  with  no  resulting  harm.  It 
increases  leukocytosis  and  raises  the  opsonic  index  (Polizzotti),  and  perhaps  com- 
bines with  some  of  the  toxins.  Silver,  in  the  form  of  a  colloidal  salt. — collargol, — 
was  introduced  by  Crede  in  1895.  As  an  ointment,  unguentum  Crede  I  have  used 
it  freely  without  observing  the  least  effect.  Given  per  rectum  it  has  also  failed. 
Given  intravenously  (10  c.c.  of  a  1  to  2  per  cent,  solution  daily)  it  produced  an 
effect,  but  this  is  not  always  good.  I  have  given  in  all  20  injections.  In  one  case 
I  felt  that  the  patient  was  benefited,  and  I  considered  the  remedy  harmless  until  one 
woman  nearly  died  in  collapse  immediately  following  the  injection,  after  which  the 
temperature  went  to  106  F.  She  was  sick  v.'ith  pyemia  for  tAvo  months  but 
ultimately  recovered.  It  is  certain  that  the  injections  cause  leukocytosis,  which 
may  have  had  something  to  do  with  the  reported  cures.  In  doses  which  it  is  safe 
to  put  into  the  blood  it  has  no  bactericidal  action.  Driessen,  van  de  "\'elde, 
Ribins,  Treub,  Boimaire,  Bar,  and  Albrecht  have  reported  some  good  results,  but 
by  no  means  invariable  improvement.  Kronig,  von  Rosthorn,  Chrobak,  Fehling, 
Harrison,  Polak,  Jones,  and  others  report  more  failures  than  successes.  Injections 
of  other  antiseptics  into  the  blood  have  hardly  historic  interest,  though  the  results 
of  salvarsan  treatment  indicate  a  fertile  field  for  experiment. 

Salt  Solution. — This  is  a  remedj^  which  has  been  much  lauded  in  the  last  few 
years  in  the  treatment  of  all  forms  of  infection,  and,  in  fact,  it  is  very  valuable,  but 
it  is  not  a  panacea.  The  best  method  of  administration  is  by  slow  infusion  in  the 
rectum — the  drop  method.  The  solution  is  kept  hot  in  a  vacuum  l)ottle  hung  near 
the  bed,  and  the  flow  is  so  regulated  by  an  artery  forceps  clamping  the  tube  leading 
into  the  rectum  that  from  30  to  40  drops  flow  in  each  minute.    If  the  rectum  becomes 


880  PATHOLOGY    OF   THE    PUERPERIUM 

intolerant,  the  injection  may  be  made  intermittently,  or  the  h3^odermic  or  intra- 
venous method  employed,  but  either  is  much  more  distressing  to  the  patient,  and 
there  is  the  danger  of  overloading  the  circulatory  system,  causing  oedema  pulmonum. 
The  action  of  the  salt  solution  is  unknown.  It  probably  does  not  wash  the  toxins 
from  the  blood,  because  these  are  usually  so  bound  onto  the  cells  that  only  bio- 
chemic  action  can  loosen  them.  Leukocytosis  is  stimulated,  but  probably  the  good 
effects  of  the  salt  solution  lie  in  the  stimulation  of  the  heart,  kidneys,  skin,  and 
intestine,  keeping  up  the  tonus  of  the  vessels,  in  relieving  thirst  and  fatigue — thus 
improving  the  general  resistance  of  the  patient.  The  stimulation  of  the  pelvic 
circulation  should  also  be  thought  of. 

Nuclein,  in  the  form  of  sodium  nucleinate,  produces  leukocytosis,  but  its 
employment  in  sepsis  has  not  improved  the  results.  In  many  cases  where  proto- 
nuclein  has  been  given  I  could  never  observe  any  benefit,  but  Hofbauer,  Schauta, 
and  others  have  reported  some  successes  with  nuclein. 

Serum  Treatment. — After  sixteen  years  of  trial,  in  which  time  all  kinds  of 
sera  have  been  tried,  we  are  forced  to  the  reluctant  conclusion  that  antistrepto- 
coccic serum  does  not  cure  streptococcic  puerperal  infection.  This  was  the  con- 
clusion reached  by  Williams,  Pryor,  and  Fry  in  1899,  and  further  experience  only 
confirms  their  findings.  Sera  prepared  from  the  horse,  inoculated  with  single 
or  many  human  strains  of  streptococci,  and  from  convalescents  from  such  infection, 
all  are  of  doubtful  utility,  though  they  are  rarely  injurious.  Since  we  know  that 
the  streptococcus  produces  no  exotoxin,  it  is  not  possible  to  produce  in  any  animal 
an  antitoxin — as  in  diphtheria.  That  means  that  we  cannot  produce  "passive 
immunity"  in  the  human  by  the  use  of  such  foreign  serum;  therefore  a  serum,  to 
be  efficient,  must  be  either  bactericidal  or  must  be  able  to  supply  substances — 
immune  bodies — ^which,  when  united  with  the  complement  of  the  individual,  pro- 
duces the  antibacterial  agent,  or  it  must  have  some  power  of  causing  the  blood  of 
the  patient  to  form  opsonins  or  other  antibacterial  substances,  or  at  least  a  protective 
leukocytosis.  In  other  words,  it  must  be  able  to  develop  ''active  immunity." 
Recently,  Weaver  and  Tunnicliff  claim  that  antistreptococcus  serum  augments 
phagocytosis.  If  we  had  a  serum  which  was  bactericidal,  it  might  be  dangerous  to 
exhibit  it  in  streptococcal  infections,  because  the  endotoxins  thus  liberated,  added 
to  the  previously  existing  toxinemia,  rnight  increase  the  dose  to  a  fatal  one. 
This  may  explain  some  of  the  bad  results  in  cases  where  the  serum  has  been  admin- 
istered late  in  the  disease.  Large  numbers  of  cases  have  been  treated  by  Bumm, 
Chrobak,  Gordon,  and  others,  including  myself,  and  a  study  of  the  reports  is  not 
encouraging.  In  three  cases  of  my  own  I  was  convinced  that  the  serum  at  least 
contributed  something  to  recovery.  Erythema  at  the  site  of  injection,  and  gener- 
alized urticaria,  swelling  of  the  joints  (simulating  pyemic  joints),  and  moderate 
increase  of  the  fever  I  have  observed,  but  never  any  indications  of  anaphylaxis, 
though  the  serum  was  repeated  daily  for  a  week.  Anaphylaxis  has  occurred  when 
a  longer  interval  than  seven  days  elapsed  between  two  injections.  To  get  any  good 
effect  the  serum  must  be  given  in  large  doses  (60  to  100  c.c.  in  twenty-four  hours) 
very  early  in  the  disease,  and  general  experience  has  shown  that  it  is  useless 
in  pyemia,  thrombophlebitis,  cellulitis,  and  peritonitis.  In  early  cases  of  acute 
streptococcic  bacteremia,  especially  if  complicated  l)y  erysipelas,  one  may  hope  for 
some  effect,  but,  to  repeat,  the  result  is  often  disappointing.  As  a  prophylactic, 
the  antistreptococcic  serum  is  useless,  but  the  tetanus  serum  useful. 

Vaccine  Therapy. — Up  to  the  present  the  clinical  results  of  the  vaccine  treat- 
ment of  acute  puci-pcral  infections  have  been  negative,  a  conclusion  reached  by 
a  committee  composed  of  Williams,  Cragin,  and  Newel  in  1910.  Polak,  however, 
recommends  a  mixed  stock  vaccine  in  doses  large  enough  materially  to  increase 
leukocytosis. 

Phagocytosis  is  one  of  the  means  of  defense  of  the  body  against  infection,  and,  though  it  has 
long  l)een  believed,  Wright  has  proved,  that  certain  bodies  are  produced  by  the  blood-serum — at 


TREATMENT   OF    PUERPERAL    INFECTION  881 

least  arc  proclurfd  sotnowlicri' — which  [jrcparo  tho  bacteria  for  the  dcvouriiiK  loui<ocytf'S.  Wright 
called  these  bodies  upsonin.s.  liy  comparing  th('  nuiiiljer  of  i)acteria  which  tlie  leukocytes  of  a 
patient  will  ingest  with  (he  iniinber  wiiich  the  leukocytes  of  a  normal  individual  will  ingest  under 
identical  cultural  conditions,  tlie  [)ower  of  the  patient's  serum  to  produce  an  opsonin  specific  for 
the  particular  infection  will  be  determined.  This  is  the  opsonic  index  of  the  patient,  and  it  varies 
as  the  i)atient  is  coiHiuering  or  not  coiHjuering  the  infecting  organism.  Wright  fouml  that  injec- 
tion into  tiie  cellular  tissue  of  sterilized  cultures  of  bacteria  containing,  of  course,  the  endotoxins 
as  well  as  the  Ixxlies  of  the  dead  bacteria,  causes  an  increase  of  the  opsonins  of  the  blood,  that  is, 
of  those  opsonins  which  facilitate  phagocytosis  of  the  particular  organism,  and  this  fact  is  discov- 
erable by  the  elevation  of  the  opsonic  index. 

It  would  seem,  th(>refore,  that  if  a  jiatient  were  exposed  to  a  certain  infection  and  we  injected 
the  dead  bacteria  and  their  endotoxins,  that  tlu;  blood  of  the  patient  would  be  .so  fortified  that 
when  the  invading  bacteria  arrive,  they  would  be  met  by  such  a  resisting,  opsonizing  blood  that 
they  would  be  rapidly  engulfeil  by  the  phagocytes.  And  clinical  experience  tends  to  Ix-ar  this  out, 
because  in  cholera,  plague,  typhoid,  and  dysentery  such  immunizing  vaccinations  have  proved 
of  decided  value. 

It  would  also  seem  rational  to  believe  tliat  if  the  patient  suffered  from  a  local  infection  in 
which  the  general  reaction  was  not  enough  to  produce  efficient  local  phagoc-ytosis,  the  injection 
of  a  vaccine  would  aid  the  wall  of  leukocytes  in  its  fight  with  the  bacteria,  and  experience  bears 
this  out  in  many  cases.  It  has  often  been  observed  that  if,  for  example,  a  breast  abscess  with 
many  sinuses  develops  a  pocket  of  pus,  cutting  this  open  is  followed  by  rapid  improvement  of 
the  whole  breast.  This  is  a  sort  of  autovaccination,  and  the  whole  body  is  called  upon  to  furnish 
antibodies  for  the  fight  going  on  in  the  l)reast. 

^^'hen  the  blood  is  infected  or  full  of  bacteria  and  toxins,  it  would  seem  irrational  to  inject 
more  endotoxins,  and  experience  confirms  this  statement. 

It  is  generally  admitted  that  in  acute  puerperal  infections  vaccine  therapy  is 
useless  and  sometimes  harmful.  It  is  not  always  possible  to  isolate  the  causative 
bacterium  or  bacteria.  In  chronic  local  infections,  suppurating  cellulitis,  peri- 
metritis, pyosalpinx,  thrombophlebitis,  the  use  of  vaccines  promises  more  success. 
The  best  results  have  been  obtained  in  chronic,  local,  staphylococcal  infections,  in 
tubercular,  Bacterium  coli,  and  gonococcal  processes,  while  with  the  streptococcus 
less  headway  has  been  made.  Stock  vaccines  are  useful  in  some  cases,  but  it  is 
probably  best  to  use  autogenous  vaccines,  that  is,  those  cultivated  from  the  patient 
herself.  Prophylactic  vaccinal  immunization  has  thus  far  proved  futile.  With 
what  bacterium  should  we  work?  The  subject  is  still  in  the  experimental  stage, 
and  the  treatment  is  not  yet  sufficiently  tried  out  to  be  recommended  for  general 
practice. 

The  Abscess  of  Fixation. — It  has  been  known  for  a  long  time  that  if  a  case  of  sepsis  has  a 
focus  of  free  sui)i)uration,  recovery  is  verj'  probable,  and  Fochier,  in  1S92,  advised  the  injection  of 
turpentine  into  the  thigh,  with  the  object  of  making  an  abscess  and  thus  inducing  leukocytosis. 
Voiturier,  in  1909,  reported  120  cases  and  reviewed  the  Uterature.  The  results  have  not  gained  any 
general  recognition  for  tlie  procedure. 

Surgical  Treatment. — Reference  has  already  been  made  to  the  treatment  of 
pelvic  inflammations  by  operation,  and  no  real  difference  of  opinion  exists  regarding 
the  procedures  advocated  for  the  treatment  of  localized  suppurations.  Two  radical 
operations,  however,  have  been  employed  in  the  treatment  of  severe  infections, 
aV)out  wliich  there  is  still  much  to  be  learned.  One  is  extirpation  of  the  uterus,  the 
other,  ligation  of  the  pelvic  veins,  with  a  view  to  stopping  the  progress  of  a  thrombo- 
phlebitis. 

Hysterectomy. — Schultze  removed  a  uterus  containing  an  infected  placenta  in 
1886,  and  the  patient  recovered,  and  since  then  the  operation — total  hysterectomy — 
has  been  done  several  hmidred  times,  but  with  not  enough  success  to  give  it  a  firm 
place  in  our  therapy.  At  the  Congress  in  Rome  in  1902  the  subject  was  one  of 
the  main  themes,  and  again  in  Madrid  in  1903.  Fehling  reported  in  Rome  a  mor- 
tality of  55.7  per  cent.,  and  Cortiguera,  in  ]\Iadrid,  51.8  per  cent.;  Doleris,  95  per 
cent.;  Mouchotte  (all  abortion  cases),  43.3  per  cent.  Tlie  main  difficulty  lies  in 
placing  the  indication.  It  is  generall}'  admitted  that  in  the  following  conditions — 
m  all  of  which  the  local  lesion  is  the  predominant  factor — hysterectomy  is  justifi- 
able: (1)  Rupture  of  the  uterus  or  vagina  with  infection,  perforation  of  the  uterus 
Avith  beginning  peritonitis,  or  perforation  of  the  uterus  during  the  local  treatment 
of  an  infection  withm  it;  (2)  infection  of  a  fibroid,  or  when  a  fibroid  has  been  much 
56 


882 


PATHOLOGY  OF  THE  PUERPERIUM 


bruised  by  an  operative  delivery  and  infection  is  feared  (a  fibroid  polypus  is  often 
removable  from  below) ;  (3)  cancer  of  the  uterus ;  (4)  infection,  with  a  molar 
pregnancy;  (5)  abnormal  adherence  of  the  placenta  and  infection;  (6)  incarceration 
of  all  or  of  a  part  of  the  ovum,  for  example,  missed  abortion  or  labor  with  infection 
(in  the  latter  three  instances  the  difficulty  of  removal  of  the  masses  in  the  usual 
manner  must  be  also  considered);  (7)  uterine  abscess;  (8)  gangrene  of  the  uterus. 
It  has  also  been  suggested  to  remove  the  uterus  in  cases  of  peritonitis,  extensive 
involvement  of  the  tubes  and  ovaries,  and  in  uterine  emphysema  (Demelin),  but 
the  shock  of  such  operations  is  very  badly  borne  by  these  intensely  septic  patients. 
The  greatest  clanger  is  from  peritonitis,  if  such  is  not  already  present,  and  it  is 
impossible,  with  our  present  technic,  to  avoid  soiling  the  peritoneum  to  some 
extent  when  the  whole  uterus  is  removed.  If  supravaginal  amputation  with  extra- 
peritoneal treatment  of  the  stump  is  practised,  soiling  the  peritoneum  may  be 
avoided  (v.  Herff). 

Much  more  uncertainty  exists  as  to  the  propriety  of  removing  the  uterus  in 


Uterine  veins 


Internal  iliac 
vein 


'xf^ 


Fig.  766. — Veins  of  the  Right  Pelvis   (from  Kownatski). 
From  a  woman  who  died  of  eclampsia  four  days  postpartum. 


Ureter 


cases  of  bacteremia,  or  at  least  in  cases  of  severe  endometritis  and  uterine  lymph- 
angitis and  phlebitis,  when  the  infection,  presumably,  is  still  more  or  less  limited 
to  the  uterus.  There  is  the  point.  If  we  could  tell  when  the  infection  is  likely  to 
pass  the  line  of  safety,  we  would  know  when  to  remove  the  uterus,  and  experience 
lias  shown  that  uteri  are  usually  removed  too  late  to  do  any  good,  and  in  those 
cases,  where  the  courageous  operator  has  done  hysterectomy  early,  he  could  never  be 
sure  that  the  mutilation  of  the  patient  was  demanded.  The  operation  may  have 
killed  her,  or  if  she  got  well,  may  not  have  contributed  to  her  recovery,  but  has 
rendered  her  sterile.  My  own  experience  with  the  operation  is  nil — I  have  never 
seen  a  case  where  I  thought  it  could  possiljly  save  life,  and  in  many  critical  cases 
recovery  ensued  without  it.  If  a  general  bacteremia  exists,  no  one  would  expect 
any  good  from  the  operation.  Williams,  Lea,  and  Edgar  take  the  same  position. 
Septic  patients  are  the  very  poorest  subjects  for  operations  and  anesthetics,  espe- 
cially chhjroform  (L.  Guthrie),  and  there  is  no  doubt  in  my  mind  but  that  many 
puorperse  annually  lose  their  lives  because  of  them. 


TREATMENT    OV    IT  I:HI>K1{AL    INKKCTION 


883 


Ligation  of  the  Pelvic  Veins. — In  1.S97  W.  A.  Frcuiid  lifiulcd  tliroiiil)Otic  ,si)crmulic  veins  lo 
cure  scplicopyciiiia,  l)iil  witlioiit  success.  In  1002  Trendclfnlairfi;  rcixjrtcd  4  fuiluros  out  of  5 
opcnitiuns.  In  \\H)\)  .J.  W.  Williams  collected  oO  cases,  o  of  his  own,  of  ligation  of  the  pelvic  veins, 
and  filvcs  tiie  literature  to  date,  lie  finds  a  mro.ss  mortality  of  4'.iM  per  cent,  when  the  veins  are 
attacked  fiom  the  peritoneal  ca\ity,  and  he  compares  this  with  the  (general  mortality  of  pyemia, 
which  he  plac<'s  at  (it)-':;  I><'i"  <"ent.  Of  his  o  ca.ses,  4  recovered,  but  none  of  the  patients  had  had 
full-term  (leli\eries  -one  at  seven  months  and  four  abortions.  If  the  speniiatif;  veins  alone  are 
involved,  the  outlook  for  the  operation  is  more  favorable  than  if  the  hypogastrics  are  affected. 
If  both  are  thrombosed,  or  if  tlie  infection  extends  into  tin;  cava,  operation  is  hopeless. 

After  a  posit iv(>  diagnosis  of  septicopyemia  is  made,  tliis  operation  should  Ije  considerefl. 
Repeated  chills,  extreme  intermittence  of  temperature,  and  the  palpation  of  hard,  worm-like  ma.s.ses 
in  the  bases  of  the  broad  lijiaments  justify  the  diagnosis  of  thrombophlebitis,  and  if  the  attendant 
I'eels  convinced  that  only  the  veins  are  implicated,  and  1he.se  not  so  far  as  the  vena  cava,  it  may  be 
justifiable  to  remove  them  from  tiie  f^eneral  circulation  by  lifiaf  inff  them  distally  from  the  infection. 
In  sul)acute  and  chronic  cases  of  four  to  six  weeks'  duration  the  most  success  has  been  attained, 
but  here  akso  are  I  lie  most  spontaneous  recoveries.     In  acute  ca.ses  the  operat  ion  is  contraindicated. 


Fir,.   767. — I.iOATiNO  the  Right  jMedi.^n  .\xd  Internal  Iliac  Veins 
Modified  from  Kownatski. 


All  writers  a^ree  on  the  difficulty  of  selectino;  the  proper  ones  for  the  operation,  and  that  the 
treatment  is  still  on  probation.  Three  methods  of  ligation  are  proposed — the  extraperitoneal,  the 
operation  being  similar  to  the  extraperitoneal  ligation  of  the  internal  iliac  artery;  the  vaginal 
route,  taught  by  Taylor  of  Birmingham;  and  the  transperitoneal,  the  one  that  seems  most  rational 
and  is  generally  adopted.  Tluough  a  sufficiently  large  median  abdominal  incision  the  pelvis  is 
broadly  exposed,  the  thrombotic  veins  searched  for  by  sight  and  palpation,  the  peritoneum  split 
over  them,  and  a  catgut  ligature  placed  beyond  the  distal  end  of  the  thromlnis.  Both  spermatics 
should  be  ligated,  and  also  one  or  both  hypogastrics.  Bumm  once  successfully  ligated  the  common 
iliac  vein.  Edema  of  the  pch-ic  tissues  and  vulva  and,  sometimes,  permanent  varices  and  venous 
congestion  follow  the  operation  when  the  majority  of  the  veins  are  tied,  conditions  resembling  the 
after-effects  of  puerperal  infections  with  much  formation  of  fibrous  tissue  about  and  in  the  veins 
and  connective  tissue  (Warnekios). 

Literature 

Barsony:  L'Obstetriquo,  November,  1909. — Baumm:  Arch.  f.  Gyn.,  vol.  lii,  iii,  p.  579. — Polak:  Jour.  Amer.  Med. 
Assoc,  November  25,  1911. — Vaccines:  Surg.,  Gyn.,  and  Obstet.,  July,  1910. — Vineberg:  Surg.,  Gyn.,  and 
Obstet.,  July,  1910.  "Ligation  of  Veins,"  p.  31. — Voilurier:  L'Obstetrique,  August,  1909. — ton  Herff:  v. 
"VN'inckel's  Handbuch  der  Geburtshilfe. —  Warnefcros:  Arch.  f.  Gyn.,  June,  1912,  vol.  xcvii,  i,  p.  71. — Wat- 
kins:  Jour.  Amer.  Med.  Assoc,  January,  1912;  also  paper  read  in  June,  1912. — Weaver  and  Tunnicliff: 
Jour.  Infectious  Diseases,  1911,  vol.  ix,  p.  130. — Williams:   Amer.  Jour.  Obstet.,  May,  1909. 


CHAPTER  LXVII 
DISEASES  OF  THE  BREASTS 

FUNCTIONAL  DISTURBANCES 

The  most  common  disorder  affecting  the  breasts  is  simple  engorgement.  The 
general  notion  #B  that  with  engorgement  the  breasts  are  overfilled  with  milk. 
This  is  true  only  in  part.  While  a  small  amount  of  milk  forms  spontaneously 
in  the  breasts,  the  symptoms  are  due  to  lymphatic  and  venous  stasis.  One  can 
see  this  in  some  cases,  even  the  skin  being^edematous.  The  engorgement  occurs  on 
the  second,  third,  or  fourth  day,  when  the  "inilk  comes  in,"  and  it  may  occur  at 
the  time  of  suddenly  weaning  the  child,  when  the  usual  relief  produced  by  nursing 
is  absent. 

Syinptoms. — The  breasts  are  very  heavy,  painful,  and  hot;    they  feel  warm, 


Fig.  708. — Masssagk  of  Breast.     Even  Co.mprehsion  of  ENTinB  Breast.     First  Motion. 


but  there  is  no  rise  of  body  temperature.  There  is  no  such  thing  as  "milk-fever" — 
a  fever  the  ancients  ascribed  to  the  engorgement  of  the  Ijreasts  on  the  third  or  fourth 
day.  Fever  at  such  time  is  usually  due  to  infection.  Examination  of  the  breasts 
shows  them  to  be  much  enlarged,  tender,  hard,  sometimes  edematous,  and  of  a 
Vjluish,  mottled  appearance.  The  nipple  is  flattened  so  that  the  child  cannot  grasp 
it,  and  the  secretion  of  milk  may  })e  suspended — the  breasts  are  choked  up  with 
swelling.  The  part  of  the  gland  running  up  into  the  axilla  enlarges  too,  and  the 
patient  cannot  bring  her  arm  to  the  side. 

If  let  alone,  the  engorgement  gradually  disappears,  the  gland  becomes  soft, 

884 


DISEASES    ()V   TlfK    BREASTS 


885 


and  the  milk  flows  readily  when  the  child  iiuises.     If  irritated  by  too  much  or  too 
rough  massage,  by  breast -pumps,  and  by  too  frequent  nursing,  tlie  engorgement  is 
slower  in  going  down,  but  it 
Avill  gradually  disapi)ear. 

Trailnient. — Since  the 
determination  of  lymph  and 
of  blood  to  the  breast  is 
due  to  hyi^eractivity,  seda- 
tive remedies,  not  stinmla- 
tion,  are  needed.  A  saline 
cathartic  may  be  given  to 
deplete  the  system;  liquids 
by  mouth  are  restricted,  and 
the  breast  is  put  at  rest  as 
far  as  possible,  which  means 
that  the  periods  between 
nursings  are  to  be  length- 
ened. A  tight  breast- 
binder  is  applied,  supple- 
mented by  ice-bags  if  the 
pain  is  marked.  Some 
patients  prefer  warmth — 
when  a  warm  wet  boric 
dressing  may  be  ordered. 
Soranus,  of  Ephesus,  a.  d. 
100,  said  not  to  pump  the 
breasts,  because  it  increased 
their  activity.     Massage  of 

the  breasts  is  employed  in  rare  cases,  and  is  practised  as  follows.  Massage  and 
the  use  of  the  breast-pump  are  contraindicated  if  there  is  the  least  suspicion  of 
inflammation. 

The  operator  sterilizes  his  hands  and  anoints  the  breasts  with  sterile  albolene  or  oil.  The 
first  motion  (Fig.  768)  is  one  of  even  compression  of  the  whole  breast.  Both  hands  are  spread 
out  as  evenly  and  smoothly  as  possible  over  the  breast,  and  firm  compression  is  exerted  against  the 
chest.     The  blood  and  lymph  are  thus  pressed  out  and  away  from  the  gland.     On  removing  the 

fingers  one  may  see  depressions  in  the  surface.  This  pres- 
sure is  not  painful,  but  the  contrary.  After  this  even  pres- 
sure has  been  practised  a  few  minutes  and  all  the  gland  cov- 
ered, gentle  circular  strokings  are  made  from  the  nipple  to- 
ward the  periphery  (Fig.  769).  The  four  fingers  make  circles 
around  the  nipples,  pressing  harder  as  they  go  awaj'  from 
the  nipple.  (See  diagram,  Fig.  770.)  The  breast  is  steadied 
by  the  other  hand.  * 

After  circling  the  breast  twice  the  third  motion  is  in- 
stituted (Fig.  771).  One  hand  steadies  the  breast,  while  four 
fingers  of  the  other  hand  wipe  the  milk  toward  the  nipple. 
Any  milk  formed  is  thus  squeezed  out  of  the  nipple.  This 
is  the  least  important  of  the  three  motions.  The  last  motion 
is  a  repetition  of  the  first  motion,  and  nearly  always  the 
patient  will  feel  much  relieved  by  the  procedure,  even  though 
no  milk  has  been  expressed.  The  breasts  are  now  bandaged 
smoothly  and  tightl}'. 


Fig.  769. — jMassage  of  Breasts 


Motion. 


Fig.  770. 


-Diagram  of  Outward  Strok- 
ings. 


Polygalactia  is  the  abnormal  increase  of  milk 
secretion.     It  occurs  mainly  in  women  of  sthenic 
habit,  and  usually  subsides  in  a  few  days  without  treatment  or  with  the  measm'es 
just  considered. 

Hyperlactation  is  a  volmitary  condition.  It  means  that  nursing  is  prolonged 
beyond  the  customary  eight  or  nine  months.  One  case  came  to  my  notice  where 
a  wet-nurse  suckled  three  successive  children  in  the  same  familv  ^^•ithout  harm  to 


PATHOLOGY  OF  THE  PUERPERIUM 


herself  and  with  benefit  to  the  nursUngs.  Ploss  says  that  such  a  practice  is  common 
in  Spain,  and  that  the  Japanese  women,  the  Chinese,  Armenian,  and  more  or  less 
civilized  tribes  nurse  their  children  for  several  years — some  even  up  to  fifteen. 
There  is  a  popular  fallacy  among  the  poor  that  nursing  prevents  conception. 
Hj'perlactation  is  usually  bad  in  its  effects  on  the  general  health  of  the  woman, 
causing  emaciation,  asthenia,  oligemia,  backache,  pain  in  the  breasts,  drawing  into 
the  shoulders  while  nursing,  anorexia,  and  general  neurasthenic  symptoms.  Head- 
ache, cramps  in  the  shoulder  muscles,  amaurosis,  and  lactation  psychoses  have 
been  observed.  More  important  is  the  usual  hyperinvolution  of  the  uterus, — 
the  so-called  lactation  atrophy, — which,  if  the  cause  is  not  early  removed,  may 
lead  to  permanent  changes  in  the  organ.  The  uterus  is  so  small  sometimes  that 
it  can  hardly  be  found.  A  tuberculous  lesion  may  become  active  in  these  conditions. 
The  treatment  begins  with  weaning  the  child;  then  tonics,  the  compound  syrup  of 
hypophosphites,  forced  feeding,  and  outdoor  living  are  prescribed. 


Fio.  771. — Massage  of  Breasts.     Third  Motion. 


Galactorrhea. — Continuous  flowing  of  a  milk-like  secretion  from  the  breasts, 
irrespective  of  nursing,  and  persisting  after  weaning,  is  called  galactorrhea.  It  is 
very  rare  and  rather  intractable.  The  cause  is  unknown,  but  the  disease  is  more 
frequent  in  neurotic  women,  and  in  some  cases  abnormal  practices  on  the  breasts 
may  be  suspected  if  simulation  and  exaggeration  are  eliminated.  It  may  be  uni- 
lateral or  bilateral,  intermitting  for  a  few  days  or  weeks,  to  recur  again;  may  follow 
abortions  or  full-term  labors,  may  be  slight  in  amount  or  profuse,  as  much  as 
several  quarts  being  lost  daily.  My  case  continued  for  four  years,  but  was  free 
from  the  flow  during  two  intervening  pregnancies,  and  her  milk  disagreed  with  the 
children,  so  that  they  had  to  be  wet-nursed.  Recovery  occurred  when  a  small 
abscess  near  the  nipple  was  opened.  Perhaps  a  chronic  galactophoritis  may  explain 
some  of  the  cases  of  galactorrhea.  Cases  are  on  record  of  the  flow  lasting  from 
eleven  to  thirty  years.  The  health  usually  suffers  more  or  less, — a  condition  called 
"tabes  lactea," — but  it  may  not  be  affected  at  all. 


DISEASES    OF    THE    BREASTS  887 

Trcdliiicni. — Compression  ol'  IIm'  hicast  1)\-  hiiidcj-  is  first  practised,  lodid  of 
potash,  generally  recommended,  failed  in  my  owti  case.  A  chronic  galactophoritis 
should  he  looked  for,  and,  if  found,  tlie  inflamed  portion  of  the  breast  excised. 
Chloral,  belladonna,  antipyrin,  bromids,  and  ergot  have  all  been  tried,  with  varying 
failui'e.  Return  of  the  menstruation  is  usually  accompanied  by  stopping  of  the 
flow,  and  therefore,  j)erhaps,  efforts  to  favor  the  return  of  the  menses  may  be  useful. 
Attention  to  the  general  health  is  advisable,  and  a  little  wholesome  neglect  of  the 
local  condition  to  distract  the  patient's  mind  from  it  may  also  be  useful. 

Abnormal  Milk. — Kemarkable  as  it  may  seem,  the  milk  of  the  mother,  although 
))lentiful,  may  not  agree  with  the  child.  The  author  has  seen  cases  where  it  seemed 
to  act  like  an  irritant  intestinal  poison,  and  fatalities  have  even  been  reported. 
These  have  all  been  neurotic  mothers,  and  most  of  them  in  the  higher  classes. 
Chemie  and  microscopic  examinations  have  not  given  satisfactory  explanations. 
The  condition  may  or  may  not  recur  in  subsequent  pregnancies. 

The  child  will  refuse  the  breast,  in  which  case  the  milk  may  have  a  foreign 
taste,  or  it  will  vomit  the  ingested  milk  or  have  a  diarrhea  from  it,  sometimes  with 
fever.  The  milk  may  appear  yellower  and  thicker  in  these  cases,  showing  either  a 
persistence  of  the  colostrum  or  an  increase  in  fat  and  proteids- — that  is,  it  is  too  rich. 
Curiously,  sometimes  a  child  will  refuse  one  breast  and  accept  the  other;  in  a  case 
of  this  kind  the  milk  of  one  breast  was  said  to  be  salty. 

If  the  milk  is  believed  to  disagree  with  the  child,  causing  green,  acrid  stools, 
the  nursing  should  be  discontinued  for  forty-eight  hours,  the  breasts  being  regularly 
emptied  in  the  mean  time  by  the  breast-pump.  The  child  is  fed  on  a  substitute 
milk,  and  at  the  end  of  this  period  another  trial  is  made  of  the  mother's  milk. 
If  it  again  causes  intestinal  disturbance,  the  wisest  course  to  pursue  is  to  obtain  a 
wet-nurse  for  the  child. 

If  the  mother's  milk  is  deficient  in  one  or  the  other  ingredient,  the  physician 
will  instruct  the  nurse  to  give  an  additional  feeding  of  this  or  that  preparation  of 
sugar,  cream,  barley-water,  etc.,  after  each  nursing.  Not  much  may  be  expected 
from  dieting  the  mother.  Illness  of  the  mother  affects  the  quality  of  the  milk, 
rendering  it  indigestible,  and  also  diminishing  the  amount.  Bacteria  circulating 
in  the  maternal  blood  are  excreted  in  the  milk,  which  is  true  of  tuberculosis, 
streptococcemia,  pyococcemia,  and  perhaps  for  malaria.  The  infant  may  be  in- 
fected from  the  germs  thus  swallowed,  or  from  the  germs  contained  in  pus  which 
comes  from  a  mammary  abscess.  Exceptions  to  this  statement  are  not  rare.  I 
have  seen  septic  women,  even  pneumonia  cases,  nurse  their  babies  with  impunity. 
A  woman  with  diphtheria,  given  antitoxin,  may  nurse.  That  drugs  administered 
to  the  mother  pass  over  to  the  fetus  is  well  known. 

Strong  emotions  certainly  affect  the  milk,  causing  indigestion,  diarrhea,  green 
corrosive  stools,  even  convulsions  and  death  of  the  infant,  many  authentic  cases 
of  which  are  on  recortl. 

Agalactia. — One  of  the  commonest  complaints  of  nursing  mothers  is  scarcity 
or  lack  of  milk.  Total  absence  of  milk  is  found  only  when  the  breasts  are  absent, 
a  rare  anomaly.  The  causes  of  deficient  milk  secretion  are  general  weakness  or 
ill  health;  malformations  or  diseases  of  the  nipples,  which  render  nursing  impossible 
or  too  painful;  occlusion  of  the  milk-ducts,  or  destruction  of  gland  tissue  from 
mastitis ;  insufficient  stimulation  of  the  breast  by  a  puny  child ;  inadequate  amount 
of  gland  tissue  as  a  congenital  anomaly,  which  might  be  hereditary,  successive 
generations  of  women  not  having  nursed  their  children;  disuse  of  the  breast  in 
successive  pregnancies;  old  primiparity — women  with  the  first  child  after  thirty- 
five  seldom  l^eing  alile  to  nourish  the  infant;  starvation,  the  wasting  diseases,  and 
the  effects  of  febrile  affections;  emotional  states,  a  quiet,  placid  disposition  con- 
tributing to  a  good  supply,  worry,  fright,  pain  and  anger,  reducing  or  temporarily 
stopping  the  flow;   lack  of  love  for  the  child  may  reduce  the  amount;  menstruation 


888  PATHOLOGY  OF  THE  PUERPERIUM 

rarely  reduces  it;  obesitj^ — but  not  invariably;  hemorrhage  during  labor;  inter- 
ruption of  lactation  for  anj^  cause.  The  milk  usually  is  not  so  abundant  when 
nursing  is  resumed.  I  have  seen  the  milk  return  five  weeks  after  the  child  had  been 
removed  from  the  breast,  and  cases  are  on  record  of  its  return  months  afterward. 
Several  reports  of  nursing  of  the  child  by  its  own  grandmother  are  authenticated, 
and  in  certain  tribes  of  savages  such  a  custom  is  common. 

Symptoms. — A  large  breast  does  not  mean  a  good  supply  of  milk,  since  it  may 
be  made  up  mainly  of  fat,  with  little  gland  tissue.  Small  breasts  with  thin  skin  and 
blue  veins  coursing  under  the  surface  usually  give  plenty  of  milk. 

The  sjonptoms  of  deficient  milk-supply  are,  first,  the  distress  of  the  child — its 
loss  in  weight;  second,  pain  in  the  breasts  and  the  absence  of  secretion.  The 
child  is  unsatisfied  with  the  nipple;  he  may  suck  for  a  short  while,  but,  finding 
nothing  there,  will  refuse  it  and  cry.     After  supplemental  feeding  he  goes  to  sleep. 


Fig.  772. — Stimulating  Massage. 

When  there  is  plenty  of  milk  the  mother  can  feel  it  leave  the  breast  and  see  the 
infant  swallow.  There  are  also  some  drops  of  "white  nourishment"  around  the 
mouth.  These  are  all  absent  in  agalactia.  Weighing  the  child  before  and  after 
nursing  proves  the  lack  of  milk.  If  the  mother  persists  in  nursing  after  the  supply 
has  diminished,  the  act  comes  to  be  attended  with  pain  in  the  breasts,  radiating 
around  to  the  back,  first  only  during  the  nursing,  later  in  the  intervals  also.  Unless 
nursing  is  interrupted,  serious  inroads  on  the  woman's  health  may  result. 

Treatment. — If  there  is  not  enough  milk  in  the  breasts,  an  attempt  may  be  made 
to  stimulate  the  secretion  by  diet,  cool  baths,  and  massage  of  the  breasts,  but  only 
a  few  cases  are  amenable  to  treatment.  Medicines  have  very  uncertain,  if  any, 
action.  Malt  extract,  somatose,  or  other  preparations  vaunted  to  stimulate  the 
secretion  may  be  prescribed.  The  author's  experience  with  malt  preparations  is 
that  they  often  fatten  the  patient  and  dry  up  the  milk. 

By  increasing  the  liquids  in  the  diet  the  total  quantity  of  milk  may  sometimes, 


DISEASES    OF   THE    BREASTS 


889 


but  not  always,  bo  increased.  When  the  milk  sui)i)ly  i.s  not  auj;incntcd,  the  pa- 
tients put  on  fat.  Milk  may  be  given  in  large  quantities,  also  water,  very  weak  tea, 
chocolate,  oatmeal  and  barley  gruels,  and  oyster-stews,  in  addition  to  the  regular 
diet.  The  effect  is  not  permanent,  and  too  much  water  thins  the  blood.  Alcoholic 
drinks  should  be  restricted,  or,  better,  avoided,  and  certainly  by  a  mercenary  wet- 
nurse.     Alcoholics  arc  not  good  for  the  infant. 

Cool  full  baths  stimulate  the  skin  and  the  breast  also.  They  may  be  taken 
daily  at  about  80°  to  84°  F.  The  whole  body  should  be  briskly  rubbed  with  a 
coarse  towel,  avoiding  the  mammae.  Bier's  method  of  producing  artificial  engorge- 
ment has  been  applied  to  the  breast  to  stimulate  the  flow  of  milk.  The  results 
thus  far  have  been  fair. 

Massage  of  the  breasts  stimulates  the  formation  of  milk.     When  massaging 


Fig.  773. — STiMri..\TixG  M.\ss.\ge. 


the  breast  for  this  purpose,  the  rules  given  on  p.  885  do  not  apply.  One  wishes 
here  to  irritate  the  gland.  This  is  done  by  raising  the  whole  breast  from  the 
chest-wall  (Fig.  772)  and  working  it  gently  between  the  fingers.  Care  should  be 
used  not  to  bruise  the  delicate  organ,  as  an  abscess  may  result.  The  gland  is  then 
held  against  one  hand,  while  the  tips  of  the  outspread  fingers  of  the  other  hand  make 
circular  movements  all  around  its  peripher.y  (Fig.  773). 

Electricity  has  been  tried,  with  indifferent  success.  The  best  stinmlant  for 
the  milk  secretion  is  a  vigorous  infant. 

One  should  not  be  discouraged  too  soon,  as  the  establishment  of  the  milk 
secretion  is  sometimes  slow.  In  one  case  sufficient  milk  did  not  come  until  the 
fifth  month.  Often,  after  the  patient  is  up  and  gets  outdoors,  the  milk  comes  in 
larger  quantities.  One  may  be  misled  to  believe  that  this  is  the  action  of  soQie 
special  drug  or  of  feeding.     If,  however,  the  measures  instituted  have  no  effect,  it 


890  PATHOLOGY  OF  THE  PUERPEKIUM 

is  wiser  to  discontinue  them  as  soon  as  this  fact  is  apparent.  Too  great  zeal  in 
forcing  the  breasts  to  act  may  result  in  mastitis. 

Drying  up  the  Milk. — Of  all  the  measures  recommended  for  this  purpose,  the 
author  has  found  the  following  the  simplest  and  quickest.  Liquids  in  the  diet  are 
reduced,  a  saline  cathartic  given  on  two  successive  days,  a  firm  breast-binder  is 
applied,  and  the  breasts  then  left  absolutely  alone.  Pumping  and  massage  only 
stimulate  the  gland  to  further  action.  Drugs  are  dangerous  or  useless.  If  the 
engorgement  folloTNdng  the  weaning  is  very  marked  and  painful,  the  treatment 
described  on  p.  885  may  be  employed. 

"Caked  Breast." — So-called  "caked  breast"  is  a  local  engorgement  affecting 
one  or  more  lobules  or  lobes.  It  is  sometimes  due  to  occlusion  of  one  or  more  of 
the  lactiferous  ducts,  but  may  be  a  simple  congestion,  due  to  injury,  which  may  have 
antedated  the  gestation.  A  lump  made  up  of  hard,  convoluted  masses  of  gland 
tissue  is  found  occupying  one  or  more  quadrants  of  the  organ,  which  is  tender  to 
the  touch,  but  presents  no  signs  of  real  inflammation,  nor  is  there  any  general  reac- 
tion. "Caked  breast"  does  not  usually  lead  to  mastitis,  though  it  is  easy  to  under- 
stand that  the  bacteria  normally  present  in  the  tubuli  lactiferi  could  thus  more 
easily  attain  invasive  qualities.  If  such  a  breast  is  roughly  handled,  as  by  ill- 
directed  massage,  infection  is  prone  to  develop. 

Treatment. — Outside  of  instructing  the  nurse  and  the  patient  to  leave  the 
breasts  alone,  to  protect  them  from  injury,  not  to  attempt  to  massage  the  lumps 
away,  nothing  is  done.  If  the  breasts  are  very  painful,  an  ice-bag  or  a  wet  warm 
dressing  may  be  applied. 

DISEASES  OF  THE  NIPPLES 

Sore  nipples  are  a  frequent  complication  of  the  first  weeks  of  nursing.  They 
are  worth}^  the  attention  of  the  accoucheur,  because  they  are  exceedingly  painful. 


Hollow  ^^^p  Mulbern-  ^^HZ  Fissured 


Inverted  ^^^^V  Mushroom        ^^^^^  Cone-shaped     ^^B  Stunted 


Fig.   771. — ^■AKIOUSLY  For.med  Nipples. 


may  prevent  lactation  entirely,  thus  harming  the  child,  and  may  lead  to  infection 
of  the  breasts,  which  may  result  in  abscess  or  even  in  death  of  the  puerpera.  Over 
half  of  nursing  mothers  suffer  from  sore  nipples;  primiparae  more  than  multiparse; 
blonds,  particularly  red-haired  women,  more  than  brunets,  who  usually  have  a 


DISEASES    OF   THE    BREASTS 


891 


thicker  skin;   old  piiinipaia'  iiioic  t liaii  yoiiii^  ones,  and  they  are  especially  common 
if  the  nipple  is  retracted  or  deformed  (Fig.  774j.     If  the  nii)ple  i.s  flat  oreven  inverted, 
the  child  will  be  unable  to  get  hold  of  it,  and  if  efforts  at  nursing  are  too  long  per- 
sist{>d  in,  engorgement,   cracks,  and   fissures  occur, 
and,  infection  being  thus  introduced,  causes  abscess. 
The  conditions  causing  sore  nipples  are  erosions,  blas- 
ters, cracks  or  fissures,  and  ulcerations.     Erosions  are 
caused  by  the  maceration  of  the  thin  epithelium  and 
the  sucking  of  the  infant,  which  thus  exposes  the  retc. 
Sometimes  the  (>])ithelium  is  raised  up  as  a  blister  by 
the  intense  suction,  and  the  blister,  bursting,  leaves 
the  eroded  rete.     If  infection  is  added,  the  process 
may  become  ulcerative.     If  the  skin  cracks,  which 
is   especially  lik(^ly  to   occur    at  the   bottom    of    a 

crevice  in  the  nipple,  a  little  blood  is  poured  out;  it  hardens  to  a  scab  under  which 
a  droplet  of  pus  sometimes  is  found.  Nursing  breaks  off  the  crust,  and  if  the  part 
is  not  treated,  a  deep  ulcer  may  form.  Cracks  are  either  circular  or  vertical.  The 
cracks  which  run  circularly  are  usually  at  the  base  of  the  nipple,  at  its  junction 


Fk;. 


WANsnnouGH's  Lead  Nip- 

I'LE-SHIKLD. 


'L  5^' 


r 


Fig. 


-The  Teterelle  in   Use. 


with  the  areola,  and  if  the  ulceration  is  deep,  the  nipple  ma}'  be  partly  or  wholly 
amputated.  Vertical  cracks  maj'  split  the  nipple  into  two.  Bacteria  are  always 
present  on  and  in  sore  nipples,  and  may  cause  sickness  in  the  baby.  If  the  cracks 
bleed,  the  child  may  swallow  blood,  which  reappears  in  the  stools  or  vomit — melsena 


892  PATHOLOGY  OF  THE  PUERPERIUM 

spuria.  Occasionally  slight  rises  of  temperature  in  the  mother  are  due  to  infected 
nipples. 

The  treatment  of  sore  nipples  begins  during  pregnancy.  (See  p.  230.)  If  the 
woman  complains  of  pain  when  the  child  nurses,  an  inspection  of  the  nipples  is 
to  be  made — ^with  a  magnifying-glass,  if  necessary.  Some  neurotic  women  have 
pain  while  nursing,  even  in  the  absence  of  disease  of  the  nipples — sometimes  so 
much  that  nursing  is  impossible  in  spite  of  sedatives  and  soothing  local  applications. 

A  blister  is  to  be  opened  by  a  fine  sterile  needle  and  the  child  withheld  from  the 
nipple  for  thirty-six  hours.  Cracks  and  ulcerations  are  first  cleansed  with  hydrogen 
dioxid,  then  one  of  the  following  measures  employed:  Leaden  nipple-shields 
(Fig.  775)  are  worn  between  nursings;  the  crack  or  ulcer  is  touched  with  2  per  cent, 
nitrate  of  silver  solution  morning  and  night,  and  this  is  allowed  to  dry  in  in  the 
sunlight;  the  whole  nipple  may  be  painted  with  the  same;  a  50  per  cent,  alcohol 
compress  is  laid  on  the  nipple  for  an  hour  thrice  daily;  glycerol  of  taimin,  glycerin 
and  boric-acid  applications,  a  salve  of  equal  parts  of  castor  oil  and  bismuth,  may 
be  applied;  compound  tincture  of  benzoin,  allowed  to  dry  in;  collodion.  Only  the 
first  four  are  used  by  the  author,  and  in  the  order  given.  A  glass  nipple-shield  is 
ordered  for  the  nursing.  Sometimes  a  teterelle,  used  for  nursing,  as  in  Fig.  776, 
wall  aid  in  the  cure.  The  attendant  is  warned  to  be  scrupulously  aseptic  in  the 
care  of  the  breasts  and  nipples,  because  of  the  great  danger  of  infection.  The 
breast  is  not  to  be  touched  by  the  nurse,  the  nipple  being  washed  with  sterile  boric 
solution  by  means  of  sterilized  cotton  wound  on  tooth-picks — the  so-called  appli- 
cators. It  may  be  necessary  to  stop  nursing  from  the  breast  until  the  crack  has 
healed,  and  if  the  sore  positively  refuses  to  cicatrize,  it  may  be  wisest  to  suspend 
lactation  entirely  to  prevent  a  breast  abscess.  This  is  especially  true  of  the  inverted 
and  deformed  nipples,  and  particularly  if  the  milk  is  scarce.  Such  a  combination 
almost  inevitably  leads  to  mastitis,  which  the  woman  ought  to  be  spared. 

MASTITIS 

Inflammation  of  the  breast  occurs  almost  exclusively  in  nursing  women.  Cases 
have  been  found  during  pregnancy,  even  in  the  non-pregnant,  and  exceedingly 
rarely  in  men.  The  predisposing  causes  are  cracks,  fissures,  and  ulcers,  which  in 
turn  are  caused  by  deformities  of  the  nipple  and  occur  in  primiparse  oftener.  While 
bacteria  are  the  direct  cause  of  mastitis,  and  while  they  may  often  be  found  in 
apparently  healthy  breasts,  an  exciting  agent  is  often  necessary.  Such  are  bruising 
of  the  breast  by  injury,  which  may  have  been  remote,  by  massage,  too  much  pump- 
ing of  the  breast,  squeezing  it,  or  efforts  to  make  it  secrete  milk  when  it  is  physically 
unaljlc  to  do  so.  Simple  milk  stasis  or  local  or  general  engorgement  seldom  leads 
to  abscess,  if  it  ever  does,  alone. 

The  germs  which  have  been  found  in  mastitis  cases  are  the  Staphylococcus 
albus  and  aureus,  the  Streptococcus  pyogenes,  the  Bacillus  coli,  the  pneumococcus, 
certain  anaerobes,  the  Oidium  albicans,  and  blastomycetes  (van  de  Velde). 
Symbiosis  may  be  present.  These  microorganisms  are  brought  to  the  breasts  by 
the  hands  of  the  attendants,  the  linen,  etc.,  or  by  the  "patient  herself,  the  usual 
source  being  the  lochia.  In  general  hospitals  unusual  and  severe  infections  may  be 
brought  to  the  breasts.  The  child  may  be  the  source  of  the  infection,  having 
thrush  or  Bednar's  aphthae  (the  lesions  of  which  usually  contain  both  the  strepto- 
coccus and  staphylococcus),  pharyngitis,  ophthalmia,  coryza,  or  pemphigoid  or 
pustular  eruptions  on  the  face,  etc.  Without  doubt  some  of  the  cases  are  caused 
])y  the  attainment  of  invasive  qualities  of  the  bacteria  normally  inhabiting  the  outer 
milk-ducts  in  the  nipple.  In  1893  I  proved  that  the  staphylococcus  existed  in  the 
milk  of  apparently  healthy  women.  When  the  breast  is  overstimulated  or  hurt, 
the  bacteria  invade  it.  Finally,  it  is  possible  for  the  germs  to  get  to  the  breasts 
via  the  blood,  as  is  sometimes  observed  in  septicopyemia,  but  this  is  very  rare. 


DISEASES    OF   THE    BREASTS 


893 


Forms  of  Mastitis  (I'iji.  111).- — The  infection  may  be  limited  to  the  areola 
outside  the  huuinii  cribrosa,  torminp;  an  abscess  running  around  the  nipple,  or  in 
one  of  the  tubercles  of  jNIontjJioinery,  or  in  the  niilk-fi;lands  attached  to  them; 
second,  the  infection  creeps  along  the  tubuli  lactiferi  into  the  parenchyma  of  the 
ghuul;  this  is  called  parenchymatous  or  glandular  mastitis  or  galactophoritis; 
third,  the  bacteria,  gaining  admission  to  the  connective  tissue  through  a  crack  or 
deep  fissure,  burrow  \\\U)  tlie  fat  around  the  lobes  and  lobules,  causing  interstitial 
or  i)hlegni()n()us  mastitis  or  lymphangitis;  this  cellulitis  may  be  superficial  ov  deep; 
occasionally  the  latter  two  forms  are  combined;  fourth,  the  infection  passes  directly 
through  the  gland  to  the  areolar  tissue  under  it  on  the  chest-wall,  producing  here 
a  submannnary  abscess. 

Symptoms. — The  parenchymatous  form  of  inflammation  is  the  most  common, 


Submaminarv  abscess — -V-/--- 


Parenchymatous  inflammation 


Areolar  abscess 


Phlegmonous  inflammation 


Fig.  777. — Diagram  of  Breast  Infections. 


and  begins  seldom  before  the  seventh  day  of  the  puerperium — most  often  from  the 
tenth  to  the  twentieth  day.  Frequently  there  is  a  little  pain  in  one  portion  of  the 
breast,  marked  while  nursing,  and  occasionally  slight  fever — 99°  F.^ — for  a  day  or 
two  preceding  the  outbreak.  This  is  manifested  by  a  more  or  less  severe  chill  and 
fever.  The  temperature  may  reach  106°  F.  and  be  accompanied  by  delirium,  but 
usually  docs  not  go  over  103°  F.,  and  the  febrile  s^-mptoms  are  moderate.  Pain  in 
the  breast  is  the  rule,  and  over  the  lobe  affected  redness  and  tenderness  are  found, 
and  usually  the  nipple  will  show  a  fissure,  the  site  of  entrance  of  the  infection. 
Any  quadrant  of  the  organ  may  be  inflamed,  though  usually  the  outer  half, 
and  here  one  or  more  large  lumps  may  be  palpated.  In  one  case  the  spot  of 
redness  and  tenderness  was  not  larger  than  a  nickel,  yet  the  w^oman's  temperature 
was  105°  F.  Under  appropriate  treatment  the  temperature  and  pain  subside 
within  thirty-six  hours  miless  the  other  breast  is  also  affected,  as  in  Fig.  779.     If 


894 


PATHOLOGY  OF  THE  PUERPERIUM 


the  fever  continues  for  more  than  forty-eight  hours,  suppuration  rarely  fails  to 
appear.  Then  the  temperature  becomes  remittent,  chills  occur,  the  portion  of  the 
breast  affected  swells  up,  containing  a  large,  hard  mass.  At  one  spot  it  softens,  and 
redness  of  the  skin,  with  a  bluish  tinge,  indicates  where  the  pus  is  coming  to  the 
surface.  Unless  promptly  operated,  successive  lobes  are  involved  until  the  whole 
breast  is  riddled  with  abscesses.  These  must  all  be  opened  and  drained,  healing 
often  requiring  weeks  or  even  many  months.  Naturally,  in  these  cases  the  cellular 
tissue  is  also  involved.  Sometimes  the  acute  symptoms  subside  and  the  accoucheur 
beheves  the  process  is  at  an  end,  but  a  few  weeks  later  fever  begins  again  and  the 
breast  suppurates,  or  pus  is  evacuated  through  the  nipple. 

In  the  cellulitic  or  phlegmonous  variety  the  infection  travels  into  the  gland  from 


Fig.  778. — Mastitis  Pdrulenta. 


a  fissure  and  along  the  connective-tissue  septa,  and  redness,  fan-shaped,  spreading 
from  the  crack,  may  be  seen  around  the  nipple.  If  the  deeper  lymphatics  are 
involved,  the  case  resembles  one  of  deep  cellulitis  anywhere,  with  brawny  swelling  of 
the  skin.  Usually  the  streptococcus  is  here  concerned, — at  least  some  heterogeneous 
bacterium, — and  such  cases  are  more  freciuent  in  general  hospital  practice.  The 
fever,  though  at  first  less  intense,  keeps  up  longer,  and  the  pulse  more  quickly  feels 
the  effect  of  the  toxemia.  Erysipelas  has  been  observed,  and  even  a  pan-mastitis. 
Suppuration  is  much  more  common  in  this  form  of  mastitis,  but  often,  too,  the 
breast  shows  only  a  firm  infiltrate,  which  may  be  absorbed  in  from  six  to  twelve 
days.  After  three  or  four  days  it  is  possible  to  foresee  which  termination  is  to  oc- 
cur.    The  axillary  lymphatic  glands  may  be  enlarged. 

In  the  submammary  abscesses,  which  Billroth  believed  were  due  to  suppura- 


DISEASES    OF   THE    BREASTS 


895 


tion  of  doep-soiited  mammary  gland  tissue,  the  pus  collects  behind  the  gland,  which 
then  seems  to  float  on  a  cushion,  and  edema  appears  at  the  perij)hery.  The  general 
symptoms  are  most  threatening  in  this  form  of  infection — indeed,  unless  ])roniptly 
evacuated,  tlie  i)us  may  burrow  far  and  llic  patient  die  of  l^acteremia. 

Treatment. — At  the  l)Of:;inninK  it  is  not  iilwiiys  possil^lo  to  dctorniino  wlicthor  the  infection 
is  of  the  i);ir('iicliyni:itous  or  the  celluhlic  vtiriety,  but  tlie  treiitment  is  the;  same  for  both.  The 
followiufz;  practice  has  been  found  very  successful  by  the  author:  (1)  Remove  the  infant  from  the 
breast,  and  from  hot  h  breasts  if  the  symptoms  are  not  very  mild;  massage  and  pumping  the  breast 
are  forbidden;  (2)  administer  a  lirisk  saline  cathartic;  (3)  apply  a  tight  breast-binder;  (4)  put 
two  or  tlu-ee  ice-bags  on  each  breast.  The  nipple  is  surrounded  by  a  ring  of  cotton;  a  layer  of 
the  same  is  laid  between  the  two  breasts;  a  rolled  towel  is  placed  to  support  the  organ  from  the 
axillary  side,  and  the  l)reasts,  lifted  up,  are  tiglitly  bandaged.  The  ice-bags  must  keep  the 
breasts  cool,  but  t lie  nurse  is  instructed  to  watch  the  skin  for  signs  of  freezing,  which,  by  the  way, 
I  have  never  seen  with  this  treatment.    ^Viter  the  temperature  has  been  normal  for  twelve  hours, 


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Fig.  779. — Acute  Double  Mastitis.  No  Absces.s.     Right  Bre.^st  First. 


the  bags  are  removed  one  by  one,  and  in  twenty-four  hours  the  child  may  be  put  back  to  the 
breast.     Tliis  treatment  i.s  more  successful  in  the  parenchymatous  forms  than  the  celluhtic. 

If  an  abscess  forms,  it  must  be  incised  as  soon  as  diagnosed.  If  the  attendant  is  certain  that 
suppuration  has  begun,  the  ice  is  replaced  with  a  hot  wet  boric  dressing.  In  opening  breast 
abscesses  the  operator  should  make  a  long  incision  in  a  Hne  radiating  from  the  nipple,  and  with 
the  finger  he  searches  out  all  the  pockets  of  the  particular  lobe  involved.  If  more  than  one  lobe 
is  suppurating,  an  incision  is  made  into  each  one  and  pus  pockets  cleared,  the  septa  between  them 
broken  down,  and  adecjuate  drainage  provided  by  tubes  and  gauze.  This  procediu-e  is  a  for- 
rnidable  operation,  and  is  often  followed  by  chill,  fever,  and  aggravation  of  the  symptoms,  some- 
times with  septic  eruptions,  but  these  sub.side  within  thirty-six  hours,  and  the  patient  goes  on  to 
recovery.  Occasionally  new  portions  of  the  breast  break  down,  forming  secondary  abscesses 
which  may  riddle  the  breasts,  and  these  may  protract  the  healing  for  months.  I  have  noticed 
that  if  such  pockets  are  not  immediately  opened,  ]iut  left  for  a  few  davs  and  then  incised  broadly 
and  the  cavity  rul)bed  Iwiskly  with  the  finger  (gloved),  a  sort  of  auto-inoculation  or  vaccination 
is  made,  wiiich  has  a  good  influence  on  the  whole  gland.  The  sinuses  drain  better  under  a  wet 
dressing,  which  is  at  first  renewed  thrice  daily;  later,  less  often.  Attention  must  be  given  to 
building  up  the  general  health,  which  is  hkely  to  suffer  from  the  profuse  suppuration  and  pro- 
longed illness.     The  patient  is  to  be  gotten  out  of  bed  and  out-of-doors  as  soon  as  possible. 

^^  hen  the  sinuses  are  very  persistent  and  new  foci  of  .suppuration  constantlv  appear,  vaccine 
treatment  is  to  be  tried.  It  is  best  to  get  the  bacterium,  usuallv  the  Staphylococcus  albus,  from 
the  patient  and  make  an  autogenous  vaccine,  giving  first  5,000,000,  then  in  a  few  davs  25,000,000 
or  50,000,000,  if  necessary. 

The  author  has  used  the  Bier  treatment  on  several  cases  of  mastitis,  and  does  not  find  that 


896  PATHOLOGY  OF  THE  PUERPERIUM 

it  materially  shortens  the  length  of  the  suppuration,  nor  does  it  enable  one  to  dispense  with  large 
incisions. 

In  the  cellulitic  variety  of  mastitis,  if  diagnosed  early,  a  hot,  wet  boric  dressing  covering  a 
large  part  of  the  chest  would  be  better  than  the  ice.  Incision  is  to  be  delayed  until  definite  sup- 
puration is  disco\'ered.  Surgeons  are  divided  as  to  the  propriety  of  incising  cellulitic  infiltrates 
early.  Judging  from  my  experience  in  treating  cellulitis  in  the  pelvis,  I  would  wait  for  actual 
pus-formation.  Submammary  abscess  is  to  be  opened  at  once  by  broad  incisions  at  the  periphery 
of  the  gland. 

SUNDRY  COMPLICATIONS  OF  THE  PUERPERIUM 

Natui'ally,  a  pucrpcra  may  suffer  from  any  of  the  diseases  she  would  contract  under  other 
conditions,  without  any  bearing  on  the  puerperal  state.     A  few  of  these  deserve  special  mention. 

Fever  from  Emotional  Influences. — See  p.  867. 

Fever  from  Constipation. — Without  doubt,  overloading  of  the  bowels  may  cause  fever 
dm"ing  the  puerperiimi,  but  such  cases  must  be  extremely  rare.  Almost  invariably  a  temperature 
that  at  fu'st  was  ascribed  to  stercorrhemia  is  found  later  to  be  due  to  an  infection  in  the  pelvis  or 
the  breasts.  The  diagnosis  must  be  made  by  exclusion,  which  is  admittedly  a  precarious  method. 
The  therapeutic  test — subsidence  of  the  fever  following  brisk  catharsis — is  absolutely  unreliable, 
because — (1)  Energetic  action  of  the  bowels  may  affect  the  uterus  and  stimulate  it  to  contraction, 
expelling  from  its  cavity  clots,  lochia,  and  detritus;  (2)  the  pelvic  circulation  is  hastened  by  the 
cathartic,  an  action  most  exhibited  by  aloes,  and  the  relief  of  an  overloaded  rectum  improves 
the  cm-rents  of  the  blood  and  lymph  in  the  pelvis;  (3)  some  cathartics  produce  leukocytosis, 
which  aids  in  repelling  infections;  (4)  a  full  rectum  may  cause  lochiometra  or  stasis  of  lochia  in 
the  vagina — its  emptying  and  the  bearing-down  efforts  of  defecation  relieve  the  stasis.  There- 
fore, if  the  fever  subsides  after  the  bowels  are  emptied,  the  case  may  have  been  one  of  infection, 
and  not  of  absorption  of  toxins  from  the  intestinal  tract,  as  supposed. 

BucUn,  in  1892,  called  attention  to  febrile  stercorrhemia,  and  Kiistner,  Oui,  Lavergne,  and 
others  have  reported  typical  cases.  Fever,  headache,  anorexia,  sometimes  nausea  and  abdominal 
pain,  are  the  sjanptoms.  The  tongue  is  heavily  coated,  the  breath  fetid,  the  skin  muddy  or  pasty, 
the  bell}'  distended  with  gas  or  doughy  to  the  touch  over  the  large  bowel,  and  often  tender.  The 
lochia,  usually  normal,  may  have  a  fecal  odor  (colon  bacillus),  but  the  uterus  and  adnexa  are 
normal.  Brisk  catharsis  and  enemata  produce  copious  fetid  evacuations,  after  which  the  symptoms 
subside.  When  the  rectum  is  packed  with  hardened  feces,  it  may  be  necessary  to  inject  a  soft- 
ening enema  (1  dram  inspissated  ox-gall  triturated  in  1  ounce  of  glycerin,  to  v/hich  are  added  2 
pints  of  water).  After  this  has  acted  for  an  hour  the  softened  mass  may  be  removed  by  the  gloved 
fingers,  aided  by  rectal  irrigation  of  saline  solution. 

Tape-worms  have  often  been  expelled  during  the  puerperium.  Fever  has  occasionally  been 
ascriljed  to  them,  but  in  two  of  my  cases  they  existed  without  causing  temperature.  The  treat- 
ment is  the  usual  one,  but  the  child  is  to  be  kept  away  from  the  breast  for  the  two  days  required 
for  the  action  of  anthelminthic  remedies. 

Tympany  and  Ileus. — Tympany  occurring  after  delivery  seldom  becomes  obstinate  or  very 
marked,  and  gi\-es  no  concern  if  the  bowels  are  moving  and  the  general  condition  is  not  affected. 
If  the  distention  does  not  quickly  subside  under  the  usual  treatment  (a  cathartic,  carminative 
enemata,  a  5-grain  asafetida  pill  three  times  dady),  the  possibility  of  a  serious  affection  should 
be  entertained,  and  a  careful  search  made  for  a  cause. 

Obstruction  of  the  bowels  may  be  due  to  kinking  from  adhesions,  the  sequelae  of  former 
operations  or  inflammations,  and  requires  the  usual  treatment.  In  one  case  I  found  that  a  retro- 
verted  puerperal  uterus  compressed  the  rectum.  After  raising  this  up  with  one  finger  in  the 
bowel  the  obstruction  was  relieved. 

Ileus  after  cesarean  section  is  the  same  as  that  met  so  often  by  surgeons,  but  it  may  follow 
operative  dehveries  from  below — hebosteotomy,  even  natural  deliveries.  Sometimes  an  acute 
dilatation  of  the  stomach  is  at  fault,  and  again  paralysis  of  the  small  intestine  or  occlusion  of  the 
large  bowel.  Bruising  the  bowel  when  the  uterus  is  massaged,  kinking  from  adhesions,  compres- 
sion of  the  ))Owel  by  the  retroverted  uterus  in  the  pelvis,  thrombosis  of  one  of  the  celiac  or  mesen- 
teric arteries,  an  unrecognized  rupture  of  the  uterus,  rupture  of  a  pus-sac,  with  beginning  peritonitis 
— all  these  may  cause  excessive  tympany  and  ileus  postpartum.  Infection  of  the  peritoneum 
from  some  cause  must  always  first  be  tliougiit  of  in  these  cases.  The  diagnosis  is  the  most  impor- 
tant part  of  the  treatment.  If  it  is  decided  not  to  open  the  abdomen,  the  following  measures  may 
ha  tried:  repeated  enemata,  of  which  the  milk  and  molasses  combination,  1  pint  of  each,  is  the 
be-st;  this  may  be  given  with  the  patient  inverted;  turning  the  patient  on  her  stomach;  elevation 
of  the  head  and  shoulders;  .5-grain  asafetida  pills  thrice  daily;  washing  out  of  the  stomach  (very 
u-sefulj;  eserin,  V.j  grain  hypodcrmically  every  four  hovu-s  for  four  doses;  hormonal  hypoder- 
mically;  puncture  of  the  gut  with  a  fine  needle; — while  said  to  be  safe,  to  be  used  only  as  a  last 
resort.     The  same  is  said  of  making  an  intestinal  fistula. 

Fissures  in  ano  are  a  not  infreriuont  complication  of  the  late  puerperium.  Inspection 
rcuflily  reveals  them,  and  stretching  of  (he  spliinclcr  wilh  a  s]K'Culum  and  a  few  applications  of 
10  per  cent,  silver  nitrate  solutic^n  to  the  cracks  as  readily  cure  them.  Oil  enemata  and  free 
action  of  the  howcls  strengthen  the  cure. 

Difficulty  of  Urination. — This  sutjject  has  already  been  touched  upon  (p.  322),  and  here  need 
be  mentioned  only  the  overfilling  of  the  bladder,  with  dril)l)ling  (incontinentia  paradoxa);  over- 
filling with  only  partial  emptying  of  the  bladder  (evid('n(;ed  liy  pain  in  the  belly,  a  displaced  uterus, 
a  soft  tumf)r  ahrn-e  the  pubis,  sometimes  tympany,  anrl  loc:liiostasis  and  fever);  and  the  dribbling 
of  urine  which  comes  through  a  vesical  fistula  or  paralysis  of  the  sphincter  vesicas. 

Exhaustion  psychoses  may  occur  after  prolonged  and  arduous  labors  in  weakened  individuals. 


PART  111 
OPERATIVE  OBSTETRICS 


CHAPTER  LXVIII 
GENERAL  CONSIDERATIONS 

During  pregnancy  and  labor  the  accoucheur's  duty  to  his  patient  is  both 
prophylactic  and  remedial.  After  providing  for  the  gravida  as  described  in  the 
Hygiene  of  Pregnancy,  p.  225,  his  course  is  one  of  watchful  expectancy. 
He  simply  studies  the  processes  of  nature  and  determines  when,  where,  and 
how  he  may  be  of  assistance,  but  he  must  always  bear  this  in  mind,  that  he 
never  can  be  of  "assistance"  unless  something  in  the  course  of  pregnancy, 
laljor,  or  the  puerperium  goes  wrong.  Under  such  circumstances  he  makes  up 
his  mind  that  he  must  interfere.  This  is  the  first;  second,  he  studies  what 
he  must  do,  and  third,  when  he  should  do  it.  That  something  in  the  course  of 
pregnancy,  labor,  or  the  puerperium  which  commands  interference,  or  any  mode  of 
treatment,  is  called  an  ''indication.^'  The  many  features  of  each  obstetric  case 
are  the  factors  which  determine  or  specify  the  nature  of  the  procedure  to  be  insti- 
tuted. We  call  them  ''conditions."  A  condition,  therefore,  is  a  prerequisite  which 
must  l)e  fulfilled  before  the  procedure  demanded  .by  the  indication  may  be  carried 
out.  The  study  of  the  case,  and  the  determination  that  there  is  a  reason  for  the 
adoption  of  a  particular  line  of  treatment,  we  call  "placing  the  indication,"  and 
this  requires  very  delicate  balancing  of  all  the  conditions.  Speaking  broadly,  all 
indications  for  interference  lie  in  the  presence  of  immediate  or  prospective  danger 
to  mother  or  child.  The  conditions  will  be  found  in  the  state  of  the  mother  at  the 
time  of  the  intended  treatment.  Only  when  the  conditions  necessary  for  carrj^ing 
out  the  procedure  are  present  may  we  act,  but  the  indication  may  be  so  strong  that 
we  have  to  "force  the  condition."  For  example,  a  woman  has  eclampsia.  The 
indication  is  to  empty  the  uterus,  but  the  cervix  is  tightly  closed.  A  condition  for 
rapid  delivery  is  an  open  cervix;  therefore  we  must  first  open  the  cervix,  or  choose 
an  operation  which  has  not  this  binding  condition.  A  condition  which  absolutely 
prohibits  a  given  line  of  treatment  we  call  a  "contraindication." 

Selection  of  Operation. — This  will  depend  on  the  indications  and  conditions, 
but  often  there  are  other  considerations,  as  the  skill  of  the  operator,  the  environ- 
ment of  the  patient,  the  religion  of  the  famih',  the  desires  of  tlie  parents.  An 
unskilful  practitioner,  unless  he  can  obtain  competent  comisel,  should  always  do 
that  operation  Avhich  promises  the  greatest  safety  to  the  mother.  If  the  patient 
is  amid  bad  surroundings,  it  may  l)e  necessary  to  sacrifice  the  child,  while  if  she  were 
in  a  good  maternity,  cesarean  section  would  save  both.  A  Catholic  family  does  not 
permit  craniotomy  on  the  living  child,  and  a  husl)and  may  absolutely  demand  that 
his  wife  be  subjected  to  no  added  risks  for  the  sake  of  the  child.  These  points  will 
agam  be  considered. 

Diagnosis. — Before  every  obstetric  procedure  the  accoucheur  must  have  made 
a  careful  general  examination.  He  must  know  the  exact  condition  of  the  kidneys, 
heart,  lungs,  thyroid,  blood,  etc.  Just  before  an  operative  delivery,  with  the  pa- 
57  '  897 


898  OPERATIVE    OBSTETRICS 

tient  on  a  table  and  perhaps  anesthetized,  the  examination  of  the  local  conditions- 
presentation,  position,  attitude  of  the  child,  the  state  of  the  cervix,  etc.,  must  be 
repeated,  because  things  may  have  changed  in  the  time  intervening,  or  the  first 
diagnosis  may  have  been  wrong.  If  the  local  findings  are  different  from  what  was 
expected,  the  original  plan  of  procedure  must  be  dropped  or  altered.  Any  other 
course  which  might  be  taken  to  save  the  accoucheur  trouble  and  mortification 
usuall}'  results  in  more  of  each  for  him,  and  endangers  the  patient.  It  may  be 
wisest  to  put  the  woman  back  in  bed  and  select  an  entirely  different  line  of  treat- 
ment. 

After  the  diagnosis  is  made  and  proved,  the  operator  may  well  rehearse  the  steps 
of  the  operation  in  his  mind  beforehand,  and  take  cognizance  of  the  various  com- 
plications which  are  likely  to  arise.  If  he  will  construct  a  mental  picture  of  the 
conditions  before  him  and  then  do  the  operation,  as  it  were,  "in  the  air,"  before 
the  patient,  he  will  be  surprised  how  much  the  correct  procedure  is  facilitated. 

Assistants. — For  good  surgical  operating  at  least  three  assistants  are  required — 
an  anesthetist,  a  first  assistant,  and  a  nurse  to  hand  instruments.  Most  surgeons 
demand  more  help  than  this,  but  most  accoucheurs  are  satisfied  with  even  less. 
Wh}^  an  accoucheur  should,  voluntarily,  deny  himself,  the  patient,  and  the  baby 
the  benefits  of  sufficient  help  is  incomprehensible.  In  private  practice  it  is  often 
impossible  to  obtain  more  than  one  assistant  to  give  the  anesthetic,  and  the  nurse 
must  do  all  the  rest  of  the  work.  Sometimes  there  is  no  nurse  even,  and  the 
accoucheur  has  himself  to  give  the  anesthetic  while  operating.  If  the  general 
practitioner  would  equal  the  work  done  in  the  maternity  hospitals,  he  must  educate 
the  public  to  allow  him  sufficient  help,  and  it  can  be  done  easier  than  he  thinks. 
Circumstances  are  very  unusual  where  another  physician,  one  or  two  medical 
students,  or  one  or  two  extra  nurses  are  not  obtainable.  It  is  unsafe  to  trust  the 
husband  to  help  or  to  hold  a  light.     He  may  collapse;   further,  it  is  cruel. 

Examination  of  the  Patient  after  Delivery. — I  have  made  it  an  invariable  rule 
to  examine  the  parturient  canal  from  the  fundus  to  the  vulva  and  the  adjacent 
viscera  and  pelvis  after  every  operative  delivery.  The  hand  is  inserted  into  the 
uterus,  palpates  the  placental  site,  removing  adherent  placental  fragments,  decidual 
debris,  membranes,  and  blood-clots,  then  encircles  the  lower  uterine  segment  three 
times,  going  from  right  to  left,  and  three  times  from  left  to  right, — this  in  order  to 
discover  a  slit-like  injury, — then  the  vagina  likewise,  and  then  the  vulva.  Tears 
of  all  degrees  are  carefully  searched  out.  The  pubic  joint  is  palpated,  the  bladder 
catheterized,  and  finally,  after  all  repairs  have  been  made  and  just  before  applying 
the  vulvar  dressing,  the  finger  is  passed  into  the  rectum  to  find  out  if  any  stitches 
have  been  put  through  it  or  if  it  is  otherwise  injured.  The  accoucheur  must  know 
and  record  the  location  and  extent  of  all  the  puerperal  wounds.  Only  by  such 
routine,  thorough,  painstaking  examination  may  a  rupture  of  the  uterus  and  other 
injuries  be  discovered,  and  I  cannot  insist  too  strongly  on  the  adoption  of  this  recom- 
mendation. Under  the  protection  of  sterile  rubber  gloves  and  thorough  antisepsis 
of  the  vulva  and  vagina  the  procedure  is  safe. 

After  operative  deliveries  the  child,  too,  requires  a  careful  gentle  examination 
of  the  head  and  all  its  members.  It  may  not  be  so  easy  to  discover  a  skull  fracture 
or  a  broken  clavicle  as  we  would  like  it  to  be. 

Refiection. — A  most  profitable  procedure  after  it  is  over  is  for  the  accoucheur 
to  revieV  all  the  details  of  his  case  and  what  he  has  done,  considering  the  result, 
and  examine  himself  to  see  if  his  judgment  has  been  good  and  his  technic  perfect; 
then  to  decide  what  he  would  do  in  a  similar  case  or  if  the  same  woman  became 
pregnant  again.  All  these  impressions  should  be  written  on  the  history  card. 
They  will  be  invaluable  for  future  reference  and  also  for  individual  improvement. 

Anesthetic. — The  reader  is  referred  to  the  chapter  on  Anesthesia  in  Normal 
Labor.     For  many  operations  an  anesthetic  is  not  necessary,  though  occasionally 


GENERAL   CONSIDERATIONS  899 

it  is  domandetl  l)y  a  very  a])i)r('li('nsivc  patient.  Such  are  packing  the  cervix  to 
induce  abortion  or  premature  labor,  the  application  of  the  metreurynter,  rupture 
of  the  membranes,  insertion  of  bougies,  vaginal,  even  uterine,  tamponade.  I 
seldom  use  anesthesia  for  ordinary  perineorrhaphies,  but  if  the  tear  is  extensive  or 
tlie  patient  too  nervous,  it  is  necessary.  Curetage  in  aljortions  with  the  finger 
or  the  curet,  and  manual  removal  of  the  ])lacenta,  in  about  half  of  the  cases  may  be 
done  without  narcosis,  and  I  have  several  times  applied  the  forceps  without  it, 
thus  getting  the  assistance  of  the  labor  pains  in  the  delivery.  Occasionally,  for  a 
short  operation,  the  patient  can  be  put  in  a  semi-conscious  condition  and  kept 
there  by  an  expert  anesthetist;  this  is  the  first  stage  of  anesthesia,  and  precedes 
the  one  of  excitement,  and  I  have  often  suggested  analgesia  to  the  patient,  either 
by  words  or  by  giving  whiff's  of  ether.  Increasing  experience  teaches  me  to  avoid 
anesthetics  wherever  possible.  Two  fatal  cases  of  hepatic  cytolysis  and  three 
cases  of  icterus  after  chloroform,  four  serious  ether  pneumonias,  and  several  bad 
bronchitis  cases  have  warned  to  care,  not  to  mention  prolonged  nausea  and  vomiting 
and  the  pain  caused  by  them.  These  three  discomforts  often  are  worse  than  the 
pain  relieved  by  the  drug.  Narcotic  drugs  also  have  a  bad  influence  on  the  child, 
and  I  am  convinced  that  many  of  the  deaths  ascribed  to  asphyxia  are  in  reality 
anesthetic  deaths. 

Ether  by  the  open  or  drop  method  is  my  choice  of  anesthetic  when  one  must  be 
used,  and  many  surgeons  are  coming  to  believe  that  it  is,  after  all,  the  safest.  For 
versions  and  extractions  the  narcosis  must  be  deep  enough  to  abolish  reflexes  and 
quiet  all  muscular  action,  thus  to  allow  the  operator  to  do  his  work  deliberately. 
After  the  child  is  born  the  mask  is  to  be  removed,  and  often  the  operation  may  be 
completed  without  giving  any  more  of  the  drug,  or  it  may  be  resumed  for  the 
cleaning  out  of  the  uterus  or  the  perineorrhaphy. 

In  cases  of  marked  anemia,  in  eclampsia,  in  other  toxicoses,  with  goiter,  in 
Basedow's  disease,  and  in  heart,  lung,  and  kidney  diseases,  in  women  with  marked 
kyphoscoliosis  or  great  abdominal  distention,  all  anesthetics  are  dangerous,  and 
may  be  used  only  with  the  greatest  circumspection.  I  employ  a  specialist  on  anes- 
thesia wherever  possible.  The  practice  of  some  accoucheurs,  unavoidable  in  some 
instances,  of  giving  the  anesthetic  and  performing  the  operation  at  the  same  time 
is  to  be  condemned.  It  is  unfair  alike  to  the  patient,  the  baby,  the  doctor,  and  the 
art  of  obstetrics. 

Nitrous  oxid  and  oxygen  anesthesia  may  be  used  for  l^rief  operations  not 
concerned  with  delivery,  such  as  curetage  in  abortions,  perineorrhaphies,  and 
manual  removal  of  the  placenta.  My  experience  has  been  that  these  operations 
are  rendered  unusually  bloody  by  the  gas.  For  operative  deliveries  I  do  not  recom- 
mend these  gases  because  of  the  initial  anaerosis  and  asphyxia  which  aftect  the  child 
unfavorably. 

Local  anesthetics  are  rarely  usable  in  obstetric  practice,  and  medullary  anes- 
thesia, I  believe,  should  be  discarded  entirely.  Several  cases  of  cesarean  section 
under  local  anesthesia  have  been  reported.  Injection  of  novocain  solution  into  the 
regions  of  the  pudic  nerves,  through  the  vagina,  is  recommended  by  ]Mliller. 

Preparations. — The  manner  of  preparation  for  operative  delivery  in  a  private  home  will  be 
described  a.s  briefly  as  possible.  In  maternities  the  technic  is  identical  with  that  of  major  opera- 
tions, plus  preparation  for  the  complicities  presented  by  the  sudden  accidents  of  delivery  and  the 
attention  required  by  the  baby.  The  principles  of  the  practice  of  asepsi-s  and  antisepsis  are  the 
same  as  in  the  practice  of  surgery,  and  have  already  been  considered.  Fig.  7S0  shows  the  oper- 
ator's dress.  If  there  is  no  one  present  capable  of  resuscitating  the  child,  the  head-piece  must  be 
arranged  to  allow  the  operator  to  use  his  mouth  for  insufflation  of  air  per  catheter  to  the  baby. 
Fig.  330  on  p.  31S  shows  the  dress  of  the  patient  during  delivery.  When  the  woman  is  put  on 
the  operating-table,  the  exposed  area  of  mons,  vulva,  perineum,  to  the  edges  of  the  leggings,  is 
again  thsinfected  with  lysol  solution,  and  1 :  loOO  bichlorid,  a  pair  of  sterile  legging.s  put  on,  and  a 
sterile  towel  laid  over  the  belly.  This  towel  is  frequently  changed  during  the  operation,  and  the 
skin  and  vulva  are  frequently  drenched  with  an  antiseptic  solution.  Even  though  once  sterihzed, 
the  leggings  are  not  touched  by  the  operator.     If  he  does  so  inadvertently,  he  washes  his  hands 


900 


OPERATIVE    OBSTETRICS 


in  the  solutions.     The  assistants  holding  the  legs  wear  gloves.     If  called  upon  to  hold  instruments, 
etc.,  thej^  too  wash  in  the  antiseptic  solutions. 

In  private  home  practice,  although  all  the  sheets,  towels,  leggings,  etc.,  are  sterilized  when 
the}'  have  been  put  on  the  patient,  the  accoucheur  should  touch  them  as  httle  as  possible.  Only 
the  area  immediately  arouml  the  vulva,  which  Jias  been  disinfected  and  is  frequently  drenched  with 
antiseptic  solutions,  ami  the  towel  over  the  abdomen,  are  to  be  considered  sterile,  and  may  be  touched 
by  the  accoucheur.  If  he  will  practise  this  principle  as  a  habit,  he  will  be  able  to  carry  out  the 
most  complicated  obstetric  procedures  amid  the  most  discouraging  surroundings,  with  greatest 
safety.  Our  operating-rooms  err  in  this  regard.  The  sterile  field  of  operation  is  made  too  large. 
The  absolute  sterility  of  the  immediate  site  of  the  operation  and  of  the  instruments,  sponges,  etc., 
which  come  into  it  is  the  bacteriologic  laboratory  idea  of  asepsis,  and,  to  my  mind,  the  correct 
one — certainly  for  private  practice.     If  everything  else  is  considered  infected,  it  is  not  so  hard  for 

the  operator  and  his  assistants  to  preserve  the  asepsis  of  the 
actual  field  of  operation. 

During  the  course  of  the  operation,  especially  if  pro- 
longed, the  vulva  and  thighs  are  frequently  swabbed  with 
antiseptic  solutions — 1:1500  bichlorid  and  1  per  cent,  lysol 
solution.  If  feces  escape  from  the  anus,  they  are  received 
with  the  greatest  care  in  pledgets  soaked  in  bichlorid  solution. 
If  the  rectum  is  very  full,  it  may  be  advisable  to  wash  it 
'^**^.  clean  with  sterilized  saline  solution.     To  try  to  keep  fecal 

,  matter  away  from  the  field  by  holding  a  towel  or  swab  over 

the  anus  is  fatuous — the  feces  are  simply  smeared  all  over 
the  perineum  by  such  procedures.  It  is  best  to  see  what 
becomes  of  the  evacuations,  and  disinfect  the  amis  contin- 
uousl}^  taking  extra  care  during  all  manipulations  not  to 
i  pass  the  hands,  instruments,  or  gauze  near  the  source  of 

j  infection.     After  delivery,  if  much  use  has  been  made  of 

I     """^.,  strong  antiseptics,  it  is  a  good  plan  to  wash  the  parts  with 

sterile  water,  to  prevent  an  eczema. 

Aseptic  technic  is  not  the  final  word  in  the  prevention 
of  infection.  Good  operative  technic,  the  preservation  of 
the  woman's  immunities,  the  prevention  of  shock  and  hemor- 
rhage, proper  selection  of  operation,  etc.,  contribute  as  much 
to  success. 

Preparation  of  Patient  for  Operative  Delivery. 
— If  the  woman  has  not  been  prepared  as  already 
described  on  p.  275,  she  is  gotten  readj^  for  operation 
just  before  the  anesthetic  is  started.  The  operator 
first  sterilizes  his  hands.  The  vulva  is  shaved, 
scrubbed  with  soap  and  water,  the  smegma  under 
the  hood  of  the  clitoris  reinoved  with  oil  or  vaselin, 
and  the  parts  thoroughly  washed  with  both  lysol 
and  bichlorid  solutions.  The  vagina,  too,  is  mopped 
out  with  lysol  solution,  care  being  taken  to  rub 
lightly  and  not  destroy  the  epithelium  too  much. 
In  order  to  prevent  hairs  and  wash-water  dripping 
into  the  vagina  during  the  shaving  and  washing,  a 
large  swal)  soaked  in  antiseptic  solution  is  packed 
into  the  introitus.  After  everything  else  is  disin- 
fected, the  swab  is  removed  and  this  part  and  the 
vagina  are  attended  to.  If  the  patient  had  already 
licen  prepared  for  normal  laloor,  all  that  is  needful 
is  a  thorough  washing  with  the  antiseptic  solutions. 

Painting  the  parts  with  tincture  of  iodin  is  practised  by  some  operators.     In  all 

cases  the  accoucheur  must  lie  sure  that  the  l^ladder  is  empty. 

Arrangement  of  the  Room. — Fig.  781  is  a  diagram  of  a  room  in  a  private  home, 

and  Fig.  782  siiows  the  arrangement  of  tallies,  etc. — a  plan  which  is  in  daily  use 

by  the  author. 

Provision  for  good  light  is  essential.     An  acetylene  bicycle  lamp  or  the  lamps 

from  an  automobile  I  have  many  times  found  useful. 

The  kitchen  or  library  table  makes  an  excellent  operating-table,  and  should 

always  be  used.     It  is  unfair  to  the  woman,  the  baby,  and  the  doctor  to  operate 


Fif!.  780.— GAnn  ron  OnsTExnic  or  Sur- 
gical Ol'KUATIONS. 
T.f>ni.'  t'.'intlit  triovgs,  hoad  and  month  and 
nose-piece. 


GENERAL   CONSIDERATIONS 


001 


on  a  wonum  lyin.a;  across  the  bed.     When  the  sui-^cons  do  apjx'iKlcctoiiiios,  and  the 
gynecologists  vaginal  hysterectomies,  witii  the  patients  lying  in  their  beds,  it  may 

l)c  jiislifialilc  lo  pci-ronii   ohslcti-ic  opci-atioiis   in  such    fashion.     I  have  personal 


WINDOW 


BASKtl 

f  OR     BAB* 


0 

0 

W  I  N  D  O  VV 


DOUCHi   BAC, 


CHAIR  ^ 

CATMIT 
TAPE 


I  R  WITH  FORCtPS 


KITCHEN 

TA8LL 


DRESSER 


VESSEL 
UNDER     BED 
FOR    PLACENTA 


BE  D 


ANESTHETlZEn 


EAL    CATHETER 


HOT  WATE  R 


BATH 

FOR    BABY 


I'itL     (61. DlAClKA.M    OF    KouM    AkhaNGED    FOR    OPERATION. 


Fig.  7'^2.  —  Ai;a  iN-GEMEXT,  t^siNc.  KiTrHFN'  Tablk  for  Obstetric  Operations  at  Home. 
Sewing  tabic  to  kll  i  ;iriirs  basin  of  lysol  solution,  bowl   of  bichlorid,  saucer  with  sci.-^sors,  artery  clamp,  and  tape 
for  cord,  and  pitcher  of  hot  sterile  water.     A  newspaper  is  folded  into  the  shape  of  a  Kelly  pad  and  does  excellently. 
Table  to  right  carries  pan  of  instruments,  pile  of  sterile  towels,  jar  of  sterile  cotton  swabs,  jar  of  sterile  silkworm-gut 
and  catgut. 


knowledge  that  many  babies  have  been  lost,  that  several  women  have  been  killed, 
and  many  more  permanently  damaged,  l^ecause  the  accoucheur  did  not  discard 
this  medieval  practice  and  put  his  patient  on  a  proper  operating-table.     It  stands 


902 


OPERATIVE    OBSTETRICS 


to  reason  that  better  work  can  be  done  on  the  table,  and,  further,  the  dignity  of  the 
specialty  of  obstetrics  is  concerned.  Even  the  specially  constructed  obstetric  beds 
do  not  possess  the  advantages  of  a  table. 


/' 


i 


Fig.  783. — Patient  Posed  for  Operative  Delivery.     Assistants  Holding  Legs. 


Fio.  7S4. — Patient  Arranged  for  Operative  Delivery  With  Sheet  Sling  to  Hold  Legs  when  Short  of  Help. 
Note  sheet  tied  below  knee  and  drawn  over  shoulder. 


Posture  of  Patient. — In  America  and  in  Continental  countries  the  parturient 
is  always  placed  on  the  back  for  operative  delivery  or  other  obstetric  operation. 


GENERAL    CONSIDKKATK^NS 


003 


England  alone  uses  the  side  position,  hut  less  now  than  roiiiicrl>'.  Ken-  uses  il 
only  for  low  forceps  oi)erations.  Fig.  783  shows  the  most  convenient  posture. 
In  cases  of  shoulder  presentation,  or  in  breech,  when  it  is  desired  to  get  the  present- 
ing part  away  from  the  inlet,  the  head  of  the  table  may  be  lowered,  as  described  by 


Fig.  785. — Author's  Operation  Telescope. 


Richardson,  a  combination  of  lithotomy  and  Trendelenburg  positions.  In  some 
cases  it  is  necessary  to  turn  the  woman  on  her  side  for  a  few  minutes — for  example, 
to  grasp  the  anterior  foot  in  back-posterior  shoulder  presentations.  The  woman's 
leg  then  is  simply  lifted  over  the  head  of  the  operator,  and  replaced  after  he  has 


Fig.  7S6. — Afthor's  Portable  Sterilizer,  Readv  for  Stove,  with  Ivstrcments  in  Pan.  Sheets  and  Towels  in 

Upper  Compartment. 


grasped  the  foot.  A  few  operations — replacement  of  cord,  disentanglement  of 
locked  twins — are  performed  with  the  patient  in  the  knee-chest  position,  and  I 
have  operated  on  several  women,  pulseless  from  hemorrhage,  with  the  body  sus- 
pended head  dowTi  from  the  shoulders  of  two  assistants.  The  ease  ■v\'ith  which 
version  can  be  done  in  this  posture  is  surprising.     Walcher's  position  (Fig.  655)  is 


904 


OPERATIVE    OBSTETRICS 


used  to  aid  the  passage  of  the  head  through  the  inlet,  and  the  exaggerated  lithotomy 
when  it  is  jDassing  the  bony  outlet  (Fig,  495,  p.  571). 

Instrumentarium. — In  city  and  town  practice  it  is  not  required  to  take  to  the 
labor  case  a  complete  obstetric  outfit.  The  satchel  shown  on  p.  270  meets  all  the 
demands  of  the  usual  labor  and  the  operations  most  commonly  performed.  If  a 
high  forceps  or  a  version,  or  the  care  of  placenta  prsevia,  eclampsia,  etc.,  is  to  be 
attempted,  or  if  the  woman  lives  far  from  the  operator's  base  of  supplies,  a  complete 
obstetric  armamentarium  must  be  at  hand,  and  such  an  outfit,  if  the  accoucheur 
wishes  to  be  abreast  of  the  times  and  give  his  patient  the  benefit  of  his  art,  must  be 
an  extensive  one.  Fig.  785  shows  the  author's  obstetric  bag  for  operative  cases, 
and  Fig.  786,  the  portable  sterilizer.     The  instruments  are  packed  in  the  pan  of  the 


Fig.   787. — Author's  Portable   Sterilizer,  Showing  Parts. 
The  pan  is  telescoped  in  the  tray. 

sterilizer;  the  other  articles  are  arranged,  without  any  especial  order,  in  the  upper 
compartment  of  the  telescope.  I  have  found  it  impracticable  to  have  special  cases 
and  compartments  made  for  each  article — the  satchel  is  complicated  enough  without 
them.  The  instruments  may  be  divided  into  sets  for  perineorrhaphy,  for  forceps, 
for  craniotomy,  and  wrapped  in  separate  towels. 


List  of  Articles  in  Telescope 

1  complete  operating  dress,  trousers,  sterile  gown,  head-piece. 
4  pairs  sterile  rubber  gloves,  long  and  short. 

2  sterile  hand-bryshes. 

2  jars  sterile  antiseptic  gauze,  one  piece  12  yards  and  one  8  yards  long. 
4  jars  sterile  cotton  and  gauze  swabs. 

4  ounces  French  gelatin,  or,  better,  2  ampules  Merck's  sterile  gelatin. 
1  douche-can  with  sterile  rubber  tube  and  salt  solution  needle. 

3  tracheal  catheters,  2  rubber  catheters. 

1    box    containing    ampules    of    sterile    epinephrin    solution,   pituitrin, 

aseptic  ergot,  hypodermic  digitalis  and  veratrum. 
1  glass  hypodermic  syringe — to  be  boiled  for  cesarean  section. 


GENERAL   CONSIDKHATKJNS  90o 

1  sac  containing  a  small  ])ottle  of  fluiclextract  of  ergot;  a  vial  witli  tapes 
for  the  cord  (sterile);  a  vial  of  bichlorid  tablets;  four  ounces  of 
liquor  cresolis  compound  (lysol);  a  vial  of  sodium  bicarbonate  or 
borax  (for  boiling  instruments);  a  glass,  screw-cap  bottle  of  sterile 
silkworm-gut  in  1:500  bichlorid  solution;  a  bottle  of  2o  per  cent, 
argyrol  solution  or  1  per  cent,  silver  nitrate;  a  baby  scale,  and  a  tape- 
measure. 

1  dozen  tubes  of  sterile  chromicized  catgut,  Nos.  1  and  2. 

2  cans  of  ether.     One  glass  ampule  of  chloroform.     A  mask.     A  stetho- 

scope. 
1  set  of  history  sheets  for  the  nurse.     Labor  cards  and  birtli-certilicates. 

List  of  Instruments 
1  pelvimeter  and  1  cephalometer. 
1  sac  containing  a  set  of  Voorhees'  rubber  bags,  all  sizes,  2  Carl  Braun 

colpeurynters,  2  large  Miiller  bags  (like  Voorhees',  but  larger),  and 

a  bulb  syringe  with  metal  joints. 
1  Bossi  dilator  (optional). 

3  obstetric  forceps.     One  small  one  for  little  babies,  the  ordinarj^  Simpson 

forceps,  and  the  same  with  longer  shanks  for  high  operations,  or  an 

axis-traction  instrument. 
8  long  pedicle  clamps;   2  angular  clamps. 
8  ordinary  artery  forceps. 
3  needle-holders — one  long. 

1  scalpel. 

3  scissors. 

4  retractors — various  sizes. 
3  tissue  forceps. 

2  ring  forceps  for  cervix. 

2  bullet  forceps  for  cervix. 

2  double  vulsellum  forceps  for  cervix. 

1  box  needles. 

1  uterine  packing  forceps. 

1  embryotomy  set,  comprising  cranioclast,  1  perforator,  1  trephine,  1  heavy 

scissors,  1  bone  forceps,  1  decapitation  hook,  and  1  blunt  hook. 
1  heljosteotomy  set,  comprising  1  special  needle,  3  Gigli  saws,  2  handles 

for  same,  1  long  curved  needle,  1  raspatorium,  and  1  flat  director. 

Previous  to  operation  the  instruments  required  are  boiled  for  ten  mmutes  in 
a  1  per  cent,  soda  or  borax  solution  in  a  covered  vessel.  This  absolutely  sterilizes 
them,  and  the  operator  serves  himself  with  them  from  the  open  trays  on  the  table 
beside  him. 

Provision  for  Complications. — It  is  wise  at  all  times  to  make  preparations  to 
comliat  postpartum  hemorrhage  and  asphyxia  of  the  child.  For  the  former,  the 
nurse  will  have  the  douche-ljag  sterilized,  filled,  and  covered,  ready  for  instant  use, 
and  the  accoucheur  will  have  a  supply  of  sterile  gauze  and  instruments  for  lacera- 
tions and  for  packing.  For  the  child,  an  appropriate  place  is  provided  to  laj'  it, 
with  the  tracheal  catheters,  warm-water  bags,  towels,  and  a  hot  bath  close  at  hand. 

Just  before  the  operation  the  accoucheur  surveys  the  room  to  see  if  everything 
is  in  readiness — as  a  general  surveys  the  field  of  battle. 

Care  of  Feces  Issuing  from  the  Anus. — This  is  a  very  unwelcome  complication 
of  any  obstetric  operation,  because  it  requires  the  most  constant  watchfulness  and 
the  greatest  dexterity  to  avoid  transporting  the  infectious  material  into  the  geni- 
tals. Sometimes  the  feces  contain  only  saproph}i:ic  and  harmless  organisms — a 
fact  which  is  proved  by  the  rarity  of  serious  infections,  when  we  know  how  often 


906 


OPERATIVE    OBSTETRICS 


fecal  matter  is  brought  into  the  vagina,  but  occasionally  the  Streptococcus  pyogenes 
and  the  gas  bacillus  in  virulent  condition  exist,  and  fatalities  in  considerable  number 
are  on  record.  Measures  should  have  been  instituted  beforehand  to  provide  for 
such  a  contingency,  that  is,  a  cathartic  administered  early  in  labor,  and  an  enema 
given  to  wash  the  lower  bowel  clean.  If  labor  lasts  several  days,  these  are  repeated 
— ^taking  care  that  it  be  not  too  shortly  before  delivery. 

If  the  bowels  move  as  the  operation  is  begun,  the  rectum  should  be  emptied 
by  squeezing  out  its  contents  from  the  vagina,  using  two  fingers.  I  prefer  not  to 
irrigate  the  rectum  with  sterile  water  unless  the  head  is  well  down  in  the  pelvis  and 
blocks  the  further  do^\^lpour  of  fecal  matter.  Hard  feces  are  easier  to  manage  than 
spattering  liquids.     After  the  rectum  is  emptied  a  pack  of  sterile  gauze  may  be 


Fig.  788. — Method  of  iNTRODrcisi;  Hand  to  Avoid  Contamination  from  Feces. 


inserted  temporarily,  but  only  until  the  presenting  part  comes  down  onto  the  per- 
ineum. Then  it  is  to  be  removed,  otherwise  the  bowel  will  be  injured  during 
delivery.  For  the  same  reason  a  suture  around  the  anus  is  hazardous.  The  anal 
region  must  be  constantly  inspected  during  the  delivery,  and,  as  feces  exudes,  it  is 
carefully  received  in  wet  antiseptic  gauze  or  cotton,  the  parts  then  being  liberally 
drenched  with  1:  1500  bichlorid  and  1  per  cent,  lysol  solutions.  Whenever  the 
hand  is  inserted  into  the  vagina,  it  is  passed  from  above  under  the  pubic  arch, 
the  possibility  of  contamination  being  always  kept  in  mind  (Fig.  788).  To  try 
to  preserve  asepsis  by  fastening  a  towel  or  pad  over  the  anus  is  illusory — the  feces 
being  thus  simply  plastered  all  over  the  perineal  region  from  the  inside  of  the 
cloth,  even  damming  back  up  into  the  vulva. 


CHAPTER  LXIX 
PREPARATORY  OBSTETRIC  OPERATIONS 

Opening  the  Cervix. — Tiie  state  of  tlic  cervix  is  a  condition  which  governs  the 
indications  of  most  obstetric  operations.  In  eclampsia,  placenta  prtevia,  and  all 
diseases  tlemantling  immediate  emptying  of  the  uterus  the  state  of  the  cervix  has 
a  guiding  influence  in  the  choice  of  procedure.     We  have  many  methods  of  gaining 


Fig.  789. — Unobliterated  Cervix. 
A  laceration  at  this  time  endangers  vessels  and  peritoneum. 


Fig.  790. — Shows  Vessels  and  Peritoneum  Retracted  away  from  Ordin.\.p.y  Danger. 

access  to  the  uterus— some  slow,  some  rapid.  The  slow  ones  are  those  which  call 
the  uterus  into  action  to  aid  in  the  dilatation,  and  the  process  resembles  natural 
labor  more  closely.  Packing  the  cervix  and  metreurysis  are  slow  operations,  but 
in  some  of  the  more  rapid  ones  uterine  action  also  aids  the  process  in  a  marked 
degree,  as  in  manual  dilatation  and  the  emplojuient  of  the  Bossi  dilator.  The 
following  operations  are  clone  to  open  the  cervix:  Packing  the  cervix  and  lower 
uterine  segment  -uith  gauze ;  manual  or  digital  dilatation ;  metreurysis ;  mechanical 
dilatation  vrith  metal  instruments;    radiating  incisions  in  the  cervix;   vaginal  ce- 

907 


908 


OPERATIVE    OBSTETRICS 


sarean  section.  Which  of  these  methods  will  be  the  one  selected  will  depend — (1) 
On  the  condition  of  the  cervix,  whether  it  is  tightly  closed,  or  already  more  or  less 
effaced  or  shortened  or  drawn  up  into  the  body  of  the  uterus;   (2)  on  the  urgency  of 


Fig.  791. — Uterixe  Packing  Tube  for  Use  After  the  Sixth  Month. 
The  tube  has  a  lumen  |  inch  across.     Gauze  3  inelies  wide  or  a  knit  bandage  is  used  for  packing.     It  is  sterilized 
as  described  in  the  Appendix,  and  preserved  in  hermetically  sealed  bottles.     It  is  served  directly  from  the  bottle. 
Smaller  tubes  and  narrower  gauze  are  used  for  abortion  cases. 

the  case  and  the  nature  of  the  complication  demanding  the  interference;    (3)  on 
the  skill  of  the  operator;    (4)  on  the  environment  of  the  patient. 

It  is  of  greatest  importance  to  distinguish  between  a  cervix  that  is  already 


Fio.  792. — Packing  Lower  Utekink  Segment  and  Cervix  for  Induction  of  Labor. 
CatchinK  the  end  of  the  gauze  strip  from  the  Ijottle,  which  is  held  near  the  vulva,  by  means  of  the  trident  plunger, 
the  gauze  is  pushed  the  whole  length  of  the  tube.  Now,  under  the  guidance  of  the  two  fingers,  placed  in  or  against  the 
cervix,  the  tube  is  inserted  into  the  lower  part  of  the  uterus.  With  short  in-and-out  strokes  of  the  plunger  the  gauze 
is  depo.sitcd  above  and  in  the  cervical  canal,  taking  care  to  distribute  it  evenly  and  not  to  rupture  the  membranes. 
This  is  easily  accomplished  by  moving  the  end  of  the  tube  in  circles  and  retracting  it  as  the  cavity  fills  up.  From  three 
to  five  yards  may  be  inserted.     In  most  cases  the  vagina  need  not  be  plugged.     It  is  occasionally  needed  in  abortions. 


effaced  or  obliterated  and  one  that  has  not  been  at  all  taken  up,  and  also  to  know 
how  far  the  process  has  advanced.  During  the  effacement  and  dilatation  of  the  cer- 
vix the  pelvic  connective  tissue  is  drawn  up  out  of  the  pelvis ;  the  bladder  is  drawn 
up,  and  its  attachment  to  the  cervix  loosened  and  displaced  upward,  the  ureters  going 


PREPARATORY   OBSTETRIC    OPERATIONS 


909 


with  it;  tlic  pcritoncuin  is  (■lc\'at('(l;  the  broad  li{i;ament!s  unfolded;  and  the  large 
vessels  at  the  sides  of  the  uterus  raised  up  and  retracted,  sometimes  even  above  the 
brim.  This  means  that  those  important  structures  are  removed  from  the  pelvis, 
where  \\\oy  are  sul).ioct  to  injury  from  l)elo\v  (Fi<j;s.  789  and  790).  In  primipara? 
this  unfoldinti;  of  the  cervix  may  occur  to  some  extent  in  the  hist  weeks  of  i)re{i;nancy, 
and  is  sometimes  accompanied  by  fuj>;itive  labor  pains,  and  this  is  also  true  of  multi- 
para), in  whom  there  is  an  additional  softness  of  the  tissues.  Artificial  opening  of 
the  cervical  canal  is  easiest  in  the  last  weeks  of  pregnancy,  but  even  then  there  is 

CERVIX 


Fig.  793. 


-Dilating  Effaced  Certix  with  Finger!?. 
Illustrates  wedge  action. 


danger  of  deep  lacerations,  and  the  more  nature  has  opened  the  cer^dx,  the  less  the 
accoucheur  has  to  do. 

Packing  the  cervix  is  sho\Mi  in  Fig.  792.  It  ma}^  be  employed  to  start  labor 
(Hofmeier,  1888),  to  induce  abortion  (AYyder,  1888),  to  soften  and  cUlate  the 
cervix  preparatory  to  the  insertion  of  a  colpeur\'nter,  and  to  stimulate  flagging 
labor-pains  in  the  first  stage.  Ordinarily,  if  not  already  present,  pains  come  on 
within  eight  hours,  but  sometimes  not  for  twenty-four,  when  the  first  packing  is 
removed  and  another  inserted,  if  needed,  or  other  methods  adopted.     This  simple 


910 


OPEEATIVE    OBSTETRICS 


operation  may  be  done  when  the  cervix  is  closed.  Anesthesia  is  rarely  required. 
I  have  never  found  it  necessary  to  use  a  metal  dilator  after  the  sixth  month  to  procure 
enough  dilatation  to  pass  the  tube,  of  which  there  are  several  sizes,  with  gauze  to 
fit.  It  may  be  done  safely  at  home.  It  is  not  useful  in  urgent  cases  nor  in  placenta 
prsevia.  The  dangers  are  infection  (which  can  be  avoided),  rupture  of  the  mem- 
branes, which  may  allow  prolapse  of  the  cord,  separation  of  the  edge  of  the  placenta 
if  situated  near  the  internal  os,  and  air-embolism.  The  latter  may  be  avoided  by 
holding  the  labia  spread  apart  by  the  fingers  and  the  instrument,  by  packing  slowly, 
and  having  the  shoulders  of  the  patient  raised.  Separation  of  the  edge  of  a  lowly 
inserted  placenta  occurred  once  in  the  very  many  cases  in  which  I  have  thus  packed. 
It  was  evidenced  by  a  slight  flow  of  pure  blood.  I  put  no  more  gauze  into  the 
uterus,  but  packed  the  cervix  tightly,  and  the  result  was  good.  Rupture  of  the 
membranes  occurred  several  times  without  bad  results — indeed,  labor  seemed  has- 
tened.    Vaginal  tamponade  was  described  under  Abortion  {q.  v.). 

Manual  Dilatation  of  the  Cervix. — This  is  the  oldest  method  of  enlarging  the 

CERVIX 


Fig.  794.- 


-DiLATiNG  Effaced  Cervix  with  Fingers. 
Shows  double  fulcrum  action. 


canal,  and  is  spoken  of  in  Hippocrates'  writings.  It  is  the  method  most  naturally 
adopted,  but  the  ancients  also  possessed  pronged  instruments  operated  by  screws. 
Pare,  in  the  forced  operative  delivery,  which  he  so  much  practised,  and  to  which 
his  pupil,  Guillemeau,  gave  the  name  "accouchement  force,"  began  with  digital 
dilatation  of  the  cervix.  First  one  and  then  two  fingers  are  insinuated  through  the  os. 
The  two  fingers  may  be  then  spread  by  one  or  two  fingers  of  the  other  hand  forced 
between  them  like  a  wedge  (Fig.  793).  After  the  tips  of  four  fingers  are  introduced 
they  are  placed  back  to  back,  the  knuckles  acting  like  a  double  fulcrum,  and  the 
cervical  ring  is  thus  expanded.  This  is  similar  to  the  methods  devised  by  Bonnaire 
and  Edgar.  P.  Harris  inserts  the  whole  hand  into  the  vagina,  and  the  cervix  is 
dilated  by  the  insinuation  into  it  of,  successively,  one  finger,  the  thumb  and  one 
finger,  then  two,  then  three  and  four,  and  finally  the  hand,  the  thumb  being  given 
a  motion  of  extension,  the  fingers  one  of  flexion.  The  only  advantage  this  method 
has  over  the  others  is  that  the  hand,  being  in  the  vagina,  is  not  so  easily  contami- 
nated by  feces  issuing  from  the  anus,  but,  by  raising  the  hands  toward  the  pubis 
in  the  performance  of  the  operation  illustrated  above,  this  danger  may  be  avoided. 


PREPARATORY    OBSTETRIC    OPERATIONS 


911 


It  is  essential  to  procure  coiiiijlctc  opening  of  tlie  canal,  otherwise  llie  delivery 
of  the  chikl  whicli  follows  may  be  difficult  or  impossible,  and  during  the  fruitless 
attempts  at  extraction  the  undilatcd  uterus  may  rupture  or  the  child  die  or  be  se- 
verely injured.  The  conditions  for  manual  dilatation  of  the  cervix  an;:  The  cervix 
must  be  effaced,  or  very  nearly  so;  the  pelvis  normal;  the  child  normal  in  size, 
and  the  presentation  and  position  favorable  or  corrigible.  The  placenta  may  not 
1)6  praivia.  The  vagina,  too,  must  be  dilatable,  or  is  to  be  enlarged  by  episiotomy. 
Unless  performed  under  these  conditions,  the  operation  is  dan^enjiis  and  may  fail 
of  its  puri)ose.  It  recjuires  from  one  to  three  hours,  and  is  often  painfully  tiring  to 
the  fingers  and  hands.  It  is  invariably  attended  by  lacerations  of  the  cervix,  and 
these  tears  are  often  deep,  sometimes  even  of  the  importance  of  a  rupture  of  the 


1,  Hirst's;    2,  Braun's; 


Fig.  "Oo. — Various  Balloon  Dilators. 
•3,  Champeticr  cle  Ribcs';    4,  Voorhces';    5,  Stowe's;    G,  Barnes'; 
9,  Chassagny's. 


Pomeroy's;    S,  Tarnicr's; 


uterus,  opening  the  peritoneal  cavity,  causing  death  from  hemorrhage  or  from 
infection.  In  multiparae  the  lacerations  are  usually  somewhat  less  extensive. 
In  all  cases  the  cervix  is  bruised  and  battered,  and  infection,  even  in  the  hands  of 
the  cleanest  obstetrician,  is  sometimes  unavoidable.  In  truly  exceptional  cases 
the  cervix  is  so  soft  that  it  may,  within  fifteen  to  thirty  minutes,  he  dilated  large 
enough  for  safe  delivery. 

Metreurysis. — Flisloric. — In  1S51  Carl  Braun  invented  the  colpeurynter,  a  rubber  balloon  to 
be  distended  with  fluid  after  being  placed  in  the  vagina.  For  a  long  time  previously  Chiari,  Wellen- 
bergh,  and  others  had  used  pigs'  bladders  for  this  purpose,  but  discarded  them  because  they 
decomposed.  In  1SG2  Tarnier  invented  the  "dilatatem-  intrauterin,"  a  soft-rubber  bag  or  condom 
on  the  end  of  a  male  catheter.  Barnes,  in  1S62,  introduced  the  soft-rubber  fiddle-shaped  bags, 
which  are  not  used  any  more.  In  18SS  Champetier  de  Ril^es  recommended  a  large,  cone-shaped, 
inelastic  bag,  and  since  then,  among  the  numerous  modifications  that  have  been  proposed,  the 
use  of  cloth  bags,  rendered  impermeable  by  rubber,  has  ah-eady  superseded  the  old  colpeurynter 
of  Braun.     Schauta,  in  1883,  published  the  use  of  the  bag  in  the  uterus,  as  practised  in  Spaeth's 


912 


OPEEATIVE   OBSTETRICS 


clinic.  Maurer,  in  1887,  introduced  constant  traction  on  the  bag  as  a  means  to  hasten  its  action. 
In  1907  Stowe  invented  a  bag  shaped  hke  the  Voorhees  bag,  but  with  a  tube  leading  through  its 
center,  through  which  sterile  salt  solution  can  be  injected  into  the  uterus  to  replace  lost  liquor 
amnii,  an  idea  suggested  several  years  before  by  Bauer  to  the  BerUn  Medical  Society.  Of  all  the 
bags  on  the  market,  I  have  found  those  of  Voorhees,  in  four  sizes,  and  the  large  ones  of  the  same 
shape  sold  in  Europe  under  the  name  of  Mliller,  the  best,  but  on  some  occasions  I  still  use  the 
Carl  Braim  colpeurynter.  Since  the  bag  is  usually  placed  in  the  uterus,  the  name  hystreurynter 
or  metreurynter  is  better.  The  bags  are  filled  wth  water  and  boiled  in  plain  water  for  thirty 
minutes,  then  laid  in  1  per  cent,  lysol  solution,  with  which  they  are  to  be  filled  for  apphcation. 

The  method  of  application  of  the  hydrostatic  bag  has  been  minutely  described 
on  p.  455,  in  the  Treatment  of  Placenta  Prsevia  {q.  v.).  Some  operators  prefer 
to  pass  the  bag  by  sight  (Fig.  796),  believing  that  thus  it  is  easier  to  avoid  carrying 
infection  from  the  vagina  into  the  uterus.  The  perineum  is  retracted  by  a  speculum, 
the  cervix  is  steadied  by  a  ring  forceps,  and  the  folded  bag  is  gently  insinuated  into 


Fig.  700. — Passixg  CoLPErHYNTER  by  Sight. 


and  through  the  canal,  in  the  direction  of  one  of  the  sacro-iliac  joints,  taking  due 
notice  of  the  curves  of  the  canal.  Force  may  not  be  used,  and  it  is  best,  in  the 
absence  of  special  indication,  to  preserve  the  membranes.  Such  special  indications 
are  eclampsia,  in  which  it  has  been  noticed  that  the  convulsions  often  cease  after 
the  liquor  amnii  has  l)een  let  off,  polyhydramnion,  twins,  and  other  conditions  of 
overfilling  of  the  uterus,  and  placenta  pnevia,  in  order  to  place  the  bag  on  top  of 
the  placenta. 

If  time  is  no  object,  traction  is  not  applied,  but  if  the  pains  are  slow  in  coming, 
a  weight  of  one  or  two  pounds  may  be  attached  to  the  tube.  After  the  first  bag  is 
expelled  a  larger  one  may  be  applied,  the  membranes  punctured,  or  the  labor  left 
to  nature,  depending  on  the  exigencies  of  the  case. 

The  action  of  the  metreurynter  is  three-fold :  First,  it  mechanically  dilates  the 
cervix  from  above  downward  like  a  fluid  wedge,  in  which  respect  it  closely  resembles 
the  bag  of  waters;  second,  by  its  presen(;e  and  by  the  dilatation  of  the  uterus  which 
its  increased  volume  causes,   but  particularly  by  pressure  on  the  retrocervical 


PREPARATORY    OBSTETRIC    OPERATIONS  913 

ganglion,  the  uterus  is  stiiuulalcd  to  action,  and  slrou;:!;  ])uins  arc  usually  soon 
inau{i;urat('(l.  Third,  it  nuiy  be  used  as  a  taiii])on,  as  in  cases  of  placenta  prasvia, 
etc.  The  selection  of  the  ha^  will  depend  on  the  object  sought,  and  if  rapid  action 
is  desired,  the  inelastic  l^ag  with  traction  \\dll  more  quickly  evoke  pains  and  dilate 
the  uterus  than  the  soft-rubber  colpeurynter,  which,  under  traction,  is  likely  to 
pull  out  into  a  sausage  shape  and  slip  through  the  poorly  dilated  cervix.  If  it  is 
simply  desircMl  to  evoke  pains,  as  in  the  induction  of  labor,  either  bag  may  be  used 
without  traction,  or  with  a  minimum  amount  of  it.  As  a  tampon  in  the  vagina,  the 
soft  colpeurynter  is  preferred;  in  the  treatment  of  placenta  prtevia,  the  Voorhees' 
conic  inelastic  bag.  Early  in  pregnancy,  and  in  the  late  months,  just  to  inaugu- 
rate uterine  action,  a  small-sized  bag  is  employed. 

Indications. — Metreurysis  is  very  useful  for  the  induction  of  premature  lal^or 
where  great  urgency  is  not  present,  though  sometimes,  if  traction  is  put  on  the  tube 
and  the  parts  are  not  too  rigid,  the  pains  start  up,  and  they,  together  with  the  mechani- 
cal dilatation,  open  the  uterus  in  a  few  hours.  Whenever  there  is  an  indication  to 
hasten  tlelivery  in  the  interests  of  the  mother  or  child,  the  bag  may  be  used,  and  to 
prepare  the  cervix  or  the  vagina  for  rapid  delivery,  as  in  breech,  shoulder,  or  face 
presentation,  or  in  the  presence  of  threatening  complications,  they  are  often  inval- 
uable. In  stenosis  of  the  cervix  the  bags  may  be  useful,  but  they  require  the  aid 
of  the  pains  to  soften  the  parts.  A  sluggish  uterus  may  be  stimulated  by  the  met- 
reurynter, but  it  is  wise  to  find  out  the  cause  of  the  w^eak  pains — rigidity  of  the  cervix, 
abnormal  adherence  of  the  membranes,  overdistention  of  the  uterus,  pendulous 
belly,  low  placenta — all  these  may  require  other  treatment.  In  cases  of  dry  labor 
the  bags  deserve  more  general  application,  since  they  replace  the  bag  of  waters  to  a 
considerable  extent.  In  shoulder  presentation,  to  preserve  what  is  left  of  the  liquor 
amnii  and  to  keep  the  presenting  part  from  impaction  in  the  pelvis,  the  met- 
reurynter should  be  applied  and  complete  dilatation  awaited.  In  contracted  pelvis, 
where  spontaneous  dehvery  is  to  be  expected,  a  bag  is  to  be  applied  if  the  membranes 
rupture  prematurely.  Generally  speaking,  metreurysis  is  useful  when  the  bag  of 
waters  ruptures  before  complete  dilatation  has  been  effected.  In  prolapse  of  the 
cord  the  hystreurynter  is  of  great  value.  Perhaps  the  most  valuable  function  of 
the  metreurynter  is  as  a  plug  in  cases  of  placenta  prsevia.  While  properly  not 
belonging  here,  it  may  be  mentioned  that  the  colpeurynter  is  useful, — placed  in  the 
vagina,  to  prepare  the  vagina  and  pelvic  floor  for  rapid  delivery,  as  in  breech  pres- 
entation, forceps,  version,  and  extraction;  to  overcome  rigidity  of  the  soft  parts; 
to  stimulate  pains;  and,  during  pregnancy,  to  lift  up  a  retroflexed  uterus,  to  raise  a 
uterus  that  may  be  causing  hj^Deremesis,  and  in  the  treatment  of  pyelo-ureteritis. 

Conditions. — The  cervix  must  Ije  open  enough  to  insert  the  size  of  bag  desired. 
Rarely  is  it  necessary  to  use  metal  dilators  first.  Packing  the  cervix  with  gauze 
for  twelve  hours  usually  suffices  to  render  it  soft  and  dilatable.  Cervical  carcinoma 
and  threatened  uterine  rupture  contraindicate  the  operation.  In  the  presence  of 
vaginal  infection  some  other  plan  should  be  selected,  if  possible,  such  as  puncture 
of  memliranes,  vaginal  cesarean  section,  even  the  Porro  operation. 

Dangers  and  Disadvantages. — In  a  few^  cases  the  uterus  does  not  respond,  the 
bag  is  not  expelled,  and  traction,  within  the  limits  of  safety,  does  not  open  the  cervix. 
Sometimes  traction  brings  one  bag  after  another  through,  but  the  uterine  action 
does  not  come  into  play  and  the  cervix  closes  up  again.  Several  cases  are  recorded 
where  pregnancy  continued.  Oftener  the  repeated  manipulations,  which  in  some 
cases  may  extend  over  a  period  of  five  or  more  days,  causes  fever  (infection),  and 
then,  unless  the  pains  come  on  strongly,  a  formidable  condition  is  presented  for 
treatment.     Such  torpor  of  the  uterus  is  rare. 

The  metreurynter  may  displace  the  presenting  part,  but  this  usually  is  not 
midesirable,  since  often  version  is  in  contemplation.     Prolapse  of  the  cord  is  a  real 
danger.     In  spite  of  close  watching  and  care  this  happened  in  two  of  my  cases,  and 
5S 


914 


OPERATIVE    OBSTETRICS 


in  one  I  lost  the  infant  because  of  it.  The  danger  of  infection  is  nil — with  proper 
precautions.  Three  cases,  one  fatal,  of  air  embolism  from  bursting  of  the  bag  are 
reported.  A  liquid  should  have  been  used  for  filling.  Rupture  of  the  uterus  has 
been  reported  in  11  instances,  but  in  several  of  them  the  extraction  of  the  child 
through  an  insufficiently  dilated  passage  was  probably  the  real  cause.  In  the 
others  excessive  softness  of  the  cervix  was  a  factor — placenta  prsevia,  nephritis. 
In  my  case,  a  primipara  aged  thirty-eight  with  placenta  prsevia,  the  bag  evoked 
such  tumultuous  pains  that  it  ruptured  the  uterus,  the  woman  dying  of  internal 
hemorrhage.  If  too  much  traction  is  put  on  the  bag,  the  uterus 
acts  too  violently,  and  such  danger  is  real.  If  too  much  fluid  is 
injected  into  the  bag,  the  uterus  is  overdistended,  as  in  polyhy- 
dramnion,  and  the  uterine  action  is  usually  weak,  but  sometimes 
the  opposite  is  true.  A  large  experience  with  the  bags,  however, 
together  with  study  of  the  voluminous  literature  on  the  subject, 
convinces  me  that  most  of  the  disadvantages  may  be  overcome  by 
proper  technic  and  by  watching  the  effects,  not  leaving  the  patient 
to  ignorant  attendants.  They  are,  indeed,  a  very  valuable,  indis- 
pensable addition  to  our  obstetric  resources.  Since  the  rubber 
deteriorates  with  time,  the  bags  are  to  be  kept  dry  in  an  ordinary 
paste-board  box,  and  thus  preserved,  will  last  one  or  two  years. 

Machine  Dilatation. — Tertullian,  in  the  second  century  after  Christ, 
mentions  pronged  uterine  dilators,  and  they  played  a  more  or  less  prominent 
part  in  gynecology  and  obstetrics  since.  Levret  (1760)  opposed  their  general 
use.  Goodell's  dilator  is  the  type  of  the  instrument  used  by  gyniatrists  and 
in  the  treatment  of  early  abortions.  In  1888  Bossi  invented  a  branched 
dilator  for  the  parturient  cervix,  which  had  great  vogue  in  the  years  1902 
to  1906,  but  now  is  almost  generally  discarded  (Fig.  797).  The  principle 
of  the  instrument  is  irrational.  Constant  elastic  distraction  of  the  cervix 
was  invented  by  Tarnier  in  his  three-branched,  glove-stretcher-like,  "ecar- 
teur  uterin,"  forced  apart  by  elastic  bands  around  the  handles.  Bossi  re- 
placed the  bands  with  a  powerful  screw  and  added  a  scale  to  show  the 
amount  of  separation  of  the  blades. 

In  all  the  cases  in  which  I  have  used  the  instrument,  ten  in  number, 
lacerations  of  greater  or  less  degree  resulted,  and  Bossi's  directions  were  care- 
fully followed.  I  use  it  only  on  women  at  or  near  term,  when  the  cervix 
is  completely  effaced  and  is  very  soft  and  dilatable,  conditions  where  the 
hands  would  render  equally  good  service.  American  authorities  do  not 
recommend  such  instruments.  Literature  and  history  of  all  dilating 
methods  are  to  be  found  in  the  articles  of  Hartz  and  Lewis  and  DeLee. 

Incisions  in  the  Cervix. — Hysterostomotomy. — The  first 
records  of  cervix  incisions  to  aid  delivery  are  from  the  eigh- 
teenth century,  but  probably  they  were  made  earlier. 
Baudelocquc,  about  1790,  condemned  them;  Simp- 
son used  them  in  cases  of  carcinoma;  Godemer  (1841), 
in  eclampsia;  Skutsch,  in  1887,  to  save  the  baby; 
but  Diihrssen,  in  1890,  showed  their  value  so  con- 
clusively that  they  are  often  termed  "Diihrssen's 
incisions."  The  field  of  usefulness  of  this  operation 
is  very  limited,  because  the  incisions  are  safe  only  after  complete  effacement  of  the 
cervix.  Reference  to  Figs.  789  and  790  will  show  tliat  a  cut  made  before  the  blood- 
vessels are  retracted  exposes  them  to  great  danger — indeed,  several  deaths  have 
occurred  from  hemorrliage,  and  if  the  tissues  are  incised  before  obliteration  of  the 
cervix  is  complete,  the  wounds  are  likely  to  tear  further  during  the  extraction  and 
open  up  the  broad  ligaments,  even  the  peritoneal  cavity.  The  ancients  made 
multiple  small  cuts  in  stellate  fashion,  but  Diihrssen  made  deep  lateral  cuts,  and  if 
these  were  not  sufficient,  posterior  and  anterior  incisions  also.  Other  operators 
make  the  cuts  in  the  oblique  diameters,  two  or  four  as  needed,  which  method  is 
preferable.     It  is  essential  that  the  greatest  deliberation  be  practised  in  the  sub- 


FiG.    707. 


-BoHsi's    Four-branched 
Dilator. 


PREPARATORY   OBSTETRIC    OPERATIONS 


916 


sequent  extraction  of  the  child  to  prevent  the  lacerations  from  extending — an 
accident  whic^h  has  hajipened  in  the  hands  of  the  world's  best  accoucheurs.  The 
preparations  for  the  ojx'ration  are  the  same  as  for  any  major  obstetric  procedure, 
l)ecause  sometimes  a  severe  iiemorrhage  must  be  faced,  and  afterward  the  wounds 
are  to  be  repaired.  The  indications  are  found  in  those  complications  bringing 
danger  to  mother  or  child,  when  the  cervix  is  obliterated,  only  the  thin  partition 
between  the  dilated  lower  uterine  segment  and  the  vagina  Ix'ing  left  to  overcome. 
It  is  a  conunon  ()i)eration  before  the  application  of  foi'ceps  in  occii)itoposterior 
positions  in  primipara^,  or  in  other  operative  deliveries  when  the  cervix  is  not  open 
enough.  Rigid  cervix  scars,  conglutination,  etc.,  are  occasional  indications.  The 
condition  which  must  be  insisted  on  is  complete  effacement  of  the  cervix.     Placenta 


Urnler  wi 


Fig.  79S. — Duhrsren's  Incisions. 
cle  exposure  of  the  field  by  broad  specula  the  cervix  is  grasped  and  rut  between  two  eight-inch  forceps,  which 
are  left  on  a  few  minutes  to  stop  hemorrhage. 


prsevia  is  a  contraindication.  Most  so-called  manual  and  instrumental  dilatations 
of  the  cervix  are  in  reality  bilateral  incisions  or  tears,  l)ut  made  with  \Aunt  instru- 
ments. 

Accouchement  Force. — This  operation  was  introduced  by  Pare,  given  the  name 
by  Guillemeau,  his  pupil,  but,  owing  to  its  great  maternal  (sepsis  and  hemorrhage) 
and  fetal  (asphyxia)  mortality,  w-as  employed  only  in  the  gravest  emergencies. 
Under  the  protection  of  asepsis  and  antisepsis  it  was  revived,  but  is  now  rapidly 
falling  into  disuse  because  of  the  almost  invariable  severe  injuries  inflicted  on  the 
mother,  the  frequent  hemorrhage  and  deaths  caused,  and  the  paucity  of  fetal  lives 
saved.  The  original  conception  of  the  operation  was  rapid  dilatation  of  the  cervix 
by  the  hands,  version,  and  forced  extraction  of  the  child.  Recently  the  term  has 
been  used  to  apply  to  any  one  of  several  methods  of  rapid  delivery  from  below. 


916 


OPERATIVE    OBSTETRICS 


"WTiile  admitting  that  a  few  cases  occur  where  it  is  not  extra-hazardous  to  dilate  the 
cervix  and  extract,  according  to  the  original  formula,  these  are  so  few  and  the  dan- 
gers of  the  others  so  great  that  the  author  would  advise  dropping  both  the  term  and 
the  operation  altogether  from  our  obstetric  surgery,  a  condition  which,  to  judge 
from  present  obstetric  literature,  will  soon  be  present.  As  a  substitute  for  this 
brutal  and  unsurgical  operation  the  metreurynter,  in  cases  of  not  great  urgency,  and 
vaginal  or  abdominal  cesarean  section  in  the  others,  are  suggested. 

Mention  may  be  made,  for  the  sake  of  condemning  the  procedure,  of  the  oper- 
ation of  using  the  body  of  the  child  as  a  dilator  of  the  parturient  canal.  Unless 
the  infant  is  dead,  and  excepting  a  few  cases  of  placenta  prsevia,  such  a  method  is 
inadvisable. 

Vaginal  cesarean  section,  or  colpohysterotomy,  is  an  operation  devised  by 
A.  Diihrssen,  of  Berlin,  April  1,  1895.     Acconci,  of  Italy,  devised  a  similar  operation, 


Fig.  799. — Instruments  for  Vaginal  Cesarean  Section. 
Shortbread  spcoula,  3  sizes,  also  1  long  narrow;  scalpel,  3  scissors,  1  of  which  is  long;  S  C-inch,  and  6  8-inch 
artery  clarnps;  2  rine,  2  double  vulsellum,  and  2  bullet  forceps;  3  dissecting  forceps;  long  and  short  needle-holders;  6 
needles;  silkworm  gut  and  catgut;  uterine  packing  forceps;  silver  female  catheter;  gauze  for  packing;  obstetric 
forceps;  tracheal  catheters;  if  vaginal  hysterectomy  is  to  follow,  add  2  Deschamps  needles  and  double  the  number  of 
long  arterj-  clamps. 


but  Diihrs.sen  ("Der  vaginale  Kaiserschnitt,"  Berhn,  1904)  conclusively  proves  his 
priority.  The  term  vaginal  cesarean  section,  used  in  the  eighteenth  century  for 
cervical  incisions,  was  considered  by  Baudelocciue  unsuitable.  Although  Diihrssen 's 
operation  is  a^formidable  one,  deserving  the  name  he  chose  for  it,  the  terms  vaginal 
hysterotomy  or  colpohysterotomy  might  supplant  it. 

Preparations. — Thcso  are  the  same  as  for  any  major  obstetric  operation.  An  anesthetist, 
two  a,ssistants,  and  a  nurse  are  neerled  if  good  work  is  to  be  done. 

A  table,  the  lithotomy  position,  and  good  iiorizontal  light  are  essential.  The  operation 
has  been  successfully  done  under  the  exigencies  of  practice  in  a  home,  but  with  increased  technical 
difficulties. 

The  Operation. — If  the  parturient  is  close  to  the  end  of  pregnancy  and  primiparous,  it  is 
best  to  make  a  deep  >inilatcral  episiotomy — on  that  side  to  which  the  occiput  points  if  forceps  are 
to  be  u.sed;  on  the  opposite  side,  if  version  is  to  l)e  performed.  This  will  prevent  laceration  of  the 
perineum  during  the  subsequent  delivery.  If  the  episiotomy  wound  bleeds  too  freely,  it  may  be 
sewn  up  temporarily,  the  line  of  suture  being  at  a  riglit  angle  to  the  line  of  incision.  Diihrs-sen 
insisted  on  the  necessity,  in  case  the  child  is  at  full  term,  of  making  both  anterior  and  posterior 
cervical  incisions.  Bumm  finds  the  anterior  incision,  if  extended,  gives  sufficient  space.  My  ex- 
perience accords  with  Duhnssen's.     The  cervix  must  be  in  the  median  line.     It  is  often  twisted  by 


PREPARATORY    OHSTETUIC    OPERATIONS 


917 


the  rotating  prcscntiiiK  JKirt  to  oiiccir  the  oilier  side.  Kiji.  SOO  shows  the  ficlil  exposed  hy  .short 
broiul  specula,  tlie  cervix  drawn  hy  vulselhiiii  t'orcei)sor  hy  silk  traction  ligatures,  and  red  Hnes  to 
indicate  the  location  of  the  incisions,  whicii  (io  thnninh  the  niucous  ineinhrane of  tJic  vagina  only. 
After  the  vagina  has  heen  reflected  oiT  the  ba.sc  of  the  bladder,  the  latter  is  pushed  upward,  off 
the  anterior  cervical  wall  (Fig.  8U1),  using  tlic  finger  covered  with  gauze.     At  the  bame  time 


Fig.  800. — Vagix-vl  Cesare.\n  Section. 

Exposure  of  field  and  line  of  incisions.     The  anterior 

cut  begins  one  inch  from  urethra. 


Fig.  801. — Pushing  the  Bladder  off  the  Cervical 

Wall. 

The  finger  is  covered  with  gauze. 


the  cervix  is  partly  freed  from  the  bases  of  the  broad  hgaments  at  the  sides,  but  care  is  required 
here,  as  large  veins  may  be  encountered.  Now  the  cervix  is  grasped  by  two  vulsellum  forceps 
and  split  medially  ( Fig.  S02)  up  to  the  internal  os.  Fig.  803  shows  this  section  made  and  the  bag 
of  waters  pouching  in  the  opening.  Operating  again  as  in  Fig.  801,  the  bladder  is  stripped  further 
oH  the  anterior  wall,  laying  it  bare  to  view,  and  the  uterovesical  fold  of  peritoneum  can  be  seen  or 


Fig.  S02. — Splitting  the  Cervix. 


felt  at  the  upper  end  of  the  wound.  A  narrow  speculum  is  inserted  to  expose  the  field  clearly. 
Now  the  medial  uterine  incision  is  continued  upward  (Fig.  804^,  the  vulsellum  forceps  being  placed 
on  successively  higher  portions  of  the  cervix  anil  lower  uterine  segment,  and  pulling  them  down  into 
the  bite  of  the  scissors.  Care  is  to  be  exercised  to  keep  in  the  median  line  and  to  avoid  injuring 
the  peritoneum.  This  is  pushed  off  the  lower  uterine  segment  before  the  advancing  scissors  by 
means  of  the  finger. 


918 


OPERATIVE    OBSTETRICS 


For  a  child  weighing  about  3  or  3^2  pounds,  an  anterior  incision  10  cm.  in  length  usually 
suffices.  One  may  test  the  size  of  the  opening  by  passing  through  it  the  fist,  made  about  the 
size  of  the  baby's  head,  by  holding  in  it  a  large  ball  of  cotton.     If  more  space  is  needed,  the  ante- 


Uterovesical 
reflection  of 
peritoneum 


Bag  of  waters 


Fig.  803. — Cekvix  Split  to  Above  Internal  Gs. 


Fig.  804. — Incising  Lower  Uterine  Segment. 


rior  incision  maybe  extended  upward  or  the  posterior  wall  may  be  incised  also  (Fig.  805).     Dtihrssen 
makes  the  posterior  cut  first  as  routine. 

Grasping  the  cervix  with  bullet  forceps,  it  is  split  to  the  vaginal  reflection,  then  the  perito- 
neum of  Douglas'  culdesac  is  pushed  upward  and  loosened  at  the  sides,  after  which  the  lower 
uterine  segment  is  divided  as  high  as  needful.     Delivery  is  now  accomphshed  by  forceps  or  by 


Fig.  805. — Incising  Po.stehior  Wall. 


Fig.  806. — Suturing  Anterior  Incision. 


version  and  extraction,  according  to  preference — I  prefer  for(;eps.  If  labor  pains  are  present, 
hemorrhage  is  not  usually  profuse,  but  if  it  is,  manual  removal  of  the  placenta  and  uterine 
tamponade  are  raT)idly  performed,  and  ergot  given  hypodermically,  or  adrenalin  (1:10,000) 
injcctedinto  the  cut  edges  of  the  uterine  muscle.  A  careful  examination  of  the  parturient  tract  is 
made  to  determine  the  extent  of  the  wounds.     Now  the  wounds  are  sutured  (Fig.  806).     By  trac- 


I'KKl'AltATOltV    OliSTirriilC    ()l'i:UATIONS 


919 


tion  on  the  silk  limps  or  viilsclhi,  pl:ice(l  oil  llic  iitciiiio  eilK<'s,  llio  iii)p<'riiiost  aiif?lo  of  tlie 
wound  is  reudily  dnivvn  iiilo  view,  wliioh  nruiy  be  :iidod  by  a  narrow  spcculiun  plarod  so  as  to 
retract  tlio  bladik'r.  A  coMtiniioiis  suture  of  No.  2  [)lain  oatj^ut,  taking  in  the  mucosa  and 
part  of  the  niuscl(>,  is  rapidly  put  in,  care  beinn  observed  not  to  include  the  uterine  packing, 
and  over  this  a  second  layer  is  placed,  after  which  the  va^iua  is  closed  with  a  runninK  suture 
of  chromic  ti;ut.  A  strip  of  {j;auze  may  be  left  to  drain  the  iar^e  subjK'ritoneal  wound  for  twenty- 
four  hours.  If  the  posterior  wall  has  been  divided,  this  is  sutured  Hrst,  with  a  rumiinf;;  throuf^h- 
;uid-thn)Uj;h  cntnut  suture,  tied  on  the  interior  of  the  cervix.  l'"inally,  the  perineum  is  rci)aired. 
The  o|)crati()n  i'e(iuires  from  eif.!;ht  to  twenty  mimitcs  for  the;  delivery  of  the  child,  and  frf)ni  twenty 
to  forty  minutes  to  repair  the  incisions.  If,  as  witii  cancer,  the  uterus  is  to  be  extirpated,  tlie 
anterior  and  posterior  incisions  are  prolonged  until  the  uterus  is  bi.sected,  and  the  broad  ligaments 
are  clamped  and  tied,  each  half  being  removed  after  the  method  of  P.  Miiller. 

D(ui(/crs. — Injury  of  tlie  bladder  and  ureters  may  be  avoided  by  proper  technic,  by  going 
slowly  without  attempts  at  spectacular  operating.  In  pushing  the  bladder  off  the  cervix  it  must 
be  liorne  in  mind  tiiat,  as  labor  progresses,  the  bladder  is  drawn  up,  and  usually  to  the  right  side. 


Peritoneum 


Fio.  S07. — Anterior  View  of  Operation. 


In  breech  and  shoulder  presentations  the  bladder  is  more  central.  One  of  my  cases  whose  oper- 
ation was  entirely  uncomplicated  returned  after  six  years  with  a  displaced  and  kinked  left  ureter 
which  causes  intermittent  hydronephrosis.  Hemorrhage  is  usually  not  marked  if  the  uterus  is 
divided  cleanly  in  the  midille  line,  if  the  tissues  at  the  side  are  spared,  and  the  cuts  do  not  tear 
further,  which  the}'  will  not  do  if  properly  placed  at  first.  In  one  case  the  tissues  were  so  friable 
that  the  traction  ligatures  and  vulsella  pulled  out,  and  hemorrhage  was  so  profuse  that  the 
vaginal  route  had  to  be  alnmdoned.  After  the  delivery,  paclcing  the  uterus  will  stop  hemorrhage. 
Pulling  tlown  the  uterus  strongly  also  has  a  good  influence.  There  is  no  reason  why  jMomburg's 
constrictor  may  not  be  applied  if  needed  at  tliis  stage.  In  one  case  the  broad  ligaments  and  pelvic 
connective  tissue  were  so  edematous  that  the  cervix  could  not  be  drawii  down  for  incision,  and  ab- 
dominal cesarean  section  was  inilicated.  To  gain  access  to  the  cervix  when  it  is  high  up  Diihrssen 
advised  a  deep  paravaginal  perineal  incision,  or  deep  episiotomy,  and  also  lately,  what  seems  to 
be  a  real  improvement  in  this  operation,  the  metreurynter,  by  means  of  which  the  cervix  is  pulled 
down  and  on  which  it  is  incised.  \Yhen  the  fully  distended  colpeurynter  can  come  through  the 
incision,  the  child  can  be  easily  delivered.  Should  the  bladder  be  opened,  it  is  to  be  sutured  after 
delivery  and  a  permanent  catheter  inserted.     If  the  peritoneum  is  torn,  it  is  sutured  at  once. 


920  OPERATIVE    OBSTETRICS 

In  both  instances  drainage  from  below  is  indicated.     Rupture  of  the  vagina  occurred  in  two  of 
my  cases,  threatening  hemorrhage  from  the  bases  of  the  broad  hgaments  in  three. 

Subsequent  pregnancies  and  labor  in  three  of  my  cases  were  entirely  uneventful,  and  many 
such  are  reported,  so  that  there  need  be  liut  little  fear  that  the  uterus  will  rupture,  but  in  several 
instances  the  wound  did  not  heal  perfectly,  leaving  an  everted  eroded  cervix. 

Indications. — When  the  cervix  is  closed  and  an  inchcation  arises  for  rapid 
dehvery,  and,  second,  when  the  cervix  is  diseased  and  nature  is  unable  to  overcome 
the  obstruction,  vaginal  cesarean  section  may  be  done.  Under  the  first  caption 
may  be  placed  eclampsia,  abruptio  placentae,  hyperemesis  gravidarum,  uncompen- 
sated heart  disease,  lung  disease,  oedema  pulmonum,  asphyxia  in  utero — in  short, 
all  acute  complications  on  the  part  of  the  mother  or  infant.  Under  the  head  of 
obstructions  cancer,  stenosis,  antefixatio  uteri,  scars  from  old  operations,  may  be 
mentioned . 

Conditions.- — Delivery  from  below  must  be  possible,  that  is,  the  pelvis  must  be 
large  enough  and  presentation  and  position  of  the  child  favorable.  Although  some 
authors  recommend  the  operation  in  placenta  prsevia,  I  would  consider  this  a  contra- 
indication, and  Bumm  recently  retracted  his  recommendation.  The  child  must  be 
living,  unless  the  indication  for  haste  on  the  part  of  the  mother  is  imperative. 
The  operation  simply  overcomes  the  resistance  of  the  cervix,  and  it  is  highly  impor- 
tant to  determine  beforehand  if  there  is  an  edema  of  the  connective  tissue  or  exces- 
sive friability  of  the  tissues.  In  30  operations  performed  by  the  author  many 
technical  difficulties  were  encountered.  It  is,  therefore,  not  to  be  undertaken 
except  by  one  skilled  in  pelvic  surgery. 

Operations  Preparing  the  Vagina  and  Pelvic  Floor  for  Delivery. — Episiotomy 
and  the  deep  paravaginal  incisions  have  already  been  described,  and  it  has  also 
been  said  that  the  colpeurynter  may  be  placed  in  the  vagina  to  prepare  it  for  the 
subsequent  delivery.  This  procedure  is  especially  useful  in  breech  and  shoulder 
presentations  in  primiparse.  Some  authors  advise  manual  dilatation  of  the  pelvic 
floor  and  vulva  preparatory  to  forceps  operation  or  other  rapid  operative  delivery, 
and  before  hebosteotomy.  My  own  experience  proves  to  me  that  in  such  cases  we 
do  not  really  stretch  the  muscle  and  leave  its  structure  perfect  afterward,  but  we 
cause  innumerable,  minute  or  larger,  submucous  tears,  and  afterward  the  women 
return,  not  with  torn  pelvic  floors,  but  with  relaxed  pelvic  floors,  the  functional 
result,  however,  being  the  same  or  worse.  I  prefer  a  clean  cut  to  these  unsUrgical 
methods,  and  am  convinced  that  the  after-effects  are  much  more  favorable.  Unfor- 
tunately, this  ideal  practice  comes  into  conflict  with  the  desire  to  avoid  the  necessity 
of  "putting  in  stitches,"  which  carries  a  certain  opprobrium  among  the  women. 
I  know  that  many  children  have  been  lost  and  much  invalidism  has  resulted  from 
this  ill-advised  and  objectionable  sentiment. 

Literature 

Burger:  Arch.  f.  Gyn.,  1900,  vol.  Ixxvii,  p.  485. — De  Lee:  "The  Use  of  the  Colpeurynter,"  Chicago  Medical  Recorder, 
1900;  "The  Bossi  Dilator,"  Amer.  Jour.  Obstet.,  1903,  vol.  xlviii,  No.  1. — Hartz:  Monatsschr.  f.  Geb.  u.  Gyn., 
vol.  xix. — Lewis:   Surg.,  Gyn.,  and  Obstet.,  December,  1906. — Schweitzer:    Centralbl.  f  Gyn.,  June  22,  1912. 


CHAPTER  LXX 

PREPARATORY  OPERATIONS  (CONTINUED).— PREPARATION  OF  THE 

BONY  PELVIS 

Enlarging  the  Pelvic  Canal. — Reference  has  already  l)een  made  to  the  itlea  of 
the  ancients  that  the  bones  of  the  pelvis  soften  and  separate  during  delivery. 
We  make  use  of  the  softening  of  the  joints  and  the  movability  of  the  bones  on  each 
other  to  protlucc  by  posture,  actual  enlargement  of  the  diameters  of  the  canal. 
Thus  it  is  certain  that  the  Walcher  position  enlarges  the  conjugata  vera,  and  the 
exaggerated  lithotomy,  the  ])ony  outlet,  particularly  in  its  transverse  diameter. 
The  idea  of  cutting  the  bony  pelvic  ring  is  not  recent. 

Symphysiotomy  and  Hebosteotomy. — Pinaeus,  in  1570,  refers  to  section  of  the  pelvic  bones; 
de  la  Courvcc,  in  111.")."),  delivered  ;i  child  by  .section  of  the  symphysis  pubis  after  the  mother  aied 
in  laljor;  Sigault,  in  1768,  invented  the  operation  of  symphysiotomy,  but  could  not  perform  it 
until  1777.  The  woman,  Mme.  Souchot,  and  her  child,  survived,  but  she  had  a  permanent  vesico- 
va<i;inal  fistula  and  difficulty  of  locomotion.  Sigault  was  given  a  silver  medal.  In  1775  Aitken 
recommended  section  of  the  bones  on  both  sides  of  the  joint  by  means  of  an  articulated  saw,  but 
never  did  it  on  a  live  woman;  in  1S21  Champion  de  Bar  le  Due  pointed  out  the  advantages  of 
cutting  the  hone  instead  of  the  symphysis,  ami  in  1830  Stoltz,  of  Strassburg,  perfected  the  opera- 
tion of  pubiotomy,  using  a  chain-saw,  very  much  as  it  is  done  today,  but  he  also  operated  only  on 
cadavers.  In  1S32  Galbiati  tried  Aitkcn's  recommendation,  but  the  mother  and  babe  died  from 
the  operation  itself,  and  pubiotomy  all  but  disappeared  until  Gigli,  of  Florence,  in  1894,  drew 
general  attention  to  the  operation  and  published  his  saw, — a  roughened  steel  wire, — which  he 
had  invented  for  the  express  pm-pose  of  cutting  the  pelvic  girdle.  Bonardi,  in  1897,  performed  the 
first  operation  with  the  saw,  Gigli  operating  in  1902  the  first  time  on  the  living.  Sj'mphysiotomy 
had  a  checkered  career.  In  France  an  acrid  polemic  was  waged  about  it,  and  Baudelocque,  Caseaux, 
DuBois,  and  La  Chapclle  finally  caused  its  abandonment.  In  Germany  and  England  the  oper- 
ation never  obtained  a  foothold,  but  in  Italy,  in  spite  of  its  high  mortality  and  morbidity,  it 
enjoyeil  a  sporadic  existence  by  grace  of  Galbiati  and  ^Morisani.  With  the  improvement  in  asepsis 
and  instrumentarium  of  the  late  eighties  and  the  proper  selection  of  ca.scs  naturally  the  results 
improved.  In  1891  Spinclli,  a  pupil  of  Morisani,  went  to  Paris,  interested  Pinard  in  the  re^'ived 
operation,  and  the  latter,  within  a  year,  performed  it  17  times.  In  1892  and  1893  it  was  being 
done  in  all  countries  with  the  overenthusiasm  begotten  by  eveiy  new  remedy,  and  for  a  time 
symphysiotomy  threatened  the  firm  position  held  by  cesarean  section.  Toward  the  end  of  the 
last  century,  however,  it  lost  ground  almost  entirely.  Zweifel,  in  Leipsic,  Kerr,  of  Glasgow,  and 
Pinard,  in  Paris,  are  among  its  few  fast  friends  even  today. 

In  1904,  as  the  result  of  the  publications  of  Gigli,  Van  de  Velde,  and  Doderlein,  pubiotomy 
took  the  center  of  the  stage,  and  in  the  subsecjuent  five  years  hundreds  of  operations  were  per- 
formed tlie  world  over.  Now  the  enthusiasm  is  waning,  because  it  has  been  found  that  the  op- 
eration has  an  unavoidable  maternal  and  fetal  mortality  and  a  consitlerable  morbidit}'.  The 
advantages  of  pubiotomy  over  sj-mphysiotomy  have  already  been  considered  (p.  719),  as  also 
have  the  indications  and  the  time  of  performance  (q.  v.). 

Anatomij. — Figs.  808  and  809  show  the  anatomy  of  the  field  of  operation.  The  large  venous 
plexuses  are  the  source  of  the  profuse  hemorrhage.  It  is  easily  seen  how  the  triangular  ligament, — 
the  urogenital  septum, — robbed  of  its  anterior  support,  is  always  torn,  exposing  the  urethra,  the 
anguli  vaginir,  and  the  vestibular  structures  to  serious  injury. 

Symphysiotomy. — There  are  several  methods  of  opening  the  pubic  joint,  some 
exposing  the  field,  others  subcutaneous.  Italian  operators  make  a  small  incision 
above  the  pul^is,  and,  under  the  guidance  of  the  finger,  pass  a  curved,  ball-pointed 
knife  around  the  joint,  severing  the  cartilage  from  below  upward.  Faralieuf  makes 
a  long  incision  over  the  joint,  cuts  the  ligamentum  suspensoriimi  clitoridis,  reflects 
the  latter  downward,  passes  a  grooved  director  around  the  joint,  and  cuts  down  on 
it  from  before  backward.  In  my  cases  I  made  a  two-inch  incision  over  the  upper 
half  of  the  pubis,  then,  by  strong  traction,  pulled  the  opening  doAAii  over  the  whole 
joint,  which  was  thus  exposed;  then  the  bone  was  divided  from  above  do^\aiward 
to  the  ligamentum  arcuatum,  which  was  severed  only  if  necessary.  In  this  way  the 
wound  was  high  up,  away  from  the  flow  of  the  lochia.     After  delivery  the  bones  are 

921 


922 


OPERATIVE    OBSTETRICS 


pressed  together,  and  three  catgut  sutures  passed  through  the  deep  structures  over 
them ;  then  the  skin  is  closed  with  interrupted  silkworm-gut  stitches.  Ayres,  of  New 
York,  did  the  operation  entirely  subcutaneously,  with  a  blunt-pointed  bistourj^,  and 
Zweifel,  of  Leipsic,  does  it  with  a  Gigli  saw,  in  a  fashion  similar  to  hebosteotomy. 


Fig.  808. — Showing  Veins  at  Site  of  Hebosteotomy  (after  Waldeyer). 
Line  indicates  the  location  of  cut. 


Fio.  809. — After  Section  of  Pubis.     Semidiagrammatic  (after  Waldeyer). 
Note  that  crus  clitoridis  is  always  torn. 


PHKl'AKATOiiV    (Jl'KUATKJNS — PKEl'AJtATIOX    (JF    THE    liONY    I'ELVIS 


923 


Hehosteolomy. — ( liji;li's  original  operation  was  an  open  (lis.section,  and  the  results 
were  no  better  than  with  symphysiotomy.  Walcher  devised  a  metliod  oi  operating 
entirely  subeutaneously,  which  Bumm  has  simplified.  Doderlein,  before  Walcher, 
had  modified  the  operation  of  (!ifi;li,  and  liis  is  tlie  one  usually  reconuiiended. 

Dodcrlciii'.'i  OinralioN. — PrcpMi'atioii.s  arc;  iiuide  for  u  scuious  openili(jii,  alt  lioiiiili  il  is  usually 
not  one.  In  rare  cases  hcinorrha^c  and  laceration.s  occur  which  tax  the  skill  of  the,  most  oxpf.Tt. 
Fig.  810  sho\v.s  the  instruments  ncMnled.  Two  trays  are  to  be  used — ^one  for  instrumcints  for  the 
work  on  the  joint  and  the  other  for  the  vaginal  work.  If  it  is  necessary  to  return  to  the  wound 
in  the  joint  after  the  hands  have  had  to  do  with  the  parturient  canal,  the  operator  should  draw  on 
another  pair  of  sterile  glo\'es. 

The  patient  is  put  in  tlic  posture  for  delivery  shown  iu  Fig.  783,  but  the  legs  are  held  by  the 


Fig.  810. — Insthuments  for  Hebosteotomt. 

Lower  tier  is  for  the  opprative  wound,  and  the  instruments  are  kept  separate  from  the  others,  whieh  are  used  for 
the  delivery. 

Pubic  Tray:  2scalpel.s;  4  artery  forceps;  4  8-inch  clamps;  .3  Gigli  saws;  1  pair  handles;  1  needle;  4  small  needles; 
2  tissue  forceps;   2  retractors;   2  scissors;   flat  spatula;    1  raspatorium;   silkworm-gut,  etc. 

Vaginal  Tray:  Obstetric  forceps;  .3  scissors;  C  artery  forceps;  2  ring  forceps:  2  vulsellum  forceps;  3  tissue  forceps; 
uterine  packing  forceps;  2  needle-holders;  6  needles;  3  specula;  tracheal  catheter,  version  sling  and  carrier,  salt 
solution  needle,  etc. 


two  assistants  nearly  horizontally.  A  transverse  or  longitudinal  incision,  one  inch  long,  is  made 
over  the  left  pubic  tubercle,  down  to  the  rectus  fascia  and  through  it,  but  the  latter  cut  is  alwaj-s 
made  longitudinally,  and  only  large  enough  to  permit  the  finger  to  pass  behind  the  pubis.  This 
finger  gently  separates  the  bladder  and  fat  from  the  bone,  until  the  ligamentum  arcuatum  is  felt. 
Now  the  needle  (Fig.  Sll),  anned  with  a  silk  ligature,  is  guided  bj^  the  finger  around  the  bone,  the 
point  of  the  needle  adhei'ing  as  closely  to  the  bone  as  possiljle.  When  the  point  lia.-^  rounded  the 
ligamentum  arcuatum,  it  is  bent  sharply  forward,  while  an  assistant  pulls  the  labium  toward  the 
right  side — this  to  bring  the  opening  in  the  skin  far  from  the  flow  of  the  lochia,  and,  hx  the  sliding 
of  the  tissues,  to  close  the  passage  of  the  needle.  A  nick  with  the  knife  allows  the  tip  of  the  dull 
needle  to  emerge;  the  tlu-ead  is  gra.sped  and  the  needle  withdrawn.  The  saw  is  pulleil  through 
by  means  of  this  thread,  and  the  saw  handles  attached.  By  to-and-fro  motions  of  the  saw,  the 
action  resembling  cutting  a  bar  of  soap  \y\X\\  a  string,  and  making  short  strokes,  the  bone  is  severed. 
In  this  motion  the  saw  may  not  be  sharply  bent.  Mayer  advises  to  place  the  patient  in  the  Wal- 
cher position  while  sawing  the  bone,  and  raise  the  limbs  gradually,  to  prevent  too  sudden  separa- 


924 


OPERATIVE    OBSTETRICS 


tion  of  the  two  halves  of  the  pelvis  and  injury  to  the  soft  parts  between.     Costa  does  the  same, 
and  Kerr  uses  the  Walcher  for  the  delivery. 

Hemorrhage  is  usually  free  from  both  wounds,  during  and  just  after  the  bone  is  sawn  through. 
Quickly  the  upper  wound  is  packed  with  hot  iodoform  gauze,  a  stitch  of  silkworm-gut  closes  the 


Fig.  812. — Hf.bosteotomy.     Passing  the  Needle.     Gigu  Raw  at  Right. 


lower  puncture,  and  an  a.ssistant  makes  counterpressurc  fiom  the  vaginal  surface  by  means  of  a 
large  gauze  swab.  In  a  few  minutes  the  hemorrhage  has  usually  ceased,  the  gauze  may  be  removed, 
and  the  pubic  wound  sewed  up  with  three  deep  silkworm-gut  sutures.  The  bones  separate  with 
a  dull,  crunching  sound,  which  is  very  unpleasant,  at  first  about  2  cm.,  and  during  extraction  up 
to  G  cm.     More  separation  than  this  endangers  the  sacro-iliac  joints. 


PREPARATORY  OPERATIONS — PREPARATION  OF  THE  BONY  PELVIS 


925 


Some  operators  leave  the  delivery  to  nature  or  wait  for  later  indication,  especially  in  primi- 
para>,  hut  by  the  majority  immediate  delivery  is  pnir-tisod.  In  primipara;  I  prefer  to  leave  the 
(Iclivcry  to  luUurc,  as  docs  Slocckcl  also. 

Version  is  ficiicrally  not  advised.  The  licud  may  i»c  prcs.xefl  into  the  inlet  from  ahove,  or  a 
few  pains  awaited  and  then  the  forceps  applied.  In  primi[)ara'  a  deep  <'pisiotf)my  should  always 
be  made  before  applyin^j;  llie  instrument,  and  in  multipara'  also  if  the  intnjitus  is  small.  The 
danf^er  now  to  l)e  avoided  is  rupture  of  tlie  anterior  va^iinai,  urethnd,  and  bladder-wall,  hence 
the  extraction  of  the  child  must  be  very  deliberate  and  the  direction  of  traction  be  downward,  to 
reia.x  the  anterior  wall  as  much  as  i)o.ssibIe.  During  the  delivery  the  a.ssistants  press  the  pelvis 
together  from  the  sides,  l)ut  1  believe  Kerr's  suggestion  to  use  the  Walcher  position  is  better. 
It  is  iiighly  important  that  t!ie  mechanism  of  laljor  be  favorable — a  posterior  occiput  or  a  brow 
presentation,  therefore,  should  be  corrected  previous  to  extraction.     It  is  my  practice  to  remove 


Fig.  S13. — Hebosteotomt.     Saw  in  Position. 


the  placenta  very  soon  and  pack  the  uterovaginal  tract  ^ntli  gauze  as  a  routine.  Now  all  vaginal 
injuries  are  repaired,  a  clean  pair  of  gloves  put  on,  and  the  pubic  wound  inspected  and  treated, 
if  necessary.     Catheterization  of  the  bladder  now  determines  if  this  organ  is  injured. 

Snbcutnneons  OpcniUon.—Bnmm  uses  a  sharp,  full-curved  needle  and  passes  it  from  below 
upw-ard  under  the  guidance  of  a  finger  in  the  vagina  (Fig.  S14).  It  is  threaded  with  the  saw,  then 
withdrawn,  and  the  operation  completed  as  above. 

Complications. — Hemorrhage  is  easiest  to  control  in  the  open  symphysiotomy  when  clamps 
may  be  placed  on  the  crura  clitoridis  and  lileeding  veins,  but  in  one  case  I  had  to  pack  the  vagina 
tightly  and  place  a  sand-bag  on  the  pubis  to  exert  counterpressure.  In  subcutaneous  operations 
compression  from  within  and  without  for  five  to  fifteen  minutes  almost  always  stops  the  hemorrhage, 
but  if  it  does  not,  delivery  must  be  effected  at  once,  the  uterovaginal  tract  firmly  plugged,  and  then 
couuterpressm-e  from  without  provided.     If  this  fails,  which  is  very  unusual,  a  deep  sutm-e  may 


926 


OPERATIVE    OBSTETRICS 


be  placed  on  either  side  of  the  wound  in  the  bone,  but  it  is  better  to  apply  a  Momburg  belt  for 
fifteen  minutes,  during  which  time  bimanual  compression  is  kept  up,  covering  the  area  of  separation. 
If  hemorrhage  recurs  on  loosening  the  belt,  the  pubic  joint  must  be  exposed  and  the  source  of  the 
bleeding  searched  for  and  quelled.     If  spontaneous  delivery  is  to  be  awaited,  a  vaginal  tampon 


Fig.  814. — Hebosteotomy   (after  Bumm). 


Fio.  81.5. — Bed  for  Symphysiotomy  or  for  Helpless  Patients. 


is  inserted,  firmly  compressing  the  site  of  bone  section,  and  counterpressure  from  the  outside  made 
with  pads  and  T-bindcsr.  Th(!se  arc  all  removed  at  tlie  end  of  thirty  or  forty  minutes,  when  the 
cessation  of  the  bleeding  is  assured. 

Ilematomata  do  not  develop  so  long  as  compression  is  kept  up,  but  as  soon  as  the  woman 
is  placed  in  bed,  they  may  form  fonc-fifth  of  the  cases  reported),  and  perhaps  are  favored  by 


PUi:i'AKA'l'()l(\     ol'KliATIONS — I'UKl'A  ItA'l'ION    OF    THE    BONY    PELVIS 


927 


roiifili  lianilliii^  of  llir  paliciil  in  Iniiisporl  iiiy;  licr.  If  ihoy  arc  large  and  growirif^,  tlicy  must  be 
incised  and  packed — an  unlovely  (iperatidu.  If  sup[)uralion  sets  in,  which  is  not  unusual,  early 
diaiiKigc  is  indicated. 

L(iccniii(>n.s. — AUhou^^li  waitin^i  for  spontaneous  delivery  seems  to  he  the  ideal  treatment 
after  oiK-ning  the  pelvis,  the  majority  of  accoucheurs  are  not  in  favor  of  it,  even  after  proper 
trial.  It  is  to  be  reserved  for  primipara%  and  where  no  indication  for  the  immediate  termination 
of  labor  exists.  If  a  vaginal  tear  communicates  with  the  bone,  the  immense  wound  i.s  closed  as 
far  as  possible,  and  a  gauze  drain  placed  in  the  prevesical  space  and  led  out  through  the  vagina. 
Injuries  to  the  bladder  are  usually  on  its  anterior  wall,  and  cannot  be  repaired  at  this  time.  A 
permanent  catheter  is  placed  in  the  bladder  and  .">  grains  of  hexamethyleiuunin  given  fotu-  times 
daily.  The  catluMer  is  to  be  removed  every  six  hours  and  a  new  one  inserted,  and  the  nurse 
nuisl  be  instructed  to  report  immediately  if  the  urine  ceases  to  flow — this  to  avoid  urinary  infil- 
tration. Lacerations  occur  from  too  great  or  too  sudden  .separation  of  the  bones,  from  direct 
injury  with  the  needle,  or  the  soft  parts  are  cut  between  the  head  and  the  sharp  edges  of  the  bones. 

Aflcr-lrcdhncut. — After  the  wound  is  dressed  a  broad  adhesive  strip  is  passed  around  the 
lielvis  ovin-  the  trochanters,  and  the  knees  bound  together  with  a  towel.  For  tne  first  w(!ek  great 
care  is  required  in  iiandling  the  patient,  becau.sc  the  bones  are  tender  and  a  hematoma  may  be 
started.  A  bed  arranged  witli  a  frame  on  which  the  patient  may  be  rai.sed  for  catheterization, 
irrigations,  urination,  etc.,  while  not  absolutely  necessary,  much  facilitates  the  treatment  and 


Fig.  816. — Turning  Occirrx  to  Front  by  Combined  JManipul.\tion. 


increases  the  pnerpera's  comfort.  For  four  days  the  woman  should  lie  on  her  back;  after  this 
she  may  move  about  in  bed.  and  may  get  out  of  it  at  the  end  of  three  weeks,  and  may  walk  as 
soon  as  she  feels  able  to  do  so,  which  is  usually  in  the  fourth  week.  .Symphysiotomj-  cases  were 
much  more  troublesome  postpartum  than  are  the  hebosteotomies. 

Indications. — Almost  the  sole  indication  for  hebosteotomy  is  mechanical 
disproportion  between  the  head  and  the  pelvis.  With  a  normal-sized  fetus,  the 
operation  is  indicated  in  flat  pelves  with  a  conjugata  vera  of  more  than  7  cm.  and 
more  than  7}4  cm.  in  a  generally  contracted  pelvis.  If  the  child  is  ovcrgroA\Ti,  of 
course,  the  pelvic  diameters  must  be  larger,  but  with  very  large  children  the 
excessive  danger  to  the  soft  parts  must  be  considered  as  contraindicating  this  opera- 
tion. The  indication  for  hebosteotomy  really  depends  on  the  time  the  patient  is  first 
seen.  During  pregnancy,  if  the  pehdc  contraction  is  discovered,  the  induction  of 
premature  labor  may  be  preferred,  or  the  patient  may  be  allowed  to  go  to  term  and 
a  conservative  cesarean  section  be  performed  at  the  very  beginning  of  labor.  The 
latter  is  my  choice.  Early  in  labor,  and  if  the  woman  is  surely  not  infected,  abdom- 
inal delivery  may  be  done,  or  the  "test  of  labor"  be  awaited.     If  the  labor  test 


928 


OPERATIVE    OBSTETRICS 


shows  that  the  head  will  not  go  through,  hebosteotomy  is  the  operation  of  choice, 
but  before  this  a  proper  trial  of  the  forceps  should  be  made.  If  the  woman  is  already 
infected,  or  presumably  so ;  if  prolonged  attempts  with  forceps  have  been  made  and 
the  maternal  parts  much  bruised;  if  the  child  is  injured  or  not  in  good  condition — 
hebosteotomy  becomes  a  dangerous  and  unsatisfactory  operation  and  craniotomy 
must  be  substituted.  With  a  dead  or  dying  child  embryotomy  is  the  only  operation. 
It  will  be  seen  that  hebosteotomy'  is  useful  only  in  border-line  cases,  where  the  at- 
tendant, believing  the  child  would  be  delivered,  has  waited  until  labor  has  advanced 
so  far  that  cesarean  section  would  be  too  dangerous,  or  has  even  attempted  delivery 
wath  the  usual  methods.  The  selection  of  the  operation  now  is  one  of  judgment  of 
the  condition  of  the  mother  and  babe  and  of  the  probable  outlook  for  both.     It  is, 


Fio.  817. — Changing  Occipitol^eva  Posterior  to  Occipitol.'eva  Anterior. 
Internal  hand  obtains  purchase  on  shoulder  and  pushes  it  past  tho  promontory.     Outside  hand  pulls  body  around. 

Arrows  indicate  motion  of  hands. 


therefore,  largely  subjective.  In  shoulder  and  breech  presentations,  where,  of 
course,  we  cannot  await  the  test  of  labor,  placing  the  indication  becomes  still  more 
subjective  and  will  be  aided  by  knowledge  of  previous  deliveries,  pelvic  and  fetal 
mensuration,  the  state  of  the  soft  parts,  etc.  I  feel  that  pubiotomy  should  be 
restricted  in  favor  of  abdominal  delivery  in  good  cases,  and  the  older  methods 
should  be  preferred  in  unfavorable  ones.  In  persistent  occipitoposterior,  and  in 
face  presentation  with  the  cliin  immovably  posterior,  an  occasional  indication  for 
section  of  the  pelvis  may  arise.  Lewis  and  Montgomery  did  symphysiotomy  for 
such  conditions,  but  there  are  only  5  others  reported  (Morse). 

Conditions. — (1)  The  pelvis  may  not  be  too  small,  that  is,  less  than  7  cm.  in 
the  flat,  and  7^  cm.  in  generall}^  contracted,  with  a  child  of  7  pounds.     It  may 


PREPARATORY    OPPmATIONS — PREPARATION    OF   THK    BONY    PELVIS 


929 


not  be  ankylosed,  u.s  l)y  tuhcrcular  disease,  advanced  age,  vXc.  (2)  Tlie  child 
may  not  be  too  large;  (3)  the  child  must  be  in  good  condition  and  not  deformed,  for 
example,  liydroceplialus,  anencephalus;  (4)  the  maternal  soft  parts  may  not  be 
infantile  nor  rigid,  lience  hebosteotcjuiy  should  seldom  be  attempted  in  pnmij)ara?, 
especially  if  very  young  or  old;  (5)  the  mother  must  be  in  good  condition  and  not 
infected,  that  is,  no  fever,  slow  pulse,  clean  conduct  of  labor;  (G)  the  cervix  must  be 
effaced  and  dilated;  (7)  the  woman  must  be  in  a  well-equipped  obstetric  operating- 
room,  with  plenty  of  assistants,  since  the  operation  is  not  one  to  be  done  in  the  home. 
ProyiiDsi.s. — The  reader  is  referred  to  p.  721.  Recently  reports  by  Williams 
and  Stocckel  show  series  of  25  and  24  cases  respectively  without  maternal  death, 


Fig.  sis. — Lr.^ding  Head  into  Pelvis  by  Combined  Presscre  and  Traction. 


and  with  8  and  4  per  cent,  fetal  deaths,  the  late  results  being  good.  Locomotion 
was  not  compromised,  though  tenderness  and  pain  were  noted  several  times. 
After  symphysiotomy  there  is  often  a  slight  permanent  enlargement  of  the  pelvis, 
so  that  subsequent  deliveries  may  be  spontaneous,  but  after  hebosteotomy  this  is 
not  so  marked.  Union  of  the  bones  by  a  strong  fibrous  callus  is  the  rule,  but  in 
many  cases,  especially  after  eight  months,  it  is  bony.  Plastic  operations  on  the 
pulnc  bones  have  been  suggested  for  the  permanent  enlargement  of  the  pelvis  by 
Frank,  Fiith,  Crede,  Groves,  and  others,  but  they  are  irrational  and  impractical. 
59 


930 


OPERATIVE    OBSTETRICS 


Subsequent  labors  may  not  be  treated  by  a  second  symphysiotomy  because  of  the 
immense  scar  which  involves  the  bones,  the  bladder,  the  urethra,  etc.,  but  pubiotomy 
has  on  several  occasions  been  performed  t^vice.  I  have  performed  cesarean  section 
in  these  cases  on  principle,  and  in  one  case  because  of  the  enormous  varicosities  of 
the  vulva  and  pelvis  wliich  followed  the  previous  (infected)  pubiotomy. 


Fig.  819. — Thotin's  .Method  of  Changing  Face  to  Occipital. 


Improving  the  Position  of  the  Fetus.— Occipitopo.sterior  positions  occasionally 
require  correction,  and  the  indications  will  be  found  on  p.  580.  The  simple  ma- 
noeuver  of  Hodge,  pressing  up  on  the  sinciput  during  the  pains,  may  increase  flexion 
and  thus  assLst  rotation.  By  combined  manipulation  (Fig.  816)  it  may  be  possible 
to  turn  a  head,  engaged  in  the  pelvis,  far  enough  to  the  front  to  be  able  to  apply 
the  forceps.     Two  or  four  fingers  of  one  hand  obtain  a  purchase  on  the  skull  behind 


PREPARATORY   OPERATIONS — PREPARATION    OF   TIIK    150NY    PELVIS 


931 


tlie  Ijuby's  L'ur,  and  .scfk  to  pull  the  occiput  dowiiwarcl  and  forward,  wliile  tlu;  oilier 
hand,  outside,  pushes  the  forehead  toward  the  back  part  of  the  pelvis.  When  the 
head  is  in  i^rojier  position,  an  assistant  holds  the  forehead  at  the  point  to  which  the 
operator  i)ushed  it,  while  the  latter  uses  his  free  hand  to  insert  one  blade  of  the 
forceps.  The  other  hand,  which  has  been  kept  inside  to  prevent  the  occiput  from 
rolling  backward  again,  guides  the  forceps  blade  into  place.  If  the  head  is  not 
engaged,  a  more  complicated  operation  is  required.  Eden  and  Kerr  record  very 
successful  manipulations.  The  following  procedure  has  been  practised  by  the 
author  for  many  years  (Fig.  817,  p.  928).  Under  deep  anesthesia  the  whole 
hand  is  pas.scd  into  the  uterus,  jnishing  the  head  up  and  out  of  the  pelvis  if  nec- 
essary.    That  hand  is  selected  which  will  have  its  palm  directed  toward  the  face 


Fig.  820. — Changing  F.\ce  to  Occipital.     Second  Movement. 


of  the  infant.  The  posterior  shoulder  of  the  child  is  sought,  and  with  the  tips  of 
the  fingers  is  s^\1mg  around  to  the  front,  past  the  promontory  of  the  sacrum.  The 
head  fitting  into  the  palm  of  the  hand  goes  with  the  trunk.  The  hand  outside  aids 
this  motion  by  pulling  the  shoulder  toward  the  front.  When  the  inside  hand  is 
leading  the  head  into  the  pelvis  in  its  new  position,  the  outside  hand  forces  the  head 
down  by  pressure  on  the  occiput,  which  is  now  over  the  pubic  ramus  (Fig.  818,  p. 
929).  It  may  be  advisable  to  draw  the  head  dow^l  deep  into  the  pelvis  \\'ith  for- 
ceps, await  four  to  six  lalwr-pains,  remove  the  forceps,  and  leave  the  case  to  nature, 
or  to  follow  a  later  indication.  The  latter  plan  is  especially  successful  in  primi- 
parse,  because  the  molding  of  the  head  and  the  softening  of  the  tissues  produced  by 
a  few  hours'  labor  and  the  progress  of  the  head  toward  the  outlet  immensel}'  facili- 
tate the  subsequent  delivery  (see  page  979), 


932 


OPERATIVE    OBSTETRICS 


The  conditions  for  this  operation  are :  (1)  The  pelvis  may  not  be  too  contracted 
for  the  subsequent  dehvery;  (2)  the  child  must  be  living;  (3)  the  cervix  must  be 
dilated  to  admit  the  hand;  (4)  the  bag  of  waters  ruptured;  (5)  the  uterus  may  not 
be  in  tetanic  contraction  or  on  the  point  of  rupturing;  (6)  placenta  praevia  and 
prolapse  of  the  cord  may  not  exist.  In  rare  instances  the  manipulation  fails,  or 
must  be  given  up  because  the  force  required  is  too  much  to  be  safely  applied.  Now 
the  forceps  alone  will  be  able  to  effect  delivery,  but  the  operator  must  be  aware 
that  they  are  very  difficult  to  apply  under  such  conditions  and  invariably  cause 


Fig.  S21 


ANGiNO  Face  to  Occipital.     Third  Movement. 


superficial  and  deep  injuries  to  the  maternal  parts.  If  the  operation  is  forced,  a 
still-l)irth  frequently  results. 

Improving  the  Attitude  of  the  Child. — Faulty  attitudes,  face,  brow,  and  other 
malprcscntatioiis,  ])rolaps('  of  cxtreniities  and  of  the  cord,  with  indications  for 
trcjatment,  have  already  been  considered  (p.  585).  It  remains  to  show  how  face 
and  brow  presentations  may  be  corrected. 

Baudelocque  recommended  to  push  uj)  flic  cliin  and  face,  and  then  slide  the 
fingers  over  the  occiput  and  pull  this  down  into  the  pelvis — all  })eing  done  by  the 
inside  hand.  Schatz  (1872)  souglit  to  alter  the  posture  of  the  head  by  changing 
the  extension  of  the  trunk  to  flexion.     In  face  presentation  the  usual  C  shape  of 


PREPARATOUV    oi'KRATIONS — PREPARATION    OF   THE    BONY    PELVIS 


933 


the  child's  spinal  coluiuii  is  chunf^ccl  to  rcsenihlc  the  letter  S,  and  Schatz,  operating 
from  the  outside,  by  pulling  the  shoulder  in  one  direction  while  he  pushed  the  breech 
ov(>r  in  the  opposite,  in  favorable  cases  could  alter  the  attitude  of  the  trunk  so  that 
the  head  went  over  from  a  condition  of  extension  into  one  of  flexion.  Thorn  (1893) 
combined  both  methods,  and  was  more  successful  than  Schatz  in  breaking  the  curves 
of  the  fetal  l)ody  and  producing  the  C'  shape  (Fig.  819,  p*.  930). 

My  own  met  hod,  which  has  failed  only  once  in  nine  cases  of  face  presentation, 


Fig.  S22.^rn.\Nr;ixr,  Face  to  OrciriTAL.     Fourth  Movement. 


and  once  in  three  cases  of  brow  presentation  where  it  was  attempted,  is  similar  to 
Thorn's,  but  more  is  done  by  the  inside  hand. 

Author's  Method. — A  s"0(l  table,  the  obstetric  position,  with  the  nates  well  over  the  edge 
to  allow  the  operator  to  sink  his  ell)ow,  and  deep  anesthesia  are  indispensable.  The  operation 
consists  of  four  acts — first,  raising  and  releasing  the  head  and  shoulder  from  the  grasp  of  the  uterus, 
so  that  the  baby  floats  free  above  the  inlet;  second,  flexion  of  the  chin  and  forcing  down  the 
occiput;  third,  pusliing  in  the  prominent  convexity  of  the  chest  to  a  concavity;  foui-th,  leading 
the  now  flexed  heatl  into  the  pelvis. 

1.  The  liand,  whose  palm  will  he  against  the  child's  face  (for  example,  in  M.D.P.,  the  left), 


934  OPERATIA^E    OBSTETRICS 

is  introduced  into  the  lower  uterine  segment,  and  witla  the  fingers  widely  apart  the  head  is  grasped, 
and  with  a  circular  motion  is  loosened  from  its  fixed  position  in  the  inlet.  It  may  be  necessary 
to  raise  the  whole  head  above  the  inlet  into  the  false  pelvis.  The  fingers  then  shde  by  the  head 
and  disengage  the  shoulders  from  the  uterine  walls.  The  child  is  thus  rendered  movable,  being 
freed  from  the  grasp  of  the  lower  uterine  segment.  Information  is  also  gained  of  the  condition  of 
the  uterus  as  to  rigidity,  thinning,  etc. 

2.  With  the  same  hand  the  chin  and  then  the  face  are  pushed  up,  the  tips  of  the  fingers 
being  applied  in  the  nasal  fossa?  (Fig.  820),  while  the  outside  hand  presses  the  occiput  down. 

3.  The  same  internal  hand  now  continues  farther  past  the  face,  either  in  front  of  the  prom- 
ontory or  behind  the  pul;)is,  until  the  finger-tips  reach  the  chest  and  shoulder  of  the  child. 
Obtaining  purchase  on  the  shoulder,  the  fingers  are  flexed,  which  throws  the  chest  first  into  a 
straight  line  and  then  into  a  concavity,  and  at  the  same  time  the  thumb  makes  downward  trac- 
tion on  the  occiput,  bringing  the  latter  into  the  palm  of  the  hand  (Fig.  821,  p.  932).  The  out- 
side hand  meanwhile  pushes  the  breech  to  the  side  on  which  the  chin  lay. 

4.  The  inside  hand,  holding  the  head  in  the  now  flexed  attitude,  with  the  fingers  over  the 
face  and  the  thumb  hooked  into  the  suboccipital  region,  gently  leads  the  head  into  the  pelvis, 
the  outside  hand  forcing  the  child  into  extreme  flexion  and  down  toward  the  inlet  (Fig.  822,  p. 
933).  An  assistant  now  places  his  one  hand  on  the  breech,  the  finger-tips  of  the  other  being  over 
the  occiput,  while  the  operator  uses  his  free  hand  to  insert  the  blades  of  the  forceps.  A  few  slight 
tractions  bring  the  head  down  into  the  pelvis,  and  engagement  having  been  obtained,  recurrence  of 
the  face  presentation  is  impossible.  Sometimes  the  first  attempt  at  correction  fails,  or  the  head, 
having  been  flexed,  extends  again  as  soon  as  the  pressure  of  the  hand  is  removed.  To  avoid 
this  the  above  advice  is  given.  In  addition,  the  assistant,  from  the  outside,  should  maintain  the 
flexion  of  the  trunk  by  firm  pressure  on  the  breech,  and  the  operator,  by  holding  the  child  in  its 
new  postiu-e  for  five  minutes,  perhaps  aided  by  a  few  pains,  may  make  the  conversion  permanent. 
Though  I  have  never  found  it  necessary,  it  occurred  to  me  to  hold  the  head  in  its  new  attitude 
by  means  of  a  vulsellum  grasping  the  scalp.  The  injury  would  be  no  more  than  is  often  in- 
flicted with  the  forceps.  It  is  best  not  to  deliver  at  once,  but,  if  possible,  to  leave  the  case  to 
nature,  awaiting  further  indications. 

Indications. — The  sole  indication  for  this  operation  is  mentoposterior  position, 
where,  from  close  observation  of  the  course  of  labor,  the  accoucheur  is  convinced 
that  the  case  is  not  likely  to  terminate  with  anterior  rotation  of  the  chin.  It  is 
not  the  routine  treatment  of  face  presentation. 

Conditions. — (1)  The  cervix  must  be  fully  dilated  because  the  hand  must  be 
introduced,  and  it  may  be  necessary  to  deliver  at  once;  (2)  the  bag  of  waters  is  to 
be  ruptured;  (3)  the  child  may  not  be  too  large  nor  the  pelvis  too  small  (very 
important) ;  (4)  the  uterus  must  not  be  too  much  thinned  or  on  the  point  of  ruptur- 
ing; (5)  the  head  may  not  be  deeply  engaged  in  the  pelvis;  (6)  placenta  praevia 
may  not  be  present;    (7)  the  child  must  be  living  and  viable. 

If  an  indication  for  immediate  delivery  on  the  part  of  the  mother  or  child 
exists,  it  may  be  better  to  perform  version  and  extraction,  and  the  same  may  be 
said  of  minor  degrees  of  pelvic  contraction.  In  placenta  praevia  and  prolapse  of 
the  cord  version  is  the  operation  of  choice. 

Version 

Version,  or  "turning,"  is  an  operation  which  changes  the  polarity  of  the  fetus 
with  reference  to  the  mother,  the  object  being  to  change  an  abnormal,  or  relatively 
abnormal,  relation  into  a  normal,  or  relatively  normal,  one.  Thus  version  may 
change  a  transverse  presentation  to  a  longitudinal  one,  or  a  head  presentation  to 
one  of  breech. 

Version  is  also  very  useful  as  a  preparatory  operation  before  rapid  delivery, 
when  the  latter  is  indicated  by  the  condition  of  the  mother  or  child.  Version  is 
only  a  preparatory  operation.  When  it  is  completed,  the  indication  for  it  is  satis- 
fied. A  new  indication  must  be  present  for  the  extraction,  which  may  not  follow 
without  such  indication. 

Version  bringing  down  the  head  is  called  "cephalic,"  and  when  the  breech  is 
brought  down,  "podalif."  Version  may  be  done  })y  purely  external,  by  internal, 
and  by  combined  manipulation — sometimes  called  "  })ipolar."  Nowadays  the  purely 
internal  version  is  not  done,  but  always  the  external  hand  is  used  to  aid  the  internal 
one. 

Internal  cephalic  version  was  done  even  before  Hippocrates'  time,  and  was  generally  pre- 
ferred to  podalic  because  of  the  belief  that  the  child  could  best  be  born  if  it  came  head  first.     Celsus, 


PREPARATORY    OPERATIOxNS — PREPARATION    OF    THE    BOXY    PEL\IS 


935 


about  IIh'  time  of  ('liiist,  Soruiius,  one  liiiiiilrc<l  ypars  iiftcr,  and  Aetius  (sixth  century  a.d.) 
pcrt'onncd  podalic  vcision,  Imt  this  knowledge  was  lost  in  tiic  (hirk  afics,  until  Anihroiso  Paro, 
in  If).')!),  dcscriljcd  and  very  successfully  performed  the  operation.  W'icKand,  in  1S()7,  introdurocl 
external  version,  hut  the  procedure  had  been  {)r('viously  used  in  Japan  and  Mexico  as  an  enipirin 
measure  during;  pre^iiiancy  to  fa\-or  labor,  and  by  I'eciiey  in  I'^n^^land  as  early  as  lOlJS.  llolil, 
in  ISh"),  Wrifiht,  of  Cincinnati,  in  1S.J4,  and  Braxton  Hicks,  in  ISOO,  perfected  the  combined 
methods  of  \-ersion. 


Presentation.— If  rccognizod  (liirin.2;  pregnancy,  the 
chihl  may  l)c  changed  by  the  wcjinan  a.ssuiiiing,  when  in 


Version  in  Transverse 
transverse  position  of  th( 
bed,  a  posture  which  favors  descent  of  the  liead — that  is,  she  should  he  on  that  side 
on  which  the  head  hes.  The  breech  then  faUs  over  to  the  side,  the  head  sUding  over 
the  inlet.  In  spite  of  a  snugly  fitting  binder  the  child  may  not  remain  in  the  new 
relation.  Even  during  the  first  stage  of  labor  postural  treatment  is  to  be  tried, 
but  here  external  cephalic  version  is  the  operation  of  choice  if  operation  is  needed. 


Fin.   S23. — Wiegand's  External  Version. 

Unquestionably,  cephalic  presentation  is  the  most  favorable  for  mother  and  child, 
and  we  should  try  to  bring  the  head  into  the  inlet  by  external  cephalic  version, 
governed,  however,  by  the  following  conditions:  (1)  There  should  be  no  contrac- 
tion of  the  pelvis  unless  pubiotoni}^  is  in  anticipation,  and  the  child  may  not  be  too 
large;  (2)  there  should  be  no  immediate  or  prospective  indication  for  the  rapid 
termination  of  labor,  because  if,  under  such  circumstances,  the  head  did  not  at 
once  engage,  another  operation — podalic  version — would  of  necessity  have  to 
follow;  (3)  the  fetus  must  be  very  movable,  which  means  that  the  bag  of  waters 
must  be  intact  and  the  pains  absent  or  weak.  Placenta  prnevia.  prolapse  of  the 
cord,  and  monstrosities  are  contraindications,  and  a  fat  or  tender  abdomen  may 
make  the  manoeuver  impossible. 

Cephalic  version  has  very  limited  application,  l^ut  I  am  convinced  it  is  used 
less  often  than  it  should  be.  ]Most  accoucheurs  prefer  to  wait  for  complete  dilata- 
tion and  then  do  podalic  version  and  extraction. 

Wiegand's  Method. — Anesthesia  is  rarely  needed,  but  the  patient  must  learn  to  relax  the 
belly-wall.     By  using  a  partial  Trendelenburg  posture  the  child  falls  away  from  the  inlet  and 


936  OPERATIVE    OBSTETRICS 

becomes  more  movable.  One  hand  is  placed  ovei"  the  breech,  the  other  over  the  head,  and  by 
alternate  stroking  and  pushing  movements  the  head  is  brought  over  the  inlet.  Operating  between 
pains  one  holds,  during  the  time  the  uterus  is  contracting,  what  has  been  gained.  Time  is  no 
object,  and  force  may  not  be  used.  Now  the  foot  of  the  table  is  lowered,  and  the  head  forced 
do\^-n  into  the  inlet,  where  it  is  held  for  five  minutes  or  until  the  pains  fix  it  there.  If  the  cervix 
is  completely  dilated,  and  if  the  cord  or  the  extremities  have  not  prolapsed,  the  bag  of  waters 
may  be  ruptured,  still  holding  the  head  firmly  in  the  inlet.  If  the  cervix  is  not  dilated,  or  if  the 
cord  lies  over  the  os,  the  membranes  may  not  be  ruptured.  Combined  internal  and  external 
version  to  bring  the  head  over  the  inlet  is  almost  never  practised  nowadays,  though  it  should  be. 

Podalic  Version. — When  version  or  turning  is  mentioned,  it  is  usually  the 
podalic  one  that  is  meant,  and  it  is  preferred,  because — (1)  As  a  rule,  cephalic 
version  is  too  difficult  or  impossible;  (2)  there  is  an  immediate  or  prospective  indi- 
cation, either  on  the  part  of  the  mother  or  the  child,  for  rapid  delivery;  and  (3) 
there  is  often  slight  pelvic  contraction.  Lately  the  latter  indication  is  being  much 
restricted  in  favor  of  pubiotomy  and  cesarean  section.  If  a  case  of  transverse 
presentation  occurs  in  a  contracted  pelvis,  the  pelvis  and  not  the  presentation  of 
the  child  decides  the  course  to  pursue. 

Very  few  operators  try  to  turn  by  the  breech  with  external  manipulations 
alone,  but  I  have  several  times  succeeded  in  doing  so,  and  it  is  almost  always  pos- 
sible if  the  case  is  simply  one  of  deflected  breech  presentation.  There  are  two 
methods  of  combined  or  bipolar  version  which  are  employed,  according  as  the 
cervix  is  open  enough  to  admit  the  hand  or  only  enough  for  one  or  two  fingers. 
The  name  of  Braxton  Hicks  is  most  often  associated  with  the  last  method,  because 
he  did  so  much  to  popularize  it.  The  other  method  might,  with  propriety,  be 
called  "bimanual"  version. 

Which  of  these  methods  is  used  depends  on  the  condition  of  the  cervix  and  the 
mobility  of  the  fetus.  If  the  cervix  is  completely  dilated,  bimanual  version,  rup- 
turing the  bag  of  waters,  is  performed.  If  the  cervix  is  not  dilated  and  the  bag  of 
waters  is  intact,  it  is  best  to  wait.  One  may  not  go  away,  but  should  stay  by  the 
patient  so  as  to  interfere  when  needed.  If  the  cervix  will  admit  only  two  fingers, 
but  the  bag  of  waters  is  ruptured,  Braxton  Hicks'  version  is  indicated.  It  is  dan- 
gerous to  wait  after  the  bag  of  waters  is  ruptured  for  the  cervix  to  dilate  to  a  size 
sufficient  to  allow  the  hand  to  pass  through.  Braxton  Hicks'  version  should  be  con- 
sidered, and  if  not  thought  feasible,  a  metreurynter  should  be  put  into  the  lower  uter- 
ine segment  to  preserve  the  balance  of  the  liquor  amnii,  to  keep  the  shoulder  away 
from  the  inlet,  and  to  prevent  prolapse  of  the  cord  and  extremities.  When  the 
cervix  is  well  dilated,  the  time  is  ripe  for  the  bimanual  version.  Should  an  indica- 
tion on  the  part  of  the  child  for  rapid  delivery  arise  before  full  dilatation  is  accom- 
plished, the  various  methods  of  opening  the  cervix  must  be  taken  up  as  additional 
preparatory  measures.  Version,  followed  by  extraction  through  an  only  partly 
opened  cervix,  is  a  dangerous  and  often  fruitless  operation. 

Bimanual  Version  in  Trojisverse  Presentation. — Few  operations  are  so  satis- 
factory as  version,  but  none  is  more  dangerous  if  performed  without  due  consider- 
ation of  the  conditions. 

Conditions. — (1)  The  cervix  must  be  dilated  enough  to  allow  the  hand  to  pass, 
and  if  the  version  is  done  in  the  presence  of  an  indication  for  extraction  also, 
it  must  be  fully  dilated;  (2)  the  pelvis  may  not  be  too  much  contracted — this 
in  view  of  the  extraction  to  follow;  (3)  the  uterus  may  not  be  in  tetanus  or 
retracted  over  the  fetus — that  is,  the  case  may  not  be  one  of  neglected  transverse 
presentation  with  the  uterus  on  the  point  of  rupture ;  (4)  the  child  must  be  mobile, 
that  is,  not  engaged,  or  in  the  process  of  spontaneous  evolution;  (5)  unless  the 
version  promises  to  be  exceptionally  easy,  the  child  must  be  living. 

The  third  and  fourth  conditions  require  most  careful  thought;  indeed,  it  is 
at  this  point  that  the  art  of  the  accoucheur  comes  into  play.  To  know  when  it  is 
safe  to  turn  and  when  the  risks  of  rupture  of  the  uterus  are  too  great  requires  much 
experience  and  delicate  judgment.     Only  too  easy  is  it  to  rupture  a  thinned  lower 


PREPARATORY  OPERATIONS — PREPARATION  OF  THE  BONY  PELVIS 


937 


uterine  segment,  and  the  inexperienced  aeeouciieur  would  do  better  to  err  on  the 
side  of  safety  to  the  mother.  It  is  impossible  to  lay  down  a  set  rule  as  to  how  long 
after  the  rupture  of  the  membranes  a  version  is  still  permissible.  All  depends  on 
the  degree  of  retraction  and  contraction  of  the  uterus.  The  longer  the  time,  the 
more  difficult  and  dangerous  the  operation.  I  have  done  a  turning  three  days  after 
the  membranes  rui)tured,  and  again  have  found  it  impossible  two  hours  afterward. 
The  preparations  are  the  same  as  for  all  obstetric  operations.  The  instruments 
required  are  those  for  the  operation  chosen  for  the  delivery  of  the  child — as  forceps 


Fig.  S24. — Version.  Fibst  Motion.  Hand  Inside  PrsHEs  rp  the  Shoulder  and  Frees  it  from  Grasp  of  the 
Uterus  by  Smoothing  Away  the  Uterine  Wall. 
In  passing  the  hand  through  the  vulva  the  labia  are  to  be  widely  parted;  the  direction  is  at  first  downward 
toward  the  sacral  hollow,  then  upward  in  the  axis  of  the  inlet,  sinking  the  elbow  downward,  and  the  motion  should  be 
spiral,  from  left  to  right.  The  hand  is  well  lubricated  with  lysol  solution.  While  the  outside  hand  steadies  the 
uterus,  the  inner  one  gently  pushes  up  the  shoulder,  and,  by  stroking  the  uterine  wall,  frees  it  from  its  grasp  on  the 
child,  at  the  same  time  noting  its  thinness,  or  perhaps  any  present  break  in  its  surface. 


or  breech  extraction.  For  the  version,  several  slings  are  to  be  provided,  smooth 
tape  a  yard  or  more  long  and  3^  inch  wide,  and  some  sort  of  sling-carrier.  Profound 
narcosis  is  needed  for  the  actual  turning,  but  later  a  lighter  sleep  is  preferable. 
INIost  often  the  dorsal  posture  is  sufficient,  but  in  back-posterior  positions  and 
pendulous  belly  the  lateral  (the  one  on  which  the  child's  feet  are)  may  be  required. 
A  modified  Trendelenburg  may  be  used  instead.  One  is  here  governed  by  surround- 
ing conditions. 

"Which  hand  shall  he  introduced?     That  hand  whose  palm  will  lie  against  the 
breech  when  in  the  uterus — when  the  breech  is  to  the  left,  the  right,  when  to  the 


938  OPERATIVE    OBSTETRICS 

right,  the  left,  hand.  The  bag  of  waters  is  usually  ruptured;  it  not,  the  membranes 
are  to  be  opened  just  as  the  hand  passes  the  cervix;  the  forearm  then  will  fill  the 
vulva  and  prevent  the  escape  of  all  the  liquor  amnii. 

Wliich  foot  is  to  be  seized?  All  authorities  recommend  to  bring  down  the  lower 
foot  in  back-anterior  presentations,  and  Simpson  and  Hohl  urged  to  get  the  upper 
one  in  back-posteriors.  They  claimed  that  then  the  back  of  the  baby  would  rotate 
so  as  to  come  anteriorly,  which  would  be  more  favorable  in  the  subsequent  extrac- 
tion.    This  is  my  practice,  but  in  cases  where  it  is  at  all  difficult  to  reach  the  feet, 


Fig.  825. — Version.  Second  Motion.  Hand  Seizing  Foot. 
Pa.ssing  the  hand  directly  aloriK  the  belly  or  .side  of  the  fetus,  taking  oarc  to  avoid  the  cord,  the  fingers  touch, 
successively,  thigh,  knee,  and  ankle.  Aided  by  the  outside  hand,  the  upper  foot  is  pressed  into  the  grasp  of  the 
thumb  and  the  two  first  fingers,  which  seize  it,  without  making  the  hand  into  a  knobby  fist.  This  ia  avoided  because 
the  uterus  might  tear  over  the  sharp  knuckles,  and,  further,  the  fist  and  the  body  of  the  child  make  too  wide  a  mass 
for  the  safety  of  the  lower  uterine  segment. 

I  usually  take  that  one  which  I  first  identify  as  such.  The  version  is  to  be  made 
on  one  foot,  if  possible.  This  leaves  the  other  leg  and  thigh  to  add  volume  to  the 
breech  end  of  the  fetal  pole,  and  thus  produce  greater  dilatation  of  the  cervix, 
which  renders  the  passage  of  the  head  easier. 

What  to  do  with  a  prolapsed  arm?  It  is  best  to  put  a  sling  on  it,  then  lay  the 
end  of  the  tape  in  one  groin.  Later,  during  the  extraction,  an  assistant  keeps  up. 
light  traction  on  it  to  hold  the  arm  alongside  the  trunk.  This  is  good  practice,  as 
it  dilates  the  cervix  more  and  renders  much  easier  the  delivery  of  the  arms  and 


PUKI'AUAroKV    OTKItATIONS — PHEPAKATIOX    OF    TFIE    HOXY    PELVIS 


939 


sh()ul(lpr-sil•(ll(^  I  often  ])rins  down  the  arm  purposely  to  put  a  sling  on  it.  Should 
the  arm  prolapse  hetore  the  cervix  is  jirepared  for  delivery,  it  may  be  replaced  in 
the  uterus  and  a  bag  inserted  1o  jjrocure  complete  dilatation. 

After  the  version  is  complete,  the  operator  has  fulfilled  the  indication  for  which 
the  operation  was  done.  He  assures  himself  that  the  child  is  in  good  condition 
(fetal  heart-tones),  and  that  the  i)lacenta  has  not  been  abrupted  by  the  manipula- 


Fio.  S26. — Version.     Third  Motion. 

Grntly  the  foot  is  drawn  into  the  pelvis,  shding  it  down  the  wall  of  the  uterus  behind  the  pubis.  In  back-anterior 
presentations  the  foot  is  led  down  posteriorly  near  the  sacro-iliae  joint,  where  there  is  more  room.  The  outside  hand 
aids  the  turning  by  pressing  the  head  toward  the  midline  and  upward.  During  the  uterine  contmrtion  no  motion  mny 
be  maile:  tlie  hands  are  to  lie  absolutely  quiet.  Between  pains  the  operation  is  renewed.  M  all  stages  the  back  of  the 
internal  hand  should  feel  the  wall  of  the  uterus  and  discover  a  separation  of  its  fibers,  or  a  beginning  abruptio  placenta. 
When  the  knee  has  passed  the  vulva,  the  version  is  complete;    the  head  will  now  be  found  in  the  fundus 

If  there  is  difficultv  in  performing  this  act — the  actual  turning — see  that  the  narcosis  is  deep  enough  to  paralyze 
the  uterus;  pass  the  h.-ind  around  the  child  to  find  if  the  shoulder  is  caught  on  the  pelvic  brim;  then,  if  necessary, 
bring  down  both  legs.  .       .  . 

If,  during  the  operation,  the  hand  instead  of  the  foot  be  brought  down,  no  harm  is  done — a  sling  is  put  on  it.  It 
is  rare  not  to  be  able  to  reach  the  feet — then  the  knee  may  be  pulled  down.  If  the  cord  prolapses,  the  version  must  be 
hurried.  Such  an  accident  is  to  be  avoided,  if  possible,  and  shows  the  wisdom  of  procuring  complete  dilatation  before 
turning.  Should,  during  the  operation,  a  beginning  rupture  of  the  uterus  be  discovered,  further  attempts  to  turn  are 
too  dangerous — cesarean  section  is  considered,  and,  if  this  is  contraindicated,  embryotomy  is  required. 


tions  (external  hemorrhage  and  bad  heart-tones);  further,  he  has  nothing  to  do. 
Often  during  the  version  the  child  suffers  and  the  heart-beat  may  be  very  slow 
after  the  turning  is  completed.  It  is  wise  to  w^atch  a  while  before  extracting,  be- 
cause usually  the  child  recovers  quickly.  A  hasty  delivery  would  hurt  the  child 
more — its  chances  would  be  improved  by  a  short  respite.  It  is  best  to  leave  the 
delivery  to  nature,  but  the  accoucheur  may  not  leave  the  woman.  She  is  to  remain 
on  the  table,  or  temporarily  put  in  a  bed  near  by.     If  an  indication  on  the  part  of 


940 


OPERATIVE    OBSTETRICS 


the  mother  or  child  arises,  extraction  may  be  performed  in  the  classic  manner. 
Expediency — ^for  example,  the  accoucheur  not  having  time  to  await  the  natural 
expulsion  of  the  child — is  a  poor  indication  for  extraction. 

Podalic  Version  in  Head  Presentation. — Indications. — (1)  Abnormal  attitude 
of  the  child — face  and  brow,  anterior  and  posterior  parietal  bone  presentation.  In 
face  and  brow  cases  version  is  preferred  by  many  to  attempts  to  convert  the  pres- 
entation to  an  occipital.  If  the  face  or  brow  case  is  complicated  by  a  prolapsed 
cord  or  placenta  prsevia,  etc.,  version  is  the  operation  of  choice,  when  vaginal  deliv- 
ery is  to  be  attempted.  Anterior  and  posterior  parietal  bone  presentation  usually 
are  caused  by  contracted  pelvis,  and  this,  not  the  abnormal  presentation,  should 
give  the  indication ;  (2)  prolapse  of  the  cord  and  of  extremities ;  (3)  placenta  prsevia ; 
(4)  any  complication  on  the  part  of  the  mother  or  child  which  demands  the  rapid 


Fig.  827. — Version  in  Sc.L.P.,  with  Patient  on  Side. 
For  baok-posterior  positions,  the  lateral  posture  or  a  modified  Trendelenburg  is  best.  The  hand  is  to  be  passed 
behind  the  pubis  anteriorly,  but  enters  the  vagina  and  rounds  the  inlet,  as  in  Sc.L.A.,  the  elbow  being  well  depressed. 
Preferably,  the  upper  foot  is  grasped,  but  not  if  there  is  too  much  trouble  to  get  it.  This  turns  the  child's  back  to 
the  front,  but  if  the  lower  foot  needs  be  taken,  it  is  easy,  in  the  following  extraction,  to  favor  rotation  of  the  trunk, 
so  as  to  bring  the  back  anteriorly. 


termination  of  labor,  when  the  conditions  for  forceps  are  not  fulfilled,  for  example, 
non-engagement  of  the  head;    (5)  contracted  pelvis  of  mild  degree. 

The  last  indication  is  the  most  discussed  one,  and  is  not  yet  settled.  The 
operation  of  version  for  contracted  pelvis  is  called  "prophylactic  version" 
(Fritsch),  and  comes  into  competition  with  prolonged  expectancy,  and  later,  if  the 
head  does  not  engage,  with  the  high  forceps.  Pare,  in  1550,  recommended  this 
operation,  and  it  has  been  done  ever  since.  The  question  is,  does  the  head  pass 
through  a  slightly  contracted  pelvis  easier  coming  last  than  going  first?  Ex- 
perience and  experiment  on  the  cadaver  prove  that  it  does,  but  it  has  to  come 
through  quicker,  and  as  a  result  many  babies  die.  Wolff  and  Leopold  showed 
that  the  results  were  about  the  same.  The  amount  of  damage  done  the  children 
and  the  mother  is  about  equal ;  it  remains,  therefore,  a  matter  of  personal  choice. 
British  accoucheurs,  prominently  Kerr,  have  given  up  prophylactic  version  in  favor 
of  prolonged  expectancy  and  forceps,  which  is  the  position  I  take  in  the  matter. 


PREPARATORY  OPERATIONS — PREPARATION  OF  THE  BONY  PELVIS      941 

Conditions. — (1)  The  cervix  must  he  dilated  cnouf!;!!  for  the  method  of  version 
chosen,  and  if  the  operatitm  is  done  to  save  the  child,  it  must  ahvaj's  be  fully  effaced 
and  dilated;  (2)  the  head  must  be  movable,  not  engaged,  but  under  profound 
anesthesia  an  ai)parently  fixetl  head  may  often  be  easily  pushed  up  into  the  false 
pelvis;  (3)  the  pelvis  must  be  roomy  enough  for  the  extraction  to  follow;  (4)  the 
soft  parts  may  not  be  too  rigitl — in  primiparie  version  is  to  be  restricted  to  the 
minimum  possible;  with  some  accoucheurs  primiparity  contraindicates  version; 
(5)  the  uterus  may  not  be  in  tetanus  or  on  the  point  of  rupturing. 

Mclhods. — Of  these  there  are  three:  Wiegand's  external  ver.sion,  the  bimanual, 
or  combined  internal  and  external,  using  the  whole  hand  in  the  uterus,  and  Braxton 


Fig.  828. — Pod.\.lic  Version  in  Occiput  Present.vtion.     Gr.\sping  the  Foot. 
Inserting  the  hand  past  the  head  into  the  lower  portion  of  the  uterus,  the  operator  quickly  perceives  if  there  is  any 
dangerous  thinning  of  the  wall  or  if  the  contraction  ring  is  tetanically  contracted  about  the  child's  neck,     .\ided  by 
the  outside  hand  forcibly  pressing  the  breech  down,  the  anterior  foot  is  seized  by  the  inner  hand  witliout  flexion  of 
the  fingers.     Deep  narcosis  is  required. 

Hicks',  inserting  only  one  or  two  fingers  through  the  cervix.  "\Miat  was  said  about 
version  in  shoulder  presentation  regarding  preparations,  posture,  hand  to  choose, 
bag  of  waters,  prolapse  of  the  cord,  and  rupture  of  the  uterus  applies  here.  The 
anterior  foot  is  the  one  to  seize,  because  it  brings  the  back  to  the  pubis.  In  face 
cases  it  is  necessary  to  pass  the  hand  far  up  into  the  fundus,  but  it  is  also  Anse  first 
to  bend  in  the  child's  chest  curve  and  force  the  l^reech  do^m  onto  the  internal  hand, 
making  the  child  more  of  a  ball  than  of  long  cylinder  shape.  The  "double  manual,  " 
a  procedure  invented  by  Justine  Sigmundine,  consisting  of  pulling  on  a  sling  at- 
tached to  the  leg  while  pushing  the  head  up  with  the  hand  from  the  inside,  and  the 
mahoeuver  illustrated  in  Fig.  831,  are  often  needed. 


942 


OPERATIVE    OBSTETRICS 


Braxton  Hicks'  version  has  a  limited  application  because,  in  cases  where 
version  is  indicated,  it  is  almost  always  desirable  to  be  in  a  position  to  extract  the 
child  when  the  turning  is  complete,  and,  too,  as  we  have  seen,  often  an  accident 
happens  during  the  operation  which  demands  immediate  extraction.  Therefore 
the  author  recommends,  in  all  cases  where  possible,  to  procure  complete  dilatation 
of  the  cervix  before  attempting  to  turn  the  child. 


Fia.  829. — PoDALic  Version  in  Occipital  Presentation. 
While  drawing  the  foot  down  in  the  axis  of  the  inlet,  the  outside  hand 
pushes  the  head  of  the  child  directly  inward  toward  its  belly,  thus  making  a 
ball  of  its  body,  which  thus  rotates  better  in  the  uterus.     When  the  knee 
is  at  the  vulva,  the  pressure  on  the  head  by  the  outside  hand  is  upward. 

The  main  indication  for  Braxton  Hicks'  version  is  placenta  prsevia.  It  is 
sometimes  done  for  prolapse  of  the  cord,  occasionally  in  shoulder  presentations,  and 
very  exceptionally  to  turn  the  head  down  in  breech  presentation.  The  conditions 
are  the  same  as  for  the  operation  last  described,  but  the  mobility  of  the  fetus  must 
be  absolutely  free. 

Cephalic  Version  in  Breech  Presentation. — While  this  is  the  very  oldest  kind 
of  version,  it  is  performed  the  least  often.     It  was  done  by  the  ancients -because 


PREPARATORY  OPERATIONS — PREPARATION  OF  THE  BONY  PELVIS 


943 


th(.'y  considcivd  all  other  than  ci-pluilic  presentations  pathologic  antl  insuperal)le. 
During  pregnancy,  if  ])reecii  presentation  is  discovered,  an  attempt  to  change  it  by 
external  nuinipulation  is  justifiable,  though  it  <loes  not  always  succeed.  The  knee- 
chest  posture  assumed  three  or  four  times  daily  may  facilitate  the  rotation  of  the 
fetus.     During  labor  in  a  primipara  with  breech  prcsentaticni,  with  or  without  a 


Fig.  830. — Applyinc.  a  Sung  to  Foot  with  Morales'  Sling-carrier. 
If  the  foot  cannot  be  readily  grasped  or  does  not  give  purchase 
enough  for  traction,  a  sHng  may  be  put  on  it.  The  ringed  laar  of 
Morales  is  mounted  on  the  middle  and  fourth  fingers,  a  tape  adjusted 
over  it  like  a  pulley,  and  the  loop  spread  out  by  the  little  finger  and 
thumb.  When  the  loop  has  been  adjusted  around  the  part  to  be 
grasped  (the  foot  or  hand),  pulling  on  the  tape  draws  the  loop  upward 
and  tightly  around  the  member. 


Fig.  831. — Shof.-horn  Manceuter. 
If  the  head  is  arrested  by  the  contrac- 
tion ring  catching  in  the  nape  of  the  child's 
neck,  one  hand  may  be  used,  after  the 
manner  of  a  shoe-horn,  while  the  other 
pulls  on  a  sling  attached  to  the  foot.  It 
is  rarely  advisable  to  bring  down  the  two 
legs,  but  this  and  Sigmundine's  manceuver 
may  often  be  found  useful. 


contracted  pelvis,  it  may  ])e  desirable,  though  seldom  possil^le,  to  Ijring  the  head 
do^^^l.  Cephalic  version  might  also  be  a  preparatory  operation  before  pubiotomy. 
The  dangers  of  the  operation  are  detachment  of  the  placenta,  coiling  and  prolapse 
of  the  cord,  and  recurrence  of  the  breech  presentation.  The  usual  conditions  for 
version  must  be  insisted  on,  especially  full  mobility  of  the  child,  but  the  presence 


944 


OPERATIVE    OBSTETRICS 


of  a  contracted  pelvis  may  not  cancel  the  indication  if  a  pelviotomy  is  to  be  performed 
eventually. 

Version  may  be  accomplished  by  external  manipulations,  by  inserting  the  whole 


Fig.  8.32. — Braxto.v  Hicks'  Version. 
While  the  whole  hand  lies  in  the  vagina,  only  one 
or  two  fingers  pa.ss  through  the  cervix.  The  head  is 
pushed  away  from  the  inlet  and  upward,  while  the  out- 
aide  band  pres-ses  the  breech  in  the  opposite  direction — 
that  is,  downward  toward  the  inside  fingers. 


Fig.  833. — Braxton  Hicks'  Version. 
Forcing  foot  into  grasp  of  two  fingers.  Seizing  the 
foot  is  not  always  easy,  since  it  may  slip  from  between 
the  fingers,  and  a  blunt  ring  forceps  (Fig.  690)  or  long 
polypus  forceps  may  be  then  used.  After  the  foot  is 
down  in  the  vagina  the  head  is  pushed  up  as  usual. 


hand,  and  Ijy  the  Braxton  Hicks'  method.  The  breech  is  pushed  upward  and  to 
one  side,  while  the  hand  outside  strokes  the  head  along  the  inner  wall  of  the  abdo- 
men toward  the  inlet.     When  it  has  been  brought  over  the  brim,  it  is  grasped  as 


PREPARATORY  OPERATIONS — PREPARATION  OF  THE  BONY  PELVIS      945 

in  Fig.  818,  p.  i)2!),  und  toned  down  into  the  pelvis,  or  pulled  in  1)\'  llie  forceps.  In 
these  cases,  also,  it  is  wise  to  procure  full  eularf^cineiit  (jf  the  cervical  canal  before 
operating,  so  as  to  he  able  to  care  for  all  po.ssihle  accidents — for  example,  prolapse 
of  the  cord  or  abruptio  i)lacenta3 — by  iinniediate  delivery. 

The  prognosis  of  version  nuiy  never  be  lightly  estimated.  It  depends  largely 
on  the  skill  of  the  operatoi-.  The  operation  may  be  directly  fatal  to  the  mother 
from  rupture  of  the  uterus,  of  the  cervix,  or  from  abruptio  placenta?.  The  danger 
of  rupture  of  the  uterus  during  version  cannot  be  too  strongly  emphasized.  For 
the  child,  the  conditions  requiring  the  interference  usually  determine  the  outlook. 
Th(>  turning  itself,  unless  unduly  i)r()longed  by  complications,  by  abruptio  placentae, 
or  by  prolapse  of  the  cord,  affects  the  infant  but  little. 

Literature 

Kerr:  Operative  Midwifery. — Morse:  Surgery,  Gyn.  ami   Ol^stetrics,   February,  1912. — Sloeck-el:  Praktische  Ergeb- 
iiiase,    Geb.    u.    Gyn.,    1911,    Heft    I. —  WiUiamis:     Aiuer.  Jour.  Obstet.,  July,  1911. 


60 


CHAPTER  LXXI 
OPERATIONS  OF  DELIVERY 

Under  this  heading  will  be  considered  those  operations  which  remove  the 
child  from  the  parturient  canal — breech  delivery,  forceps,  craniotomy,  and  cesarean 
section.  The  technical  term  "extraction"  would  apply  to  all  such  manoeuvers, 
but  usage  has  limited  it  to  the  removal  of  the  unmutilated  child  through  the  natural 
passages. 

EXTRACTION 

General  Indications. — Why  should  we  desire  to  deliver  the  woman?  Why 
must  we  extract  the  child?  Here  is  the  broad  indication  in  a  few  words.  We 
deliver  the  child  because  the  mother  is  unable  to  do  so.  The  indication  for  extrac- 
tion, therefore,  is  insufficiency  of  the  powers  of  labor,  and,  as  Schauta  did,  this 
general  indication  may  be  subdivided  into,  first,  absolute  weakness  of  the  powers; 
second,  relative  insufficiency;  third,  insufficiency  of  the  powers  in  relation  to  the 
necessary  rapid  termination  of  labor.  Under  the  first  head,  actual  weakness  of 
the  forces  of  labor,  may  be  mentioned  weak  pains  from  maldevelopment  of  the 
uterus,  fibroids,  overdistention,  poor  innervation,  tetanus  uteri,  hour-glass  con- 
traction, infantilism,  rupture  of  the  uterus,  generally  poor  muscular  development, 
diastasis  recti,  inflammatory  conditions  in  the  abdominal  cavity  which  weaken 
the  abdominal  muscles,  etc. 

Relative  insufficiency  of  the  powers  may  be  due  to  increase  of  the  resistances 
offered — (a)  on  the  part  of  the  mother,  such  as  rigidity  of  the  cervix,  vagina, 
perineum;  contracted  pelvis;  tumors  of  the  passage;  and  (b)  on  the  part  of  the  child, 
such  as  overgrowth,  hydrocephalus,  malpresentations,  malpositions,  etc.  The 
pains  may  be  strong  or  even  stronger  than  usual,  yet  unable  to  complete  delivery. 

Insufficiency  of  the  powers  in  relation  to  the  desired  rapidity  of  the  delivery  is 
a  very  common  indication  for  extraction.  The  powers  may  be  sufficient  and  effi- 
cient, the  resistances  may  be  normal  or  even  less  than  normal,  and  the  woman  could 
complete  the  labor  unaided,  but  a  complication  has  arisen  demanding  immediate 
delivery,  A  few  may  be  cited — on  the  part  of  the  mother,  eclampsia,  acute  and 
chronic  pulmonary  and  heart  diseases,  hernia,  appendicitis,  hemorrhage  from  the 
genitals  or  from  the  lungs,  etc.,  and,  on  the  part  of  the  child,  asphyxia  threatening 
from  any  cause,  or  severe  compression  of  the  brain,  etc. 

General  Conditions. — (1)  The  pelvis  may  not  be  too  severely  contracted. 
A  flat  pelvis  with  a  c(jnjugata  vera  of  less  than  8  cm.  will  very  rarely  permit  a  nor- 
mal-sized child  to  pass,  and  if  the  pelvis  is  a  justominor  one,  a  conjugata  vera  of 
nearly  9  cm.  is  necessary.  If  the  child  is  estimated  to  weigh  over  8  pounds,  the 
conjugata  vera  must  be  over  9  cm.  In  short,  an  absolute  prerequisite  for  extraction 
is  that  there  be  no  insuperable  disproportion  between  the  babe  and  the  pelvis. 
If  pubiotomy  or  embryotomy  is  in  reserve,  the  degree  of  contraction  may  not  go 
below  7}/^  cm.  and  6J^  cm.  respectively. 

(2)  The  cervix  must  be  efl'aced  and  the  os  dilated.  This  condition  is  impor- 
tant in  relation  to  the  ease  of  the  extraction,  the  integrity  of  the  maternal  tissues, 
and  the  life  and  safety  of  the  child.  If  it  is  necessary,  in  the  interests  of  the  infant 
or  the  mother,  to  deliver  before  this  prerequisite  is  fulfilled,  the  cervix  must  be 
opened  by  one  of  the  preparatory  operations — metreurysis,  incisions,  etc.     The 

946 


OPERATIONS    OF    DELUKltY 


947 


evils  of  extra<'ti()n  Ix'lorr  dilatation  is  coinijlctc  have  been  referred  to,  and  will  bear 
reiteration. 

(3)  Before  delivery  the  huf^  oi  waters  must  be  ruptured. 

(4)  With  few  exceptions  one  must  insist  that  the  child  be  living. 

If  the  child  is  dead,  eml)ryotomy  is,  as  a  rule,  a  preferable  operation.     If  in 
doubt,  the  child  gets  the  l)enefit,  within  a  reasonable  limit. 

(5)  In  cephalic  presentations  the  head  nuist  be  engaged  in  the  pelvis,  or  SO 


Fig.  834.— Second  Act  of  Extraction.     Dluvery  of  Breech  to  SnorLDERs. 
An  assistant  makes  continuous  even  pressure  over  the  whole  uterus  with  both  hands.     The  accoucheur  takes 
the  breech  in  two  hands,  with  the  thumbs  over  the  back  of  the  sacrum,  the  index-fingers  resting  on  the  anterior  superior 
spines,  the  others  evenly  distributed  over  the  pelvis  and  thighs.     Gentle,  even  traction  is  made  downward  in  the  di- 
rectioa  of  the  axis  of  the  inlet  until  the  anterior  shoulder-blade  becomes  visible  or  palpable  under  the  pubis. 


nearly  engaged  that  it  is  almost  certain  that  a  slight  pull  from  below  will  complete 
the  engagement.     (]'l(lr  Yorccp^.) 

Extraction  by  the  Breech. — The  reader  is  referred  to  p.  605  for  the  details  of 
the  treatment  of  breech  presentation. 

Manual  Aid. — Even  though  the  majority  of  breech  labors  ends  without  the 
necessity  of  aid  by  the  accoucheur,  it  is  ■\^^se  to  have  the  woman  on  a  proper  table 
and  to  have  all  the  instruments  for  forceps  delivery  and  for  the  repair  of  lacerations 
ready,  with  the  room  cleared  for  operation.  When  the  lireech  has  l^een  delivered, 
the  woman  is  urged  to  bear  dowTi,  failing  which  an  assistant  exerts  strong  pressure 
on  the  child  from  the  abdomen,  and  if  this  does  not  make  rapid  progress,  the  indi- 


948 


OPERATIVE    OBSTETRICS 


cation  for  "manual  aid"  is  present.  In  multiparae  manual  aid  is  seldom  required. 
An  anesthetic  is  used  only  if  the  woman  is  unruly  or  if  the  soft  parts  are  very  rigid. 
In  primiparse  I  make  a  deep  unilateral  episiotomy — on  the  side  on  which  the  occiput 
will  come  down- — as  a  routine  measure.  It  facilitates  all  the  manipulations  of  the 
delivery,  preserves  the  child  from  injury  due  to  the  application  of  force,  saves  time, 
which  lessens  the  danger  of  asphyxia,  and  safeguards  the  sphincter  ani  from  lacer- 
ation. If  the  child  is  astride  the  cord,  the  latter  is  gently  loosened  and  stripped 
over  one  thigh,  failing  which  it  is  cut  between  two  ligatures  and  the  delivery  rapidly 
ended.  The  bladder  is  to  be  empty.  Feces  issuing  from  the  anus  must  be  carefully 
removed,  and  this  part  watched  with  great  solicitation,  because  in  the  hurry  of  the 


Fig.  835. — Delivery  op  Postebior  Arm  and  Shoulder. 
The  posterior  shoulder  and  arm  are  to  be  disengaged  first,  using  the  hand,  whose  palm  will  apply  flat  to  the  child's 
back.  The  other  hand  seizes  the  two  feet  of  the  infant  and  swings  the  body  through  an  arc  toward  the  mother's  groin, 
which  motion  draws  the  shoulder  down  into  the  hollow  of  the  sacrum,  bends  the  child  around  the  ramus  pubis,  and  gives 
more  room  for  the  insertion  of  the  hand.  Leaving  the  thumb  outside,  two  fingers  are  passed  over  the  back,  over  the 
shoulder,  down  the  arm,  lo  the  elbow,  and  wipe  the  arm  over  the  face  and  chest,  down  and  out  of  the  vulva. 


successive  manoeuvers  it  is  only  too  easy  to  soil  the  operating  hand  and  carry 
infection  into  the  uterus.     (See  p.  906.) 

Complete  Extraction. — When  in  breech  cases  an  indication  arises  for  delivery, 
preparations  are  identical  with  those  for  version.  The  operation  itself  is  divided 
into  four  acts:  First,  bringing  out  the  breech  and  legs;  second,  delivery  to  the 
shoulders;  third,  disengaging  shoulder-girdle;  and  fourth,  the  birth  of  the  head. 
Complete  extraction  is  manual  aid  preceded  by  one  act,  i.  e.,  bringing  down  the 
foot  or  feet. 

First  Ad. — How  to  deliver  the  breech  will  depend  on  its  station  or  location  and 
upon  the  attitude  of  the  child.  If  the  breech  is  deeply  engaged  in  the  pelvis,  a 
little  traction  with  the  finger  in  one  groin  may  suffice;  if  one  or  both  feet  are  down, 
traction  is  made  on  the  extremity.  The  following  methods  have  been  employed  to 
deliver  the  breech:  (a)  Bringing  down  one  leg;  (h)  the  finger  in  the  groin;  (c)  the 
use  of  a  fillet  or  sling  placed  over  the  groin;    (r/)  a  blunt  hook,  or  two  hooks,  one  in 


OPERATIONS    OF    DELIVERY 


949 


each  groin,  or  specially  constructed  forceps,  shaped  like  hooks;    (e)  use  of  the 
obstetric  forceps  on  the  breech. 

Of  all  these  methods,  extraction  on  one  or  both  legs  is  by  far  the  best,  and  I 
have  not  yet  met  a  case  where  it  was  impossible  to  get  a  foot  down.  Deep  anes- 
thesia and  the  Trendelenburg  posture  have  always  enabled  me  to  reach  the  extrem- 
ity, no  matter  how  firmly  the  breech  seemed  wedged  into  the  pelvis  at  the  start. 
In  cases  of  contracted  i)elvis,  unless  cei)halic  version  is  to  be  performed,  it  is  advis- 


Fia.  836. — Delivery  of  Anterior  Arm.  Turning  Anterior  Arm  to  Hollow  of  S.^critm. 
Sometimes  it  is  easy  to  pass  two  fingers  over  the  anterior  shoulder  down  to  the  elbow  of  the  anterior  arm  and  dis- 
engage it  from  behind  the  pubis,  in  a  manner  similar,  but  reversed,  to  that  just  described,  but  if  not  easy  on  the  first 
attempt,  the  child  is  allowed  to  fall  onto  the  hand  which  delivered  the  arm,  the  arm  is  laid  as  a  splint  alongside  the  chest, 
the  operator  grasps  the  chest  of  the  child  with  both  hands,  the  index-finger  of  the  second  hand  obtaining  a  purchase 
on  the  anterior  scapula,  and  the  other  fingers  being  evenly  distributed  over  the  thorax.  Then,  with  gentle  rotation,  the 
anterior  arm  is  turned  to  the  back,  following  the  direction  of  the  child's  belly,  and  the  now-posterior  second  arm  and 
shoulder  are  delivered,  reversing  Fig.  S35,  p.  948. 


able  to  liring  down  the  foot,  and  in  pendulous  alxlomen  it  is  also  desirable,  the  leg 
Straightening  out  the  child  in  the  axis  of  the  inlet,  which  permits  the  uterus  to 
work  to  good  advantage.  In  single  breech  presentations  the  manoeuver  is  the 
hardest  to  carry  out;  in  double  breech,  two  fingers  may  be  able  to  grasp  the  ankle, 
which  lies  near  the  internal  os.  The  anterior  limb  is  to  be  selected  whenever  pos- 
sible, because  this  brings  the  back  to  the  pubis,  but  if  too  much  trouble  is  experi- 
enced, the  posterior  one  is  seized,  and  in  the  subsequent  extraction  due  notice  is 
taken  of  the  mechanism  intended  by  nature. 


950 


OPERATIVE    OBSTETRICS 


Delivery  by  the  finger  in  the  groin  is  the  least  harmful  of  all  the  other  methods 
mentioned,  which  possess  real  dangers  of  injuring  the  skin,  vessels,  and  nerves  in 
the  groin  and  of  fracturing  the  neck  of  the  femur.  The  blunt  hook,  the  fillet,  the 
breech  forceps,  and  the  head  forceps,  in  my  opinion,  should  be  used  only  on  a  dead 
fetus.  But  very  few  authorities  recommend  them,  and  in  my  practice  so  far 
they  have  been  entirely  dispensable.  Barnes,  in  his  immense  experience,  never 
failed  to  bring  do^^^l  a  leg. 

The  second,  third,  and  fourth  acts  of  extraction  have  been  fulty  described  under 
Manual  Aid  {q.  v.,  p.  947). 

It  remains  to  discuss  the  difficulties  that  are  likely  to  arise  during  the  extraction. 


Fig.  837. — Wiegand-Martin  Method  of  Delivering  the  After-coming  Head. 
Remernboring  the  iiiccliuriism  of  brcffh  hibor,  the  acooucheur  will  know  on  which  side  of  the  pelvis  the  mouth  will 
be.  The  hand  whoso  p.alm  applies  to  the  belly  searches  for  the  child's  mouth,  and  two  fingers  are  passed  into  it  until 
they  come  to  rest  at  the  posterior  angles  of  the  jaw,  the  child  lying  on  the  forearm.  Standing  to  the  patient's  side, 
the  accoucheur  places  the  other  hand  on  the  head  from  the  outside  (having  carefully  pushed  the  intestines  out  of  the 
way),  and,  by  combined  pressure  from  above,  with  very  light  traction  from  below,  the  head  is  brought  down  into  the 
pelvis,  rotated,  and  delivered,  following  the  inc'liitii-iM  usually  adopted  by  nature.  The  chin  is  kept  well  flexed,  and 
when  the  nape  of  the  neck  stems  behind  the  pul.i-,  iIh  <hin,  face,  forehead,  and  vertex  are  brought  slowly  over  the 
perineum.     In  primiparse  episiotomy  is  usually-  pi  i i.jriuc  d. 


Two  facts  require  emphasis  at  the  very  start.  One  is  that  the  mechanism  of  breech 
labor  may  be  pathologic  throughout  its  whole  course,  or  may  rectify  itself  at  any 
point,  and  a  normal  mechanism  may  become  pathologic  at  any  point.  The  other 
is  that  when  an  extraction  is  done  to  save  the  child,  the  conditions  for  dehvery 
must  be  insisted  upon,  especially  the  one  relating  to  the  complete  dilatation  of  the 
cervix.  To  force  the  delivery  through  an  ill-prepared  cervix  is  to  expose  the  mother 
to  the  greatest  danger  of  rupture  of  the  uterus,  and  for  so  much  hazard,  in  all 


OPERATIONS    OF    DKMVERT 


951 


probal)ility,  loso  the  cliild.  Tlic  rif^id  cervix  dclaj's  tho  extraction  so  long  that  the 
chikl  .succunihs,  unless  the  accoucheur  is  prepared  to  make  deep  incisions  into  the 
constricting  structures. 


Fig.  838. — Bringing  Down  Foot.  Pinard's 
Manceuver. 
Passing  the  hand  high  up  into  the  uterus, 
avoiding  the  cord,  which  is  kept  on  the  back  of 
the  hand,  the  index-finger  is  pressed  into  the 
popliteal  space.  This  shortens  the  hamstring 
muscles  and  flexes  the  leg,  upon  which  the 
three  fingers  slip  over  the  knee  to  the  ankle, 
the  foot  now  being  wiped  along  the  other  thigh 
posteriorly  into  the  pelvis  and  out.  During 
the  pains  no  move  may  be  made — the  hand 
should  lie  passive  until  the  uterus  relaxes. 


Fig.  839. — Delivery  of  Anterior  Hip. 
Laying  the  thumbs  parallel  to  the  long  bones  and  distributing 
the  fingers  evenly  over  the  rest  of  the  limb,  traction  is  made  down- 
ward in  the  axis  of  the  inlet  until  the  crest  of  the  ilium  has  passed 
the  ligamentum  arcuatum,  the  hands  being  adjusted  higher  and 
higher  as  the  limb  aiipear.s.  No  bending  nor  twisting  motions  are 
allowable,  and  the  action  must  be  smooth,  not  jerky. 


Complications  During  the  First  Act. — If  the  posterior  leg  is  brought  dowTi,  the 
anterior  hip  may  catch  on  the  pubic  ramus.     Sometimes  the  operator  brings  one 


952 


OPERATIVE    OBSTETRICS 


leg  down  so  that  it  crosses  the  other  which  hes  athwart  the  inlet.  Treatment:  A 
sling  is  put  on  the  ankle  delivered  and  the  other  extremity  brought  out.  Occasion- 
ally the  foot  drags  out  the  cord,  and  this  demands  rapid  dehvery  if  the  conditions 
are  fulfilled. 

During  the  Second  Act. — Large  or  very  fat  babies  or  a  contracted  pelvis  may 
render  the  delivery  from  the  breech  to  the  shoulders  difficult.  Care  must  be  exercised 
in  applying  pressure  to  avoid  injuring  the  abdominal  viscera.  If  more  than  ordinary 
resistance  is  met,  pass  the  fingers  alongside  the  child  to  find  if  a  distended  abdomen 
exists  (for  example,  ascites,  cystic  kidneys,  liver  tumor,  etc.).     With  large  and  fat 


Fig.  840. — Delivery  of  Posterior  Hip. 
As  soon  as  possible  thn  indox-fingor — -only  one  finger — of  the  other  hand  is  passed  over  the  back,  along  the  cyest 
of  the  ilium,  into  the  posterior  groin,  and  with  combined  traction  the  whole  pelvis  is  brought  out,  following  the  usual 
mechanism.     The  second  leg  is  allowed  to  drop  out. 


babies  it  is  wise  to  deliver  the  arms  before  the  shoulders  have  become  wedged  into 
the  pelvis,  therefore,  not  to  draw  the  trunk  down  until  the  scapula  is  palpable  under 
the  pubi,s,  but  to  begin  the  third  act  sooner. 

During  the  Third  Act. — Normally,  the  arms  lie  crossed  over  the  chest,  and  if 
nothing  interferes,  are  delivered  in  this  position.  If  traction  is  made  on  the  body 
too  soon;  if  the  pelvis  is  small;  if  the  cervix  is  not  sufficiently  dilated — the  arms 
may  be  arrested  and  stripped  up  above  the  child's  head  (Fig.  842).  In  such  cases 
it  is  necessary  to  pass  the  four  fingers  high  into  the  pelvic  inlet,  leaving  the  thumb 
outside,  and,  as  usual,  gliding  over  back,  shoulder,  humerus,  elbow,  to  the  forearm; 
this  latter  is  pushed  to  the  side  of  the  pelvis,  wiping  across  the  face  and  then  down 


OPERATIONS    OF   DELIVERY 


953 


and  out.  The  pusti'iior  iinn  is  first  dolivcred.  Episiotomy  is  the  rule  in  primiparse, 
because  the  thickness  of  the  hand  added  to  that  of  the  chest  is  usually  too  much  for 
the  perineum.  It  may  be  well  to  push  the  child  back  a  little  to. loosen  the  arms 
from  the  wedge-like  action  of  tlie  head.     If  it  is  too  hard  to  get  the  posterior  arm, 


Fig.  841. — Delivery  of  Breech  with  Fixger  in  Groin.     Other  Hand  Supports  Wrist. 
In  extracting  the  breech  with  one  finger  in  the  anterior  groin  the  whole  hand  is  placed  in  the  vagina,  the  finger 

E asses  from  in  front,  while  the  thumb  seeks  to  aid  a  better  grasp  on  the  pelvis.  Traction  is  to  be  made  downward, 
ut  the  pull  must  be  toward  the  belly  of  the  child,  to  avoid  injury  to  the  structures  in  the  inguinal  region  and 
fracture  of  the  femur.  This  operation  is  very  tiring,  hence  the  hands  may  be  changed  and  the  wrist  supported  as 
shown.  Episiotomy  and  patience  are  required.  As  soon  as  the  posterior  groin  is  accessible,  the  index-finger  of  the 
other  hand  is  placed  in  it,  and  delivery  of  the  breech  accomplished  easier. 


the  child  may  be  rotated  ventrally  so  as  to  bring  the  anterior  arm  to  the  hollow 
of  the  sacrum,  and  this  arm  is  liberated  first,  then  the  trunk  is  rotated  back  for  the 
first  arm.  If  the  operator's  fingers  are  short,  or  if  the  arm  is  very  high  up,  the  whole 
hand  should  be  passed  in  to  get  the  arms.  Then  the  thumb  should  lie  parallel  to, 
never  opposed  to,  the  fingers,  and  it  may  not  be  used  to  grasp  the  arm.     During 


954 


OPERATIVE    OBSTETRICS 


these  manipulations  the  assistant  should  not  exert  pressure  on  the  fundus  uteri, 
since  this  renders  internal  manipulation  difficult. 

A  second  and  a  bad  complication  occurs  in  the  third  act,  when  the  arms  are 
throAAii  back  into  the  nape  of  the  neck  and  cross  the  pelvis  under  the  head.  This 
is  usually  caused  by  anomalous  rotation  of  the  child's  trunk,  and  is  commoner  after 
version  and  improper  efforts  at  extraction  (Fig.  843).  This  condition  is  recognized 
onlj'  when  the  fingers  are  passed  in  to  liberate  the  posterior  arm.  Without  delay 
the  body  of  the  child  is  pushed  back,  or  stuffed  in  a  few  inches,  to  release  the  arms 
from  their  imprisonment  by  the  head,  and  the  half  hand  inserted  directly  up  the 
child's  back  to  the  forearm.  This,  then,  is  pushed  up,  the  fingers  wiping  the  baby's 
elbow  and  forearm  over  its  face,  past  the  sacral  promontory  to  the  other  half  of 
the  pelvis,  down  and  out.  If  this  does  not  succeed  the  first  time,  the  child  should 
be  pushed  back  a  little  further  and  the  manceuver  tried  once  more,  failing  which  the 
anterior  arm  should  be  liberated.     Grasping  the  chest  as  indicated  in  Fig.  836,  p. 


Fig.  842. — Arms  Stripped  Up.     Whole  Hand  Required  to  Bring  Them  Down. 
The  thumb  may  not  be  used  to  grasp  the  arm. 


949,  the  child  is  rotated  ventrally  so  as  to  bring  the  anterior  arm  behind;  then, 
with  four  fingers  deeply  inserted,  or  even  the  whole  hand,  the  just  mentioned  motion 
with  the  child's  forearm  is  carried  out.  Rotation  of  the  trunk  much  facilitates 
the  release  of  the  arm. 

It  is  not  allowable  to  pull  down  on  the  shoulder  to  make  the  arm  and  elbow 
more  accessible.  Fracture  of  the  clavicle  is  the  certain  result.  Nor  may  the  arm 
be  brought  down  over  the  back,  obviously,  for  the  same  reason.  If  the  accoucheur 
will  go  at  his  work  deliberately,  it  will  not  be  needful  to  exert  brute  force  and  break 
the  clavicle  or  humerus.  To  try  to  deliver  the  head  without  previous  liberation 
of  the  arms  (Deventer)  is  not  good  practice. 

Kiistner  recommended,  where  difficulty  is  apprehended,  to  bring  down  one 
arm  immediately  after  the  navel  appears,  and  Guffey  advises  this  for  all  breech 
cases.  In  version  cases  it  is  good  practice  to  put  a  sling  on  one  arm  prophylac- 
tically. 


OPERATIONS    OF    DELIVKUY 


955 


During  the  Fourth  Act. — Arrest  of  tho  head  may  occur  at  the  pelvic  inlet,  and 
after  it  is  in  the  excavation  or  at  the  outlet.  If  the  child  is  larfi;e  or  the  pelvis  small, 
the  head  wedges  into  the  inlet  with  the  sagittal  suture  in  the  transverse  diameter. 
Extension  occurs  and  the  mouth  is  thrown  up  high — sometimes  above  the  Ijrim. 
Treatment:  \\'i(>gand-IMartin's  method,  remembering  that  the  chin  is  high  up  and 
to  the  side,  that  the  head  mu.st  be  brought  tlirough  the  inlet  in  the  tran.sverse 
diameter,  that  it  should  wA  be  strongly  flexed,  and  that  it  may  not  be  rotated  to 
bring  the  occiput  forward  until  it  is  deep  in  the  excavation.  The  pull  must  be 
downward  in  the  axis  of  the  inlet,  hence  the  patient  is  best  on  a  high  table,  but 
most  of  the  work  is  to  be  done  by  pressure  with  the  outside  hand.     Where  this 


Fig.  843. — Arms  ix  Nape  of  Neck. 


method  fails,  the  ]\Iauriceau-Smellie-Veit  method  is  tried  (Fig.  844).  One  hand 
searches  the  mouth,  and  two  fingers  are  placed,  as  l~)eforc,  on  the  lower  insertions  of 
the  pterygomaxillary  ligaments.  The  other  hand  is  placed  fork-like  over  the 
shoulders,  with  the  finger-tips  resting  on  the  sternum,  not  on  the  sides  of  the  neck. 
The  knuckles  rest  against  the  mastoid  processes.  While  an  assistant  presses  the 
head  forcilily  downward  from  without,  the  operator  pulls  gently,  but  firmly,  down- 
ward from  within,  observing  the  mechanism  just  described.  In  particularly  diffi- 
cult cases  the  Walcher  position  may  be  used,  and  the  operator,  by  pushing  the  head 
to  one  or  the  other  side  of  the  promontory,  maj^  gain  more  room  for  the  large  bipa- 


956 


OPERATIVE    OBSTETRICS 


Fig.  844. — Mauriceau-Smellie-Veit  Method,   Aided  by  GtrTsiDE  Hand. 


Fig.  845. — Fokceps  on  the  After-coming  Head. 
An  assistant  holds  the  child  up  and  out  of  the  way  with  its  arms  behind  the  back,  and  the  blades  are  applied  in 
the  usual  manner.     In  his  hurry  the  operator  may  not  forget  the  usual  precautions  to  safeguard   the   cervix,  pelvic 
floor,  and  the  child. 


OPERATIONS   OF   DELIVERY 


957 


rictal  diameter  to  pass,  or,  l)y  tilting  the  liead  upward  or  downward,  may  seek  to 
briiif^  the  hiparietal  pUme  through  the  inlet  on  a  slant.  Noti  vi,  sed  arte  applies 
with  double  toree  in  this  operation. 

If  the  head  will  not  come  into  the  pelvis  under  the  exhibition  of  moderate  force 
applied  above  and  below,  it  is  best  to  desist,  because  the  end  sought,  a  living  child, 
will  be  defeated  by  the  attempt  itself,  and  the  mother  will  suffer  irreparable  injury. 
Now  there  is  no  occasion  for  hurry.     Craniotomy  should  be  performed.     In  prac- 


FlG, 


S46. — Lettixo  Air  to  Child's  Lrxas  when  Head  is  Arrested  in  Breech  Delivery. 


tice  there  is  usually  no  compunction  about  such  a  course,  since  the  child  has  almost 
always  died  by  this  time. 

Forceps,  useful  later,  are  hardly  applicable  when  the  head  is  high  up  in  the 
inlet.     They  are  then  dangetous  to  the  mother  and  barren  of  results. 

When  the  head  is  arrested  in  the  excavation,  a  quick  examination  determines 
if  the  delay  is  caused  by  the  cervix  or  by  the  bonj''  pelvis.  A  tight  cervix  must  be 
stripped  back  or  cut,  which  is  not  always  a  simple  matter.  If  the  methods  of 
delivery  just  mentioned  do  not  show  immediate  results,  the  forceps  should  be 
applied  to  the  after-coming  head.     ]\Iy  practice  for  years  has  been  to  apply  forceps 


958 


OPERATIVE    OBSTETRICS 


to  the  after-coming  head  if  it  does  not  quickly  follow  moderate  traction,  and  Kerr 
recommends  it  very  highly,  quoting  also  Smellie,  Barnes,  and  Hermann  in  its  favor. 
Williams  opposes  the  practice,  as  do  some  of  the  German  authorities,  though  several 
— Nagel,  Klien,  Kehrer,  Crede,  and  others,  and  French  operators,  Bar  and  Tarnier — 
employ  the  instrument  in  some  cases.  I  am  convinced  that  many  children  will  be 
saved,  that  fracture  of  the  clavicle,  hematoma  of  the  sternomastoid,  dislocation  of 
the  vertebrae,  Erb's  paralysis,  and  many  lesser  injuries  could  be  avoided  if  the 
application  of  the  forceps  to  the  after-coming  head  were  taught  in  the  schools  and 
more  generally  practised.  It  is  a  more  humane  way  of  delivering  the  head  in  cases 
of  moderate  difficulty  than  the  Mauriceau-Smellie-Veit  method.  At  least,  in  all 
breech  cases  the  forceps  should  be  ready  for  use. 

A  very  valuable  manoeuver,  practised  for  many  centuries,  is  the  retraction  of  the 


Fig.  847. — Bringing  Down  Arms  in  B.\ck  to  Back  Position.      Arrow  Indicates  Direction  of  Movement. 


perineum  by  the  hands  or  by  broad  specula,  wiping  the  vagina  dry  and  allowing 
the  child  to  breathe  with  its  head  still  in  the  pelvis  (Fig.  846).  A  stiff  rubber  tube 
may  also  be  inserted  into  the  child's  pharynx.  Stowe,  in  one  case,  did  tracheotomy 
and  saved  the  infant. 


Abnormal  Rotation  in  Breech  Cases. — Thus  far  we  have  considered  the  operation  of  delivery 
when  the  incf  liani.sni  (>{  labor  luis  hcen  the  usual  one — that  is,  with  the  back  anterior.  Just  as 
in  vertex  presentations,  we  have  errors  in  the  mechanism  due  to  abnormal  rotation.  In  some 
breech  deliveries  the  child's  back  turns  to  the  mother's  back,  and  the  belly  lies  forward,  behind 
the  pubis.  This  complication  occurs  oftencr  in  footling  presentations  when  the  posterior  leg 
has  come  down,  after  version  when  the  operator  has  seized  the  posterior  leg,  and,  rarely,  during 
an  otherwise  natural  breech  labor  when  improper  attempts  at  rotation  had  been  made.  As  was 
said  in  discussing  breech  presentation,  nature  almost  always  rectifies  the  abnormal  start  of  the 
mechanism  by  turning  the  back  three-fourths  of  a  circle,  making  it  rotate  the  "long  route," 
past  the  promontory,  through  the  other  half  of  the  pelvis  to  the  front.  The  back  rotates  in  the 
direction  opposite  from  that  which  one  would  expect.  An  acute  observer  will  notice  this  tendency 
of  the  breech  to  swing  around  in  front  of  the  sacrum.  By  not  appreciating  this  point  and  resist- 
ing the  mechanism  sought  by  nature,  the  accoucheur  may  cause  the  V)ack  to  remain  directed 
behind.  During  the  first  and  second  acts  this  is  of  little  moment.  Watching  the  rotation  intended 
by  nature,  the  operator  seeks  to  aid  it  by  pulling  harder  on  that  groin  which  tends  to  turn  forward. 


OPERATIONS    OF   DELIVERY 


959 


In  a  few  cases,  oven  when  the  posterior  limb  is  down,  the  buck  takes  the  "short  route,"  through 
one-fourth  of  a  circh',  to  the  pubis. 

Abnormal  Roialinn  l)iirin(/  the  Third  Act.— The  arms  may  he  folded  across  the  chest,  may  be 
stripped  up  alongside  the  head,  or  may  be  crossed  in  the  nape  of  the  neck.  In  the  first  case  the 
matter  is  very  simple.  The  child  is  supported  a  little  above  the  horizontal  with  one  hand,  while 
two  fingers  of  the  other  go  in  over  the  back,  over  the  shoulder,  down  the  arm  to  th(,'  elbow,  and 
wipe  the  forearm  over  the  chest,  out  from  behind  the  pubis,  the  usual  mana-uver  bemg  reversed. 
It  may  also  be  possible,  sinking  the  trunk  toward  the  floor,  to  i^o  directly  to  the  forearm  from 
behind  the  pubis,  and,  indeed,  this  may  be  the  only  way  if  the  child  is  large  or  the  pelvis  small— 


Fig.   8-48. — Rotatint,   Head  by  Conjoined  Manipulation. 

there  may  be  no  room  behind.  When  the  arms  are  stripped  up  above  the  head,  great  difficulties 
are  usually  met,  and  if  they  are  in  the  nucha,  it  may  be  impossible  to  liberate  theni  without 
fracture.  'Under  no  conditions  may  the  arms  be  brought  down  over  the  cliild's  back.  In  the 
first  place,  if  the  accoucheur  sees  that  the  cliild's  back  remains  persistently  posterior,  he  will 
bring  the  arms  down  as  early  as  possible.  It  is  sometimes  necessary  to  pass  the  whole  hand  into 
the  parturient  canal  in  order  to  reach  the  arms— especially  if  the  accoucheur  has  short  fingers. 
This  overdistends  the  vagina  and  perineal  floor,  hence  a  deep  episiotomy  is  made,  as  a  rule.  Some 
authors  recommend  that"  the  arms  be  brought  down  after  sinking  the  child's  trunk  and  entering 
and  operating  beliind  the  pubis.  I  prefer,  with  Fritsch  and  the  majority,  to  raise  the  body  of  the 
child  somewhat  (one  cannot  pull  it  up  so  far  as  when  the  back  is  anterior),  and  pass  the  four 


960 


OPERATIVE    OBSTETRICS 


fingers  from  behind  up  to  the  head  and  push  the  forearm  forward  and  to  the  opposite  anterior 
quadi-ant  of  the  pelvis,  then  down  over  the  chest,  as  in  Fig.  847.  If  the  first  attempt  does  not 
succeed,  the  trunk  of  the  child  is  rotated,  at  the  same  time  stuffing  it  back  somewhat  to  free  the 
arms  above  the  inlet,  and  the  anterior  arm  is  delivered  first.  The  child  is  now  turned  back  for 
the  other  arm  to  come  behind.  Pulling  on  the  shoulder  to  make  the  arm  more  accessible  fractures 
the  clavicle.  In  a  few  cases  I  was  able  to  aid  the  internal  hand  by  letting  an  assistant  support 
the  body  of  the  child,  while  I  pushed  the  arms  into  proper  position  from  the  outside.  External 
manipulation  is  not  used  enough  in  our  obstetric  operations.  In  only  one  case  from  a  very  large 
number  was  I  constrained  deliberately  to  break  the  arm  in  order  to  preserve  the  life  of  the  child, 
which  was  jeopardized  bj'  the  delays  in  the  delivery.  It  is  wise  to  announce  this  necessity  before- 
hand. A.  Miiller's  procedure,  delivery  of  the  shoulder-girdle  without  previous  liberation  of  the 
arms,  is  not  to  be  recommended  since  fractures  of  the  extremities  and  rupture  of  the  spinal 
column  are  very  common.     The  operation  is  not  artistic,  but  brutal. 

During  the  Fourth  Act. — Referring  to  the  chapter  on  Abnormal  Mechanisms  with  Breech, 
it  will  be  found  that  the  head  may  be  arrested  at  the  inlet  with  the  chin  caught  over  the  ramus 
pubis,  or  the  head  may  engage  in  the  pelvis  with  the  chin  to  the  front,  and  that  nature  may  ter- 
minate these  cases  in  two  ways — one  is  by  flexion:  the  body  depends,  the  chin  remains  applied 
to  the  sternum,  and  the  face,  forehead,  and  vertex  roll  out  from  behind  the  pubis,  the  nape  of  the 


Fig.  S49. — Van  Hookn's  Method,  Aided  by  Outside  Hand. 


neck  resting  on  the  perineum;  the  other  is  by  extension:  the  chin  leaves  the  sternum,  and  if  the 
child  is  lifted  up  to  the  belly  of  the  mother,  the  occiput,  vertex,  and  face  come  over  the  perineum, 
the  neck  resting  behind  the  pubis,  and  the  face  issuing  the  very  last. 

In  the  first  case  the  accoucheur  may  attempt  to  turn  the  head  so  as  to  bring  the  occiput  to 
the  front,  the  chin  to  the  roar  or  to  the  side,  if  the  pelvis  is  a  flat  contracted  one.  LaChapelle 
passed  the  hand  in  on  the  side  opposite  that  on  which  the  chin  lay  and  tried  to  pull  the  face  around. 
Zweifel  recommended  pressure  with  four  fingers  on  th(^  upp(?r  jaw.  In  four  cases  the  following 
mancEUVcr  succeeded  quickly:  Two  fingers  hcliind  the  pubis  obtained  a  purchase  on  the  malar 
bone,  and,  while  pushing  this  to  the  rear,  the  outside  hand  pulled  the  occiput  to  the  front  (Fig.  848). 
Now  the  mouth  was  readily  accessible,  and  the  usual  mechanism  could  be  carried  out.  In  another 
case  I  pushed  the  chin  to  the  side  with  the  outside  hand,  while  the  inside  hand  pulled  the  occiput 
to  the  front. 

If  rotation  of  the  head  does  not  quickly  take  place,  it  may  be  better,  since  seconds  are  very 
valuable,  to  try  to  deliver  the  head  without  turning  the  chin  behind.  Van  Hoorn's  method  is 
used  if  the  occiput  has  not  engaged  in  the  pelvis,  combined  with  pressure  on  the  forehead  from  the 
outside  (Fig.  849).  This  pres.sure  should  do  most  of  the  work.  The  child  is  lifted  up  over  the 
pubis,  to  which  its  chest  applies,  and  thus  the  occiput  rolls  past  the  promontory  into  the  hollow 
of  the  sacrum.  Too  much  force  exerted  now  will  break  the  child's  ne(;k.  When  the  occiput  comes 
into  the  hollow  of  the  sacrum,  the  accoucheur  quickly  determines  if  the  mouth  of  the  infant  is 


OPERATIONS    OF   DELIVERY  961 

accessil)l('  Ix'hiiid  the  piihis — tliiit  is,  if  extension  or  flexion  is  present.  If  the  finder  ean  Ix;  inserted 
into  the  mouth,  the  .M;iuiice:ui-Snielh<'-\'eil  method  upside  down  is  pei-formed;  if  extension  hius 
oceurred,  the  chin  lyinj;  ai)ove  the  pubis,  a  modified  Van  lloorn's  method  is  j)ra(;tised.  I  believe 
tiie  forceps  would  l)e  preferai)le  to  either  of  these  mamt-uvers.  Indeed,  the  necessity  for  them  is 
of  the  greatest  rarity,  since  it  is  almost  always  possible  to  bring  tlie  head  down  in  proper  rotation. 

A  coini)lct(>  cxtriu'tioii  hy  tlic  bi-ccch,  if  jjroperly  executed,  is  one  of  the  most 
brilliant  operations,  and,  if  the  complications  are  successfully  mastered  without 
injury  to  the  motlicr  or  child,  it  takes  rank  with  the  technically  most  difficult  of  all 
surgery.  Every  motion  is  the  result  of  centuries  of  study  and  practice  by  the 
world's  best  accoucheurs,  and  the  movements  must  follow  each  other  with  delilx-r- 
ation,  exactness,  and  speed.  Four  minutes  are  allowed  for  the  arms  and  four  for 
the  head.  More  time  consumed  endangers  the  child.  It  is  a  good  plan  for  an 
assistant  to  count  aloud  the  minutes.  While  a  child  may  live  five  minutes  after 
its  placental  circulation  is  cut  off,  it  is  greatly  endangered,  and  may  die  later  of 
atelectasis,  pneumonia,  sepsis,  or  the  results  of  profound  asphyxia. 

Finally,  attention  should  be  drawn  to  complications  offered  by  the  soft  parts. 
If  extraction  is  undertaken  before  the  cervix  is  fully  dilated,  dangers  of  no  mean 
order  are  incurred  for  both  mother  and  child.  For  the  mother  there  is  risk  of  tears 
of  the  lower  uterine  segment  and  cervix,  which  in  placenta  prsevia  are  particularly 
fatal  from  hemorrhage.  Sepsis  is  a  later  result.  For  the  child  the  risk  lies  in  the 
delay  incident  to  the  stripping  up  of  the  arms  by  the  tight  ring  of  the  cervix,  and,  too, 
even  after  liberation  of  the  arms  the  cervix  may  close  down  around  the  neck  and 
face,  at  the  root  of  the  nose,  buttonholing  the  head  in  the  uterus.  Traction  in 
such  cases  brings  the  constricting  cervix  into  view  as  a  thick,  purplish  and  white 
])an(l.  This  ring  may  be  carefully  stripped  back,  or  if  too  tight,  may  be  incised. 
It  may  be  possible  to  admit  air  to  the  child's  mouth  by  means  of  specula  and  wait 
for  the  head  to  come  through  (Fig.  846,  p.  957). 

Deep  lacerations  of  the  perineum,  even  to  the  third  degree,  are  very  common  in 
])reech  deliveries.  They  occur  when  the  hand  is  inserted  alongside  the  trunk  or 
during  the  rapid  delivery  of  the  head.  I  make  an  extensive  episiotomy  in  most 
breech  cases,  not  alone  to  preserve  the  sphincter  ani,  but  also  to  facilitate  all  the  re- 
quired manipulations,  which  save  the  child  from  asphyxia  and  from  injury. 

Lack  of  space  prevents  reference  to  the  many  accoucheurs  who  perfected  each 
of  the  various  manoeuvers  above  detailed.  The  history  of  the  operation  of  breech 
extraction  may  be  found  in  the  Edgar-Winckel  Text-book  of  Obstetrics. 


FORCEPS 

Definition. — The  forceps  of  obstetrics  is  an  instrument  designed  to  extract 
the  fetus  by  the  head  from  the  maternal  passages,  without  injury  to  it  or  to  the 
mother.  As  soon  as  the  right  of  either  is  encroached  upon,  the  instrument  ceases 
to  be  the  forceps  of  obstetrics,  but  becomes  simply  an  instrument  of  extraction, 
similar  to  the  craniotomy  forceps,  and  not  so  good. 

History. — Hippocrates  advised  pulling  on  the  head  with  the  hands,  but  probably  used  the 
manccuver  onlj'  for  small  heads;  the  Arabians  used  a  three-  or  four-bladed  hooked  tractor  for 
dead  fetuses;  in  1554  Rueff,  of  Ziirich,  published  a  jointed  forceps  similar  to  that  used  in  Uthot- 
omy;  in  1561  Pierre  Franco  advised  a  three-bladcd  duckbill  speculum,  obviously  impractical; 
the  .Japanese  for  centuries  used  whalebone  loops  and  silk  nets  brought  over  the  head  by  means 
of  strips  of  whalebone;  Smellie  tried  to  draw  fillets  over  the  occiput  and  chin.  It  is  remarkable 
that  the  idea  of  the  ol^stetric  forceps  was  so  long  in  coming  As  Schroder  says,  this  was  probably 
because  men  were  not  allowed  at  the  confinement-l)cd  except  in  the  most  difficult  cases  And 
here,  for  lack  of  experience  in  normal  cases,  they  knew  little  except  to  mutilate  the  child  and  extract 
it,  and  often  the  viscera  of  the  mother,  with  sharp  hooks.  Unless  the  child  presented  by  the  breech 
or  shoulder,  so  that  the  accoucheur  could  grasp  a  leg  on  which  to  pull,  he  was  powerless,  except  as 
stated.  Small  wonder  the  women  took  alarm  when  a  "man-midwife"  had  to  be  called,  because 
they  had  observed,  says  Smellie,  that  "either  the  mother  or  the  child  or  both  were  lost." 

In  1720  Palfyn,"^  of  Cdient,  laid  before  the  Academy  of  Medicine  in  Paris  his  forceps  (Fig. 
850)  for  the  extraction  of  the  child  without  mutilation.  This  rough,  clumsy  instrument  was 
61 


962 


OPERATIVE    OBSTETRICS 


modified  by  others.     Dusse  crossed  the  blades  and  lengthened  them,  and  Levret,  1746,  added 
the  pelvic  curve,  also  the  French  lock,  still  used,  though  modified. 

The  first  forceps  were  invented  probal^ly  in  1580  by  Peter  Chamberlen,  the  elder,  the  son  of 
a  Huguenot,  WilUam  Chamberlen,  who  fled  from  Paris  in  1569  and  settled  in  Southampton. 
In  1670  Hugh,  one  of  the  large  family,  went  to  Paris  and  tried  to  sell  the  instrument  for  $7500. 
Mauriceau,  to  test  the  value  of  Chamberlen's  pretenses,  suggested  that  the  latter  attempt  the 
delivery  of  a  woman  with  extreme  contraction  of  the  pelvis,  upon  whom  he  had  decided  to  perform 


Fig.  850. — A  Few  of  the  Hundreds  of  Forceps  Models. 
a,  Chamberlen  No.  1;     &,  Chamberlon  No.  2;     c,  Palfvn;     rf,  Pulfyn,  1721;     p,  Duseo,  173.3;    /,   Gregoire,  1746; 
g,  Smelhe,  1752;  A,  Levret,  1747;    i,  Mathias  Soxtorph,  1791;  j,   Coutonly;  /,:,  Hamon,  1867;    I,  Baumers  of  Lyon, 
1849;    m,  Santarelli,  1794;  n,  Japanese  forceps;    o,  Chassagny;    p,  Rudford'.s  asymmetric;    r,  Pean's  vectis. 


cesarean  section.  Chamberlen  declared  that  nothing  could  be  easier,  and  at  once,  in  a  private 
room,  set  about  the  task.  After  three  hours  of  vain  effort  he  was  obliged  to  acknowledge  his 
defeat.  The  woman  died  from  injury  to  the  uterus,  the  negotiations  for  the  sale  were  dropped, 
and  Chamberlen  returned  with  his  secret  unrevealed  to  England.  Later,  after  wrecking  a  bank, 
he  fled  to  Holland,  where  he  sold  the  secret  to  a  Roonhuysen,  in  Amsterdam,  who  sold  it  in  turn 
to  any  doctor  having  the  necessary  large  amount  of  money,  but  sold  only  half  the  forceps, — 
the  vectis, — adding  fraud  to  infamy. 

In  1753  Vischer  and  van  de  Poll  purchased  the  secret  and  made  it  public,  but  by  this  time, 


OPERATIONS    OF    DELIVERY 


963 


throuKh  Piilfyn,  Drinkwater,  and  others,  the  forceps  had  become  common  property.  Palfyn  died 
poor  iuid  ii('<i;k'c(('<l,  l)u(  in  17St  his  resting-place  in  Clhont  was  marked  by  a  statue  of  a  weeping 
woman.  Tlio  orjiiiiuil  forceps  of  the  ( 'liamhcrlcns  were  foun<l  in  lSl.5  in  a  hidden  attic  of  a  hou.se 
in  Ksscx,  iMi^iland,  ()ccii])ied  by  several  fieneraticjiis  of  the  family  (Infi;raliarn).  Numberless  altera- 
tions and  modifications  iiav(!  been  made  on  tli(^  forceps.  Fig-  S.'jtj  shows  a  few  of  them,  the 
only  radical  clianjj;es  from  the  original  Chaniberlen  and  Dussci  models  being  the  addition  of  axis- 
traction  by  Tarnier  in  1877. 

Description. — The  forceps  consists  of  two  blades,  which  are  named  riftht  and 
left,  accordinii;  to  the  side  of  the  mother's  pelvis  in  Avhich  they  lie  when  appHed. 
Each  blade  has  a  handle  and  a  hook-like  projection,  added  by  Busch.  Gregoire 
(1740)  put  the  fenestrum  in  the  blade,  but  the  Chamberlen  forceps  also  had  it. 
Some  of  the  latest  forceps  are  unfenestrated,  for  example,  the  McLane-Tucker. 
The  blades  are  curved  on  the  flat  to  fit  the  head, — the  "cephalic  curve," — and  on 
the  edge  to  fit  the  concavity  of  the  sacrum — the  "pelvic  curve."  The  two  blades 
are  fitted  together  by  a  lock,  which  in  the  English  forceps  consists  of  opposing 
shoulders  with  a  flange;  in  the  French  forceps,  a  screw  or  pin;  and  in  the  German 
instrument,  a  sort  of  combination  of  both  principles.  Smellie  and  the  English  used 
a  very  short  forceps,  because  the  operation  was  practised  only  after  the  head  was 
well  dowTi  in  the  pelvis.  The  French  used  long  forceps,  since  they  often  extracted 
the  head  before  engagement  had  occurred.     The  German  forceps  is  rather  long, 


Fig.  Sol. — Simpson's  Forceps  or  Vienna  School  Forceps. 
Handle  slightly  modified  by  author. 


and  resemble  the  French  in  having  a  small  cephalic  curve  and  a  marked  pelvic 
curve. 

I  have  found  that  the  best  forceps  for  general  use  is  the  one  of  Simpson,  as 
adopted  by  the  Vienna  School,  often  called  the  Vienna  School  forceps  (Fig.  851). 
I  made  the  hooks  larger  and  flatter,  so  as  not  to  hurt  the  hand,  and  modified  the 
handles  a  little  to  secure  lightness  and  ease  of  cleansing,  but  the  essentials  of  the  in- 
strument are  unchanged. 

The  function  of  the  forceps  is  simply  one  of  traction,  as  Levret  pointed  out  in 
1746.  Some  irritation  of  the  uterus  ensues  after  the  blades  are  in  j^lace  and  may 
evoke  pains.  This  is  the  so-called  "dj^namic  action."  An  attempt  to  strengthen 
this  very  uncertain  action  by  the  aid  of  the  faradic  current  was  made,  but  failed. 

The  forceps  is  not  a  rotator,  in  the  strict  sense  of  the  term — that  is,  the  instru- 
ment may  not  be  used  to  twist  the  head  from  one  position  to  another,  for  example, 
from  an  occipitoposterior  to  occipito-anterior.  Such  motions  tear  the  vagina  off  its 
pelvic  attachments  or  even  open  the  bladder.  A  certain  amount  of  rotation  may 
sometimes  be  given  the  head,  together  with  horizontal  traction,  the  movement 
being  thus  a  turbinal  or  spiral  one.  This  distinction  is  highly  important.'  Even 
the  turbinal  movement  endangers  the  soft  parts  to  an  extent. 

As  a  lever,  the  forceps  may  also  not  be  used,  that  is,  pendulum  motions  are  not 
permissible.  The  maternal  soft  parts  are  then  the  fulcrum,  and  will  be  bruised  and 
torn.     Levering  and  tw^isting  are  not  observed  in  nature. 

Compression  of  the  head  is  inevitable,  but  we  seek  to  reduce  it  to  the  mmimmn. 


964 


OPERATIVE    OBSTETRICS 


Experiments  have  proved  what  a  httle  reflection  would  show,  that  we  can  reduce 
the  volume  of  the  fetal  head  but  a  few  cubic  millimeters  by  means  of  outside  force, 
and  even  this  is  attended  by  great  danger  to  the  child.  If  one  applies  forceps  to  the 
head  of  a  still-born  child  in  mannikin  practice,  it  will  be  observed  that  closing  the 
blades  causes  the  head  to  bulge  out  in  the  diameter  at  right  angles  to  the  direction 
of  compression,  but  only  slightly.  What  is  more  noticeable  is  the  lengthening  of 
the  head  in  its  long  diameter,  a  point  which  Levret,  Baudelocque,  Budin,  and  Milne- 


Fio.  S52. — Experiment  to  Show  Comprkhhion  Effect  of  Traction. 

Murray  refer  to.  Much  depends  on  the  softness  of  the  head  and  the  shape  of  the 
canal  through  which  it  is  to  pass,  lleference  to  Fig.  852  will  show  how  the  head 
suffers  compression  in  three  ways.  By  squeezing  the  handles  of  the  forceps  to- 
gether at  P",  the  action  is  that  of  a  lever  of  the  first  class,  the  lock  being  the  ful- 
crum, F,  the  resistance  being  the  head,  R.  Traction  downward  at  P'  acts  in  the 
same  way,  but  since  the  pull  is  on  the  short  arm  of  the  lever,  the  pressure  at  li  would 
be  less,  were  it  not  that  in  practice  we  put  on  more  tractive  force  at  P'  than  we 
do  compressive  force  at  P".     The  sum  of  the  two  compressions,  however,  must  be 


OPERATIONS    OF   DELIVERY  965 

considerable.  The  compression  at  P"  we  can  regulate  ourselves,  hut  tlie  amount 
exerted  at  P'  depends  entirely  on  the  amount  of  pull  exerted  to  deliver  the  head. 
A  third  source  of  compression  is  the  resultant  <jf  the  ])ull  of  the  forceps  against  the 
bony  pelvis  or  the  soft  parts,  that  is,  any  resistance.  Here  again  power  is  applied 
at  P',  or,  as  is  advised  in  practice,  at  F,  but  the  fulcrum  is  at  X,  and  the  power  is 
applied  to  the  long  arm  of  the  lever,  obviously  the  most  dangerous  circumstance 
for  the  fetal  head.  This  item  of  compression  increases  with  the  resistance  met. 
Taking  these  facts  into  consideration,  I  nmst  disagree  with  Barnes,  believing  that 
the  compression  is  not  one-half  of  the  power  of  the  traction,  but  probably  greater 
than  the  traction.  Compression  of  the  head  has  very  noxious  influences  on  the 
brain.  If  suddenly  applied,  the  child  suffers  from  concussion.  If  slower  in  action, 
the  circulation  is  hindered,  the  pneumogastric  is  stimulated,  the  pulse  being  slowed, 
and  asphyxia  resulting,  or  smaller  or  larger  hemorrhages  occur — all  these  outside  of 
direct  injury  to  structure  or  fracture  of  the  bones.  Children  vary  very  much  in 
their  ability  to  stand  compression.     Some  seem  to  have  charmed  lives. 

Traction, — simple  traction, — then,  is  the  dominant  function  of  the  forceps. 
It  supplies  from  below  the  force  which  is  lacking  from  above,  and  our  art  enables 
us  to  apply  this  traction  to  the  best  advantage.  How  much  traction  may  safely 
be  applied  is  hard  to  say.  Attempts  to  measure  it  with  dynamometers  have  failed. 
It  is  rarely  necessary  to  pull  with  more  than  the  strength  of  the  biceps,  as  in  Fig. 
860.  To  brace  the  feet  against  the  table  and  pull  with  all  the  strength  of  the  back 
and  shoulders  is  I^rutal,  unscientific,  and  murderous.  Craniotomy  is  more  humane. 
The  accoucheur  should  alwaj^s  remember,  when  working  with  the  forceps,  that  he 
has  a  child's  brain  in  the  grasp  of  a  powerful  vise,  and  that  only  the  greatest  care 
and  gentleness  will  save  its  wonderfully  delicate  structure  from  injur}^ 

Indications  for  Forceps. — These  are  the  same  as  for  extraction  in  general,  com- 
prising those  conditions  which  threaten  the  hfe  of  the  mother  or  child.  Some 
accoucheurs  apply  the  forceps  as  soon  as  the  head  reaches  the  perineum,  with  the 
sole  object  of  saving  the  woman  the  pain  of  the  second  stage.  This  practice  is  to 
be  deprecated,  but  at  the  same  time  it  is  cruel  to  allow  the  woman  to  remain  many 
hours  in  the  second  stage,  waiting  for  signs  of  actual  danger  to  the  mother  or  child, 
when  the  accoucheur  is  convinced  that  she  will  not  be  able  to  deliver  herself.  As 
Barnes  said,  we  should  wait  to  see  what  the  woman  is  able  to  accomplish,  not  what 
she  can  endure.  Then,  too,  when  the  signs  of  danger  to  the  mother  or  the  child 
are  present,  often  real  damage  has  been  done — it  were  wiser  if  the  accoucheur  had 
anticipated  the  dangers.  In  America,  75  per  cent,  of  the  forceps  operations  are 
done  because  of  insufficiency  of  the  powers  of  labor  when  the  head  has  come  onto 
the  perineum  or  even  is  visible  during  a  pain.  Either  the  head  is  a  little  too  large, 
or  the  perineum  a  little  too  resistant,  or  the  w^oman's  nerves  have  given  out.  In 
either  case  labor  has  come  to  a  standstill,  the  pains  weaken,  the  woman  bears  down 
less  and  less  strongly,  and,  if  not  relieved,  may  get  into  a  highly  nervous,  even 
delirious  condition,  which  is  not  without  after-efTects  on  her  constitution.  The 
child  suffers  too,  the  heart-tones  are  slowed,  then  grow  faster  and  irregular,  and  a 
caput  succedaneum  forms  and  soon  attains  large  dimensions  and  hardness. 

It  is  not  easy  to  select  just  the  right  time  to  interfere  in  these  cases.  Needless 
to  say,  the  conditions  must  all  be  fulfilled.  In  general,  it  is  wise  to  operate  long 
before  the  exhaustion  is  marked,  before  the  signs  and  symptoms  of  threatened  rup- 
ture of  the  uterus  are  present,  and  before  the  child  presents  evidences  of  asphyxia. 
It  is  impossible  to  assign  an  arbitrary  limit,  but  in  my  own  practice,  when  the 
head  has  come  well  down  onto  the  perineum  and  makes  no  progress  for  two  and 
one-half  to  three  hours,  I  usually  interfere.  If  the  perineum  seems  to  be  too  resist- 
ant, a  deep  episiotomy  may  allow  the  head  to  go  through — a  procedure  which  is 
much  preferable  to  forceps.  If  episiotomy  does  not  give  exit  to  the  head,  noth- 
ing has  been  lost,  because  the  perineum  would  probabl}^  have  been  incised  for  the 


966  OPERATIVE    OBSTETRICS 

succeeding  delivery  anyway.  I  believe  that  the  forceps  operation,  combined  with 
deep  episiotomy,  will  spare  the  child  the  dangers  of  prolonged  cerebral  compres- 
sion, and  thus  prevent  subsequent  cerebral  diseases. 

Arrest  of  the  rotation  of  the  head  is  another  frequent  indication  for  forceps. 
Occipitoposterior  positions  are  most  often  here  concerned,  the  occiput  not  turning 
completely  to  the  front,  but  stopping,  usually  in  the  transverse  diameter  of  the 
pelvis — ^the  so-called  dee-p  transverse  arrest.  It  is  not  uncommon  to  find  the  child 
in  the  "military  attitude,"  that  is,  one  of  slight  deflexion,  with  the  head  set  squarely 
on  the  shoulders.  The  sagittal  suture  runs  across  the  pelvis,  the  two  fontanels 
being  about  on  one  level. 

Third  in  frequency  may  be  grouped  a  large  number  of  complications  which 
affect  the  mother,  but  secondarily,  the  child  also,  a  few  of  which  may  be  mentioned. 
Eclampsia,  fever,  or  infection  during  labor,  with  or  without  tympania  uteri;  acute 
diseases,  as  pneumonia,  typhoid;  chronic  diseases,  tuberculosis,  heart  disease, 
with  the  possibility  of  hemoptysis,  heart  failure,  or  edema  of  the  lungs;  hernia, 
appendicitis,  and  other  intra-abdominal  conditions;  placenta  prsevia,  abruptio 
placentae,  prolapse  of  the  cord,  etc. 

Face  and  brow  presentations  per  se  do  not  indicate  forceps  or  any  interference, 
but  the  accoucheur  is  oftener  called  upon  to  intervene. 

Contracted  pelvis  of  itself  is  really  a  contraindication  for  forceps.  Schroder 
says  they  fit  the  contracted  pelvis  like  the  fist  on  one's  eye.  After  the  head  is 
molded  so  that  it  is  almost  ready  to  come  down  into  the  excavation,  and  in  cases  of 
generally  contracted  pelvis,  where  the  powers  give  out  after  the  head  has  engaged, 
it  is  justifiable  to  use  the  forceps  as  an  instrument  of  trial,  but  the  accoucheur  must 
be  constantly  aware  of  their  murderous  possibilities. 

Finally  may  be  mentioned  the  use  of  forceps  on  the  after-coming  head,  a  prac- 
tice which  should,  in  my  opinion,  supersede  many  of  the  difficult  Smellie-Veit 
extractions. 

Conditions  for  Forceps. — These  are  the  same  as  for  extraction  in  general.  (1) 
The  pelvis  must  be  large  enough  to  permit  delivery  of  the  unmutilated  child.  If 
this  point  cannot  be  settled  beforehand,  the  forceps,  if  used,  is  only  an  instrument  of 
trial — of  diagnosis.  Forceps  may  not  be  used  on  a  hydrocephalus,  since  the  blades 
will  usually  shp  off.  If  the  child  is  very  small,  a  diminutive  pair  of  forceps  is  to 
be  employed.  (2)  The  cervix  must  be  effaced  and  dilated,  or  sufficient  enlargement 
must  be  easily  procurable.  Dilatation  of  the  cervix  by  means  of  the  head  pulled 
down  by  forceps  is  a  dangerous — really  unjustifiable — procedure.  (3)  The  mem- 
branes must  be  ruptured  and  out  of  the  way,  because  of  the  danger  of  disloca- 
tion of  the  placenta.  (4)  The  head  must  be  engaged,  or  so  nearly  so  that  a  cautious 
trial  of  the  forceps  may  be  permissible.  (5)  The  child  must  be  living.  If  the  fetus 
is  dead,  craniotomy  should  he  performed;  if  in  doubt,  the  forceps. 

Technic. — We  speak  of  "high,"  "low,"  and  "medium"  forceps,  but  there  is 
no  uniformity  of  teaching  as  to  what  these  terms  mean.  It  would  be  better  to 
designate  the  operation  by  the  name  of  the  plane  in  which  the  biparietal  diameter 
is  found,  for  example,  outlet  (for  low),  mid'plane  (for  medium  or  mid),  when  the 
parietal  bones  He  in  the  bispinous  line,  and  inlet  forceps  (for  the  term  high),  when  the 
head  lies  in  the  plane  of  the  inlet,  but  has  not  yet  completely  engaged.  To  apply 
the  forceps  on  the  floating  head  is  usually  a  lapsus  artis. 

A  few  commonly  used  expressions  require  explanation.  The  "front"  of  the 
forceps  is  the  side  of  the  concavity,  the  side  on  which  the  lock  opens,  and  to  which 
the  tips  of  the  blades  point.  The  forceps  may  lie  in  the  pelvis  in  any  of  its  diameters. 
The  forceps  is  said  "to  lie  in  this  or  that  diameter"  when  a  line  drawn  through  the 
centers  of  the  fenestra  lies  in  the  diameter  specified.  The  front  of  the  forceps, 
therefore,  would  look  in  the  diameter  at  right  angles  to  the  one  the  forceps  lies  in. 
The  best  diameter  for  the  forceps  to  take  is  the  transverse,  because  then  their  pelvic 


OPERA.TIONS    OF   DELRTSRY 


967 


curve  corresponds  to  the  mother's  pelvic  curve.  Tlio  cliild's  liead  is  said  "to  lie 
in  this  or  that  diamotor"  of  the  pelvis  when  tlio  sasittul  suture  lies  in  that  diameter. 
When  the  head  lies  in  the  anteroposterior  diameter  and  tiie  forceps  lies  in  the  trans- 
verse, the  head  will  he  grasped  in  the  most  favorable  manner,  and  the  delivery  of 


Fig.  853. — The  Forceps  Lying  in  their  ;Most  Favorable  Position. 
The  head  is  on  the  perineum  and  rotation  is  complete. 


Fig.  854. — Forceps  in  CD. A. 
The  forceps  lies  in  the  right  oblique  diameter  of  pelvis. 


the  child  will  be  attended  with  the  least  difficulty  (Fig.  853).  When  the  head  lies 
in  an  oblique  diameter  of  the  pelvis,  the  forceps  should  be  applied  in  the  opposite 
diameter,  the  front  of  the  forceps  pointing  in  the  direction  in  which  the  point  of 
direction  lies  (Fig,  854).     Some  operators  still  place  the  blades  in  the  sides  of  the 


968 


OPERATIVE    OBSTETRICS 


pelvis,  that  is,  in  the  transverse  diameter,  letting  them  grasp  the  head  whichever 
way  they  will.  Other  operators  apply  the  blades  to  the  sides  of  the  head.  When 
the  child^s  head  lies  with  its  long  diameter  transversely  in  the  pelvis,  the  only  way 
the  forceps  can  get  a  good  hold  on  it  is  when  they  lie  in  the  anteroposterior  diam- 
eter, but  then  one  blade  would  rest  on  the  promontory  while  the  anterior  one  would 
cut  into  the  bladder,  the  curves  of  the  forceps  and  of  pelvis  antagonizing  each  other. 
In  such  cases  a  compromise  must  be  made,  and  the  blades  are  laid  in  one  oblique 
of  the  pelvis  and  grasp  the  child's  head  over  one  malar  bone  and  the  opposite  parietal 


Fig.  855. — Forceps  Grasping  Head  in  an  Unfavorable  Diameter. 
There  is  a  strong  tendency  to  slip.     This  application  to  be  avoided  if  possible. 


(Fig.  856).  This  is  better  than  to  place  the  blades  one  over  the  face  and  the  other 
over  the  occiput,  the  instrument  lying  in  the  transverse  as  in  Fig.  855.  If  the  head 
is  excessively  flexed,  this  last  is  not  so  objectionable.  The  api^lication  of  the  for- 
ceps to  the  head,  not  to  the  pelvis,  is  the  original  method  taught  by  Levret  and 
SmeUie,  and  is  more  scientific,  yet  not  invariably  feasible. 

A  rule  of  the  forceps  operation  to  which  there  are  no  exceptions  is  that  the  front 
of  the  forceps  should  point  in  the  direction  of  the  point  of  direction.  If  the  occiput 
lies  on  the  right  side  of  the  pelvis,  the  front  of  the  forceps  points  to  the  right,  and  as 
the  occiput  rotates  to  the  front,  the  front  of  the  forceps  looks  more  and  more  forward. 


OPERATIONS    OF    DELIA'^KRY 


969 


Of  the  two  blades,  the  left  is,  with  rare  exceptions,  passed  first;  it  is  grasped 
in  the  left  hand  and  laid  in  the  left  side  of  the  mother.  The  rifrht  blarle  is  held  })y 
the  right  hand,  and  comes  to  lie  in  the  right  side  of  the  pelvis. 


Fig.  856.— Forceps  in  O.D.T. 
The  head  lies  in  the  transverse,  the  forceps  lies  in  the  right,  oblique.    The  front  of  the  forceps  points  to  the  right  anterior. 


Fig.   857. — IxsTRrMEXxs  for  Forceps  Oper.^tiox. 
Obstetric  forceps;    G  artery  clamps;    3  scissors;    3  retractors;    2  necdie-holdcrs;    0  needles;   2  vulsellum  forceps;   2 
ring  cervix  forceps;    2  tissue    forceps;    uterine  packing  forceps;    tracheal  catheters;    stethoscope;    female    catheter; 
salt-solution  needle;   silkworm-gut,  catgut,  etc. 


Every  forceps  operation  consists  of  four  acts — application  of  the  l^lades;  adap- 
tation or  locking;  extraction  of  the  head;  removal  of  the  instrument.  The  prep- 
arations for  the  operation  have  already  been  discussed.  Fig.  857  shows  the  in- 
struments needed. 


970 


OPERATIVE    OBSTETRICS 


First  Act — Applicatio7i  of  Blades  to  Head. — Having  reassured  himself  that  his 
diagnosis  is  correct  by  a  careful  examination  after  the  patient  is  asleep  and  quiet, 
the  accoucheur  seats  himself  on  a  chair  of  convenient  height  and  rehearses  the  in- 
tended operation  in  the  air  before  the  patient.  Two  fingers  of  the  right  hand  are 
passed  into  the  vulva,  vagina,  and,  if  the  cervix  can  be  reached,  inside  the  cervix 
and  ■v\dthin  the  membranes.  Nothing  may  lie  between  the  forceps  and  the  head, 
and,  to  be  certain  of  this,  the  fingers  must  feel  the  head  all  the  way  and  be  passed 
up  as  high  as  possible,  guarding  the  tip  of  the  forceps  until  it  goes  beyond  reach. 
In  higher  forceps  operations  the  half  hand  should  be  inserted.  Now  the  left  blade 
of  the  forceps  is  taken  in  the  left  hand,  poised  vertically  in  the  introitus  vaginae. 


Fig.  858. 


iRA.spixG  Blade  Like  a  Pen.     Insertion  of  Second  Blade. 


being  held  like  a  pen  (Fig.  858),  and  passed  with  the  delicacy  of  a  urethral  sound. 
As  the  Vjlade  glides  along  the  fingers  in  the  vagina  the  tip  is  held  closely  to  the  head, 
so  as  to  get  under  the  cord  or  the  membranes  if  they  should  fall  in  the  way.  The 
thumb  of  the  left  hand  is  used  to  guide  and  press  the  blade  into  place.  As  the  fenes- 
trum  disappears  inside  the  vulva,  the  time  is  come  to  sink  the  handle,  and  when  the 
lock  rests  near  the  perineum,  the  first  half  of  this  act  is  completed.  In  most  forceps 
operations,  if  properly  applied,  the  blades  will  fall  into  the  right  position  of  their 
own  weight.  As  the  handle  sinks  down,  the  operating  hand  glides  over  the  top  and 
now  grasps  it  like  a  scalpel  (Fig.  859).  It  is  not  good  to  hold  the  forceps  like  a 
catlin  in  the  whole  fist. 


OPERATIONS    OF   DELIVERY  971 

Tho  ri<i;lit  blade  is  passed  in  like  manner,  the  two  fingers  of  the  left  hand  being 
inserted  and  acting  as  guide  and  protectors  of  the  maternal  tissues.  The  lock  Ixnng 
on  the  top  of  the  left  blade,  this  one  must  be  passed  first,  otherwise  the  handles 
would  have  to  be  recrossed  outside  tlu;  vulva,  after  tlu;  application,  wiiich  would 
subject,  the  maternal  tissues  and  the  child  to  injury  by  the  tips  of  the  instrument. 

Second  Act — Adaptation  or  Locking. — The  technic  of  this  movement  will  de- 
pend on  the  presentation  and  position  of  the  head,  sinco  the  blades  must  be  applied 
so  as  to  fit  it  in  the  best  way. 

In  th(^  usual  oi)eration  of  forceps  the  head  is  low  down,  and  tlu;  small  fontanel 
has  rotated  all  the  way  or  nearly  all  the  way  to  the  front,  and  the  blades,  after  being 
inserted,  fit  naturally  to  the  sides  of  the  head.  Often,  however,  they  need  a  little 
adjusting  before  it  is  possible  to  fit  the  lock  neatly.  The  simplest  method  to  })ring 
the  blades  into  position  is  to  press  the  handles  gently  downward  onto  the  perineum. 
If  this  is  not  successful,  they  are  depressed,  and  at  the  same  time  twisted  lightly 
by  means  of  the  hooks  on  the  handles,  and  if  this  does  not  do,  a  triplex  motion  is 
given  the  instrument.  The  handles  are  pressed  doAvnward,  pushed  upward  into 
the  pelvis,  and  twisted  slightly,  all  in  one  movement,  but  withoid  the  exhibition  of 
much  force.  If  it  does  not  succeed  easily,  the  forceps  must  be  removed  and  re- 
applied, because  there  is  some  obstacle  to  locking,  which  must  be  recognized  and 
relieved.     To  force  the  locking  is  bad  practice,  and  always  results  in  fetal  or  ma- 


Fio.  859 — Graspi.ng  Forceps  Blade  Like  a  Scalpel.     Second  Motion  of  Insertion. 

ternal  injury.  Usually  the  accoucheur  will  find  he  has  made  an  error  in  diagnosis 
or  that  the  child  has  a  hydrocephalus. 

After  locking,  the  heart-tones  should  be  auscultated.  First  listen  and  note 
their  frequency  and  strength,  then  close  the  blades  and  listen  again.  If  the  tones 
at  once  become  faint  or  slow,  the  cord  is  in  the  grasp  of  the  forceps;  if  the  slowing 
occurs  only  when  the  handles  are  kept  tightly  closed,  it  is  due  to  cerebral  com- 
pression. By  pushing  one  or  two  fingers  up  along  the  back  of  the  child's  neck, 
behind  the  pubis,  it  is  possible  to  feel  the  cord  if  it  encircles  the  neck.  Should  there 
be  a  suspicion  that  the  tip  of  the  forceps  squeezes  the  cord,  the  instrument  must 
be  removed  and  reapplied.  If  compression  of  the  cord  is  unavoidable,  the  delivery 
must  be  quickly  effected.  An  internal  examination  is  also  made  to  find  if  the  cord 
or  cervix  or  an  arm  is  caught  in  the  grasp  of  the  instrmnent. 

Third  Act — Extraction. — After  locking  the  forceps  one  gentle  pull  is  made  on 
them  to  see  if  the  blades  lie  properly  and  fit  well,  also  to  give  the  accoucheur  an  idea 
of  the  amount  of  resistance  likely  to  be  met.  This  is  called  the  trial  traction,  and 
after  it  is  made  the  heart-tones  should  again  be  listened  to.  Four  points  must  be 
borne  in  mind  with  each  traction:  (1)  Each  traction  is  made  ^\dth  the  uterine  pains, 
and  if  these  are  absent,  the  pain  is  imitated,  that  is,  the  pull  is  gradual  at  first,  slowly 
reaches  an  acme,  is  held  for  a  moment,  and  then  slowly  relaxed;  (2)  as  little  power 
is  exhibited  as  possible,  regulating  the  amount  by  the  advance  of  the  head.     With 


972 


OPERATIVE    OBSTETRICS 


the  elbows  at  the  side  and  the  arms  flexed  the  strength  of  the  biceps  alone  should 
suffice,  and  more  than  60  pounds  will  almost  never  be  required — usually  much 
less.  Time  should  be  disregarded,  but  the  fetal  heart-tones  carefully  watched; 
(3)  with  the  single  exception  soon  to  be  considered  the  traction  should  be  simple, 
not  combined  with  pendulum,  corkscrew,  nor  twisting  motions;  (4)  the  line  of 
traction  should  correspond  to  the  axis  of  the  parturient  canal. 

After  the  trial  traction  the  forceps  are  grasped,  as  shoAvn  in  Fig.  860,  the  right 
hand  over  the  lock,  with  the  little  finger  between  the  shoulders  of  the  shanks  of  the 
blades,  the  left  hand  on  the  handles,  both  thumbs  underneath.  One  slow,  even  pull 
is  made,  at  first  in  the  horizontal  plane  or  downward,  or  somewhat  upward,  de- 
pending on  the  station  of  the  head  and  the  curve  of  the  parturient  canal  at  that 
particular  point.     Carefully  note  the  amount  of  progress  of  the  head,  and  allow  the 


Fig.  800. — .Showing  Posture  of  Operator  for  Traction. 


head  to  recede  very  slowly;  then  listen  to  the  heart-tones,  loosening  the  forceps 
after  each  traction.  After  one  or  two  full  minutes  by  a  clock  placed  directly  in 
front  of  the  operator,  another  traction  is  made — if  necessary,  a  little  stronger  than 
the  first.  The  descent  and  rotation  of  the  head  are  determined  by  frequent  ex- 
aminations, the  fingers  searching  for  the  location  of  the  small  fontanel.  As  the 
head  bulges  the  perineum  traction  is  more  upward,  and  the  usual  precautions  to 
save  the  pelvic  floor  are  to  be  observed,  such  as  slow  delivery,  bringing  the  head 
through  with  its  most  favorable  diameters,  and  episiotomy.  In  my  own  practice 
I  seldom  deliver  a  primipara  with  forceps  without  first  doing  an  episiotomy.  This 
saves  the  child's  head  from  prolonged  com})rcssion,  shortens  the  time  of  operation, 
forestalls  fetal  asphyxia,  and  prevents  a  ragged  laceration,  which  is  almost  in- 
evitable.    If  the  perineum  is  elastic,  it  may  sometimes  be  sufficiently  dilated  with 


OPERATIONS    OF    DELIVERY 


973 


the  hands.  When  the  head  is  well  (■ii<i;a.i;c(l  in  ilic  vulvar  outlot,  the  forceps  may, 
if  preferred,  l)e  rein()V(>(l,  and  the  dehvery  completed  by  pre^'sun;  on  the  head  from 
behhid  the  anus — Hitji;en'.s  mana'uver.  If  the  operator  is  right  iianded,  he  stands 
off  at  the  left  side  of  the  patient,  and  if  lie  uses  his  left  hand,  to  her  right  (Tig. 
860).  He  grasps  the  forceps  at  the  lock  with  the  right  (or  left  j  hand,  with  the  little 
finger  between  the  shanks,  and  gently,  slowly,  advancing  line  by  line,  he  turns  the 
head  out,  the  handles  of  the  forceps  pointing  toward  the  abrlomen.  At  the  same 
time  the  head  is  jKilled  up  vertically  somewhat,  to  keep  the  nucha  applied  snugly 
to  the  subpubic  ligament.  From  fifteen  to  thirty  minutes  are  required  for  an  ordi- 
nary forceps  delivery,  most  of  which  time  is  spent  in  bringing  the  head  to  the  peri- 
neum. If  the  operator  wishes  to  deliver  without  episiotomy  and  tries  to  "save  the 
perineum,"  he  must  l^-ing  the  head  through  the  pelvic  floor  very  slowly,  taking  as 
nmch  time  as  a  natural  delivery  would  take.     My  experience  with  this  method  was 


Fig.  SOI. — Standing  at  Side  and  Delivering  Head. 
To  show  the  forceps,  the  thighs  were  bent  on  the  abdomen.     In  the  dehvery  the  thighs  should  be  held  more  horizontally. 


not  encouraging,  and  Kerr  found  the  same, — the  children  became  asphyxiated, — 
and  now  I  perform  episiotomy. 

Fourth  Act — Removal. — Some  operators  prefer  to  remove  the  instrument  only 
after  the  head  is  born,  claiming  the  forceps  allows  them  to  prevent  too  rapid  exit 
of  the  head.  Others  remove  them  when  the  head  is  held  tightly  by  the  vulvar  ring, 
claiming  that  the  thickness  of  the  blades  increases  the  tendency  to  perineal  rupture. 
Neither  claim  appeals  to  me,  but  I  usually  deliver  the  head  with  the  forceps.  If 
they  are  removed  sooner,  the  action  is  the  reverse  of  that  of  the  application,  taking 
care  not  to  tear  the  scalp,  the  ear,  or  the  soft  parts  of  the  mother. 

Low  or  Outlet  Forceps. — Here  rotation  is  complete  or  nearly  so,  the  head  is 
most  easily  seized  by  the  instrument,  and  the  blades  lie  on  the  sides  of  the  head, 
over  the  ear.  Applying  the  blades  to  the  sides  of  the  pelvis  allows  them  to  grasp  the 
head  properly.  This  is  the  commonest  forceps  operation,  also  the  least  dangerous. 
The  general  description  just  given  is  all  that  need  be  said  about  it. 


974 


OPERATIVE    OBSTETRICS 


FORCEPS  m  THE  UNUSUAL  MECHANISMS  OF  OCCIPITAL  PRESENTATION 

Deep  Transverse  Arrest. — In  some  cases  where  a  delay  in  labor  has  been 
manifest  for  some  time  an  examination  reveals  the  head  well  down  in  the  pelvis, 
the  sagittal  suture  in  the  transverse  diameter,  the  small  fontanel  to  one  side, 
generally  the  right,  the  large  fontanel  to  the  other  side,  and  both  on  the  same  level. 
This  condition  is  called  "deep  transverse  arrest" — sometimes  "impaction,"  the 
head  being  wedged  in  between  the  ischial  tuberosities.  (See  Deflexion  Attitudes, 
p.  585.)     When  an  indication  for  the  termination  of  labor  arises  at  a  time  when 


AXIS 


AXIS 


Fig.  862. 
If  handles  are  twisted,  the  blades  tend  to  describe 
an  arc  in  the  pelvis,  tearing  the  vagina  from  its  attach- 
ments. 


Fig.  863. 

If  we  wish  to  give  a  rotatory  movement  to  the  blades,  the 

handles  should  be  made  to  describe  an  arc. 


rotation  of  the  occiput  is  not  yet  complete,  two  objects  are  to  be  accomplished: 
first,  rotation  must  be  completed ;  second,  extraction  is  to  be  made.  Some  Ameri- 
can and  French  operators  turn  the  head  around  in  the  pelvis  with  the  forceps,  and 
twist  the  head  through  an  arc  of  over  135  degrees.  The  author  does  not  recommend 
this  practice.  The  lacerations  of  the  vagina  and  the  avulsion  of  the  bladder  and 
the  vagina  from  their  bony  attachments  are  too  great.  It  is  allowable  to  give  the 
head  the  same  turbinal  or  spiral  movement  it  takes  in  nature,  but  the  accoucheur 
mast  be  aware  that  we  are  but  poor  imitators  of  nature,  and  even  with  the  greatest 
care  deep  injuries  are  often  inflicted.     Fig.  862  shows  the  effect  of  twisting  the  for- 


OPERATIONS    OF    DELIVERY 


975 


ceps,  and  Fig.  863  how  the  handles  should  be  swung  through  a  segment  of  an  arc, 
if  wc  Avish  to  impart  a  rotatory  movcmont  to  the  head  within  (he  pelvis.     This 


Fig.  S64. — Diagram  op  Forceps  in  O.D.T. 
F  indicates  front  of  forceps. 


Fig.  S6o. — Forceps  Applied  in  O.D.T.     Ready  for  Traction.     . 

rotation  of  the  handles  of  the  forceps  must  be  combined  with  the  pull,  or  traction, 
and  the  two  motions  are  to  be  absolutel}'  synchronous — never  rotation  without 
progressing  traction. 


976 


OPERATIVE    OBSTETRICS 


It  is  obvious  that  in  transverse  arrest  if  the  forceps  were  applied  to  the  sides  of 
the  head,  the  blades  would  have  to  lie  in  the  conjugate  diameter  of  the  pelvis, 
which  is  mechanically  a  bad  principle,  the  pelvic  curve  of  the  forceps  being  then 
directl}'-  opposed  to  the  curve  of  the  pelvis.  A  straight  forceps  might  thus  be  ap- 
plied were  there  not  other  objections,  for  example,  injury  to  the  bladder  by  the 
anterior  blade.  If  the  instrument  were  laid  transversely,  it  would  seize  the  head 
over  the  face  and  occiput  (Fig.  855),  injuring  the  eyes,  defiexing  the  head,  and  in- 
viting a  tendency  to  slipping.     It  is  best  to  grasp  the  head  obliquely  (Fig.  864), 


Fia.  860. — Rotating  Left  Blade  around  Head  in  O.D.T. 


one  blade  lying  on  the  parietal  bone,  the  other,  on  the  malar.  The  forceps,  there- 
fore, will  lie  in  an  oblique  diameter  of  the  pelvis.  In  O.D. Transverse,  the  forceps 
will  lie  in  the  right  ol)li(|U(',  in  O.L.Transvers(!,  in  the  left. 

Operation  in  Transverse  Arrest  in  O.D.P.— Since  the  front  of  the  forceps 
must  point  in  the  direction  of  the  point  of  direction,  in  this  case  the  occiput,  the 
blades  must  be  brought  to  lie  in  the  right  oblique  diameter  of  the  pelvis,  one  an- 
teriorly behind  the  iliopubic  tubercle,  lying  over  the  anterior  malar  bone,  the  other 
posteriorly,  opposite   the   right  sacro-iliac  joint,  lying   on  the    posterior  parietal 


OPERATIONS    OF    DELIVERY 


977 


1)0110.  The  left  l)la(l(',  tlicroforc,  lias  to  ho  guided  around  tlio  side;  of  tlio  pelvis 
ovor  tho  child's  faco,  to  como  into  position,  (I''igs.  8(i0  and  8()7j,  while  the  right  hlado 
does  not  have  to  "wander"  at  all,  but  may  be  laid  directly  opposite  the  sacro-iliac 
joint.  While  th(>  blade  is  l)(>ing  pushed  in  by  the  outside  hand,  the  fingers  inside 
pull  it  around  the  pelvis.  Locking  is  not  easy  in  these  cases,  1)ut  is  done  as  before 
(loscrilxMJ,  and  the  operator,  knowing  that  the  head  is  grasped  in  one  of  its  long 
(lianioters,  will  not  bring  the  handles  too  close  together.  A  go(Kl  way  for  the 
accoucheur  to  assure  himself  that  the  child's  head  does  not  suffer  injurious  pressure 
is  for  him  to  put  tho  index-finger  of  his  left  hand  between  tho  handles  while  making 
traction.  Extraction  is  acconijianiod  by  slight  and  gentle  rotation,  the  two  move- 
ments being  absolutely  synchronous,  producing  a  turbinal  or  spiral  rotation  (Fig. 
868).  The  front  of  the  forceps  points  to  the  right,  and  the  turbinal  movement 
imparted  to  the  instrument  is  from  right  to  left  and  from  above  downward,  opposite 


Fig.  S67. — Showing  how  to  Tubn  Forceps  Blade. 


that  sho^\^l  in  Fig.  868,  which  is  for  O.L.T.  At  the  same  time  the  force  applied  is 
so  directed  that  the  tractive  impulse  is  first  felt  on  the  parietal  bone  lying  pos- 
teriorly. It  is  chfficult  to  describe  this  delicate  operation,  because  this  is  the  art 
of  the  accoucheur,  and  is  attainable  only  by  practice.  The  first  traction  should  be 
simply  downward,  to  see  if  rotation  will  not  take  place  inside  the  forceps,  which 
not  seldom  occurs.  If  there  is  no  tendency  for  this,  the  second  traction  is  combined 
with  rotation,  from  right  to  left,  so  as  to  bring  the  occiput  aromid  to  the  front. 
After  a  little  rotation  has  taken  place,  which  is  discovered  by  frequent  examinations, 
the  small  fontanel  l^eing  the  landmark,  the  blades  are  opened  and  allowed  to  rest 
at  the  sides  of  the  head.  A  few  pains  may  complete  the  process.  As  rotation 
occurs  the  blades  are  readapted  so  as  to  lie  more  and  more  on  the  sides  of  the  head, 
and  as  the  instrument  grasps  the  head  in  more  favorable  diameters,  the  handles 
come  closer  and  closer  together.  If  the  fetal  heart-tones  are  good,  time  may  be 
62 


978 


OPERATIVE    OBSTETRICS 


disregarded.  After  rotation  is  complete  the  forceps  may  be  removed  and  the  case 
left  to  nature.  This  is  often  desirable  in  primiparse  with  rigid  parts  and  large  babies. 
If  the  pains  are  strong,  the  head  is  properly  molded  within  a  few  hours,  and  the 
subsequent  low  forceps  operation,  if  it  becomes  necessary,  is  much  easier.  Many 
object  to  this  "two-stage"  forceps  operation,  as  subjecting  the  parturient  to  two 
anesthesias,  and  because,  when  she  awakens,  she  is  disappointed  not  to  have  been 
delivered,  also  on  the  score  of  the  consumption  of  time  and  the  increase  of  trouble 


Fig.  868. — Tdhbinal  Motion  of  the  Forceps. 
This  is  as  applied  to  a  head  in  O.L.T. 


on  the  part  of  the  accoucheur  and  nurses,  but  extensive  experience  has  convinced 
me  that  the  benefits  resulting — absence  of  lacerations,  avoidance  of  fetal  injury  and 
asphyxia,  and  ease  of  subsequent  operation— often  offset  the  disadvantages.  Nat- 
urally, one  may  wait  only  when  there  is  no  indication  for  the  immediate  termination 
of  labor. 

If  the  delivery  must  he  completed  at  once  after  the  small  fontanel  comes  to 
the  front,  the  rest  of  the  operation  is  the  same  as  was  described  under  Low  Forceps. 


OPERATIONS    OF    DELIVERY 


979 


Forceps  in  Occipitoposterior  Positions. — The  reader  is  referred  to  p.  584  for 
details  of  treatment  of  occipitoposterior  positions.  Since  tlie  forceps  operation 
may  be  considered  at  all,  it  means  that  the  head  has  engaged,  and  that,  in  spite  of 
strong  pains,  or  eventually  in  spite  of  the  proc(;dures  of  rectification  before  men- 
tioned, the  occiput  remains  persistently  posterior.  I  have  very  seldom  found  it 
necessary  to  apply  the  forceps  to  an  occipitoposterior  as  such,  and  these  cases  were 
almost  always  those  where  the  head  was  fast  on  the  pelvic  floor,  the  small  fontanel 
pointing  to  the  sacrum,  and  the  time  for  manual  correction  past.  Under  such 
circumstances  the  occiput  must  be  delivered  over  the  perineum,  and,  as  will  be 
seen  if  reference  is  made  to  the  chapter  devoted  to  the  Mechanism  of  Occipito- 
posteriors,  it  is  best  to  deliver  the  head  in  extreme  flexion.  Some  operators  use 
for  this  purpose  straight  forceps  without  pelvic  curve,  since  they  allow  a  better 
grasp  over  the  parietal  bosses,  but  my  experience  shows  that  the  advantage  is  not 
great  enough  to  induce  one  to  have  a  pair. 

The  application  of  the  blades  is  made  as  usual,  but  the  front  of  the  forceps 
looks  toward  the  forehead,  which,  from  now  on,  becomes  the  point  of  direction 
(Fig.  869).     Locking  the  blades  is  the  same  as  usual,  but  after  they  are  locked  the 


Fig.  869. — Forceps  in  Occiput  Postebior  Position  on  Pelvic  Floor. 


handles  are  raised  a  little  toward  the  pubis — this  to  increase  flexion.  Traction  is 
made  on  the  parietal  bosses,  a  little  upward  from  the  horizontal  plane.  This  in- 
creases flexion,  and  it  has  happened,  though  I  have  never  observed  it,  that  even 
as  late  as  this  anterior  rotation  has  occurred.  The  occiput  is  first  delivered  over 
the  perineum,  the  forehead  resting  behind  the  pubis;  then  the  brow  and  face  come 
from  under  the  pubis.  Much  power  is  often  necessary,  and  it  is  advisable  to  per- 
form episiotomy  in  primiparse,  as  a  rule,  and  almost  always  in  multiparse,  to  avoid 
extensive  lacerations  of  the  pelvic  floor  and  sphincter. 

When  it  becomes  necessary  to  apply  forceps  with  the  occiput  in  a  position 
between  the  transverse  diameter  and  the  hollow  of  the  sacrum,  great  difficulties  are 
met,  and  the  operation  should  not  be  lightly  undertaken.  I  am  convinced  that  ten 
times  the  number  of  babies  are  lost  from  this  complication  in  the  United  States 
than  from  contracted  pelvis.  It  is  often  possible,  by  combined  manipulation,  to 
rotate  the  head  into  the  anterior  quadrant  of  the  pelvis,  or  at  least  into  the  trans- 
verse, and  hold  it  there  until  the  forceps  can  be  applied,  which  very  much  simplifies 
the  operation.  If  this  is  impossible,  the  forceps  are  applied  in  the  transverse  di- 
ameter of  the  peh-is,  and  traction  made  in  the  horizontal  plane,  no  attempt  at  rota- 
tion being  practised,  the  ol^ject  being  to  observe  and  discover  the  mechanism  in- 


980 


OPERA.TIVE    OBSTETRICS 


tended  by  nature.  If  the  occiput  comes  down,  flexion  is  increased  and  some  anterior 
rotation  occurs.  If  it  is  noticed  that  nature  intends  this  mechanism,  the  forceps 
are  opened  and  reappHed  in  a  manner  to  favor  the  indicated  mechanism,  the  process 
being  repeated  at  intervals  as  the  small  fontanel  turns  toward  the  pubis.  If,  on 
the  contrary,  the  occiput  should  show  a  tendency  to  rotate  posteriorly,  no  attempt 
should  be  made  to  hinder  this.  To  force  the  rotation  into  an  anterior  position 
would  seldom  succeed,  and  there  is  great  danger  of  tearing  the  soft  parts.  The 
accoucheur  should  be  guided  by  what  he  finds  nature  is  intending  to  do,  and  should 
aid  that  mechanism.  It  may  be  necessary  to  remove  and  reapply  the  forceps  three 
or  four  times  to  accommodate  the  different  positions  which  the  head  takes  in  pas- 
sage. Some  accoucheurs  prefer  the  axis-traction  forceps  for  these  cases  on  this 
account,  but  for  the  man  who  knows  the  mechanism  of  labor  and  is  willing  to  be 
guided  by  the  action  of  the  natural  powers  they  are  unnecessary,  and  in  the  hands 
of  a  man  ignorant  of  the  principles  of  the  science  of  obstetrics  the  instrument  is 
too  dangerous. 

Scanzoni-Fritsch  Method. — Williams  speaks  very  highly  of  this  method  of 


Fig.  870. — Fokceps  in  Face  Presentation. 
Dotted  line  shows  forceps  as  first  applied.     Traction  is  applied  after  handles  are  lowered. 


forceps  delivery,  but  in  a  not  small  experience  I  have  used  it  only  twice,  and  then 
merely  to  try  it.  It  is  entirely  dispensable,  and,  in  my  opinion,  is  fraught  with  too 
great  dangers  to  the  maternal  soft  parts  to  be  practised  by  any  but  experts.  The 
forceps  are  applied  with  the  front  looking  toward  the  forehead.  By  rotating  the 
instrument  the  forehead  is  brought  to  the  rear,  which,  of  course,  inverts  the  forceps. 
They  are  removed  and  reapplied,  with  the  front  toward  the  occiput,  which  has  come 
to  the  pubis,  and  the  operation  is  completed  as  usual  after  rotation  has  occurred. 
Jaggard  taught  that  it  is  too  dangerous  to  rotate  the  head  through  an  arc  exceeding 
one-fourth  of  a  circle,  and  my  experience  convinces  me  that  he  was  right. 

Forceps  in  Face  Presentations. — Per  se  face  presentation  is  no  indication  for 
forceps,  but  labor  is  often  delayed  and  help  often  required  with  all  the  deflexion 
attitudes.  In  face  presentation,  to  the  conditions  demanded  for  forceps  in  general 
one  new  one  must  be  added — the  chin  may  not  be  behind  the  transverse  diameter 
of  the  pelvis — that  is,  anterior  rotation  of  the  chin,  at  least  to  the  transverse  di- 
ameter, must  have  occurred.  The  forceps  operation  otherwise  is  usually  equiva- 
lent to  a  craniotomy. 


OPERATIONS    OF    DKLI\  KUY 


981 


Apjylication  of  the  blades  afhr  I  he  cliiii  Jkih  rotated  is  very  easy,  although  care  is 
rofiuircd  not  to  injure  the  baby's  eyes.  Adaptation  or  locking  is  different.  In- 
stead of  depressing  the  handles,  it  is  V^est  to  raise  them  well.  This  sinks  the  blades 
towartl  the  IkjIIow  of  the  sacrum,  and  thus  they  obtain  a  firmer  hold  over  the  parietal 
bosses.  Straight  forcejis  should  l)e  useful  here.  If  the  blades  are  placed  and  locked 
in  the  usual  manner,  they  will  slip  off  the  narrow  brow  and  face — they  are,  there- 
fore, locked  with  the  handles  raised,  and  then  the  latter  are  lowered,  which  man- 
aniver  increases  extension  (Fig.  870).  Traction  is  first  downward,  to  increase 
deflexion,  then  in  the  horizontal  plane,  until  the  chin  is  well  out  from  under  the 
pubis,  then  upward,  but  not  so  acutely  as  with  the  occiput,  because  the  delicate 
larynx  is  Ix'tween  the  spine  of  the  child  and  the  bone.  Episiotomy  is  the  rule  in 
primipane. 

Forceps  in  Arrested  Rotation  of  the  Chin, — To  deliver  with  forceps  when  the 


Plane  of  inlet 
Plane  of  head 


Interspinous  line 

Fig.  871. — The  Engagement  of  the  Head. 

The  largest  circumference  of  the  head  is  about  to  pass  the  inlet.     The  lowest  part  of  the  head  lies  in  the  interspinous 

line.     Owing  to  the  perspective,  it  seems  as  if  it  were  below  this  line. 


chin  is  directed  toward  the  hollow  of  the  sacrum  is  possible  only  when  the  child  is 
small,  and  then  only  at  the  expense  of  extensive  lacerations.  To  try  to  rotate  the 
chin  anteriorly  b}'  means  of  forceps  from  a  posterior  quadrant  of  the  pelvis  is 
equivalent  to  a  craniotomy,  and  much  more  damaging  to  the  mother's  tissues.  It 
is,  however,  possible  safely  to  deliver  a  face  presentation  arrested  in  rotation  after 
the  chin  has  reached  or  passed  the  transverse  diameter,  but  the  operation  is  very 
delicate,  very  difficult,  usuall}^  causes  deep  tears,  and  often  costs  the  child's  hfe. 
The  reason  for  the  last  is  obvious.  One  blade  compresses  the  neck  and  always 
injures  the  structures  exposed  by  the  extreme  extension  of  the  cervical  spine.  The 
forceps  lie  in  an  oblique,  the  front  pointing  in  the  direction  of  the  point  of  direction. 
In  M.D.T.  the  forceps  lie  in  the  right,  in  jM.L.T.  in  the  left,  oblique.  Extraction 
must  be  most  carefully  done,  loosening  the  forceps  frequently  and  readapting  them 


982 


OPERATIVE    OBSTETRICS 


at  the  earliest  possible  moment  to  the  sides  of  the  head.  Rotation  is  effected  by 
giving  the  forceps  a  slight  turbinal  movement,  but  much  may  also  be  accomplished 
by  manipulation  with  the  fingers. 


Fig.  872. — Diagram  Showing  Traction  with  Usual  For- 
ceps. 


Fig.  873. — Diagram    of    Action    of    Axis-traction 
Forceps. 


Fig.  874. — Pajot's  (O.siander's)  Manceuveu  with  Forceps. 
By  this  method  axis-traction  is  obtained. 


Forceps  in  Brow  Presentation. — What  was  said  under  Face  Presentation  ap- 
]:)lies  here.  The  brow,  instead  of  the  chin,  must  come  to  the  pubis  and  appear  in  the 
vulva,  the  face  resting  Ijchintl  the  symphysis  until  the  occiput  can  be  brought  over 


OPERATIONS    OV    DKLIXKUV 


oas 


tlie  pcriiicum,  alter  which  the  face  coiiics  down  from  Ix'hiiid  the  pubis.     Episiotoniy 
is  tho  rule  in  primipiinc  and  in  niiiiliparsc,  too,  if  the  child  is  large. 

Inlet  Forceps  Operations-  "High  Forceps." — In  most  of  the  cases  of  forceps 
just  described  1  he  head  occupies  (he  excavation  of  the  pelvis,  and  we  might  speak 
of  "nutlplane  fc^-cejis,"  a.s  was  already  mentioned.  The  term  "high  forceps"  is 
best  limited  to  those  cases  where  the  biparietal  diameter  is  in  the  region  of  the  su- 
perior strait,  but  has  not  yet  passed  lower,  or  has  not  even  as  yet  entered  the  inlet, 
but  is  arr(>sted  just  above  it.  Some  operators  permit  the  use  of  forceps  on  the 
"floating  head."     I  have  not  found  this  necessary,  having  been  able  to  do  a  version, 


Sanger. 


Leroyenne. 
Fig.  87.5. — The  Principle  of  Axis-traction. 


or  at  least  to  force  the  head  down  into  the  pelvis,  by  means  of  outside  pressure,  so 
that  it  could  be  easily  grasped.  In  some  cases  (Fig.  871)  the  head  is  so  well  fixed 
that  it  may  be  impossible  to  move  it  away  to  do  version,  and  j'et  it  is  not  quite 
engaged  so  as  to  fulfil  the  condition  for  forceps.  Under  these  circumstances  the 
forceps  is  an  instrument  of  trial,  or,  as  Carl  Braun  said,  "an  instrument  of  diag- 
nosis." We  want  to  see  if  the  head  will  come  into  the  pelvis.  If,  after  suitable 
trial,  the  head  will  not  come  in,  we  must  do  a  craniotomy,  even  if  the  child  be  alive, 
or,  if  both  patients  are  in  prime  condition,  perform  hebosteotomy. 

For  deliveries  begun  when  the  head  is  above  the  level  of  the  spines  of  the  ischia 
many  authors  recommend  a  special  instrument, — the  axis-traction  forceps, — that 


984 


OPERATIVE    OBSTETRICS 


is,  an  instrument  which  will  enable  us  to  apply  force  to  the  head  parallel  to  the  axis 
of  the  pelvis. 

The  head,  when  high  up,  has  a  curve  to  traverse.  Owing  to  the  forward  pro- 
jection of  the  sacrum  and  perineum,  traction  cannot  be  applied  in  the  axis  of  the 
inlet.  If  applied  in  any  other  line,  the  problem  is  like  trying  to  pull  an  object 
around  a  corner — both  the  corner  and  the  object  suffer. 

Fig.  S72  shows  the  effect  of  the  ordinary  forceps  when  applied  on  the  high  head;  if  traction 
is  made  in  tlie  usual  way,  a  large  part,  estiniated  by  Tarnier  as  almost  half,  of  the  force  will  be 
exerted  against  the  symphysis.  The  older  obstetricians  appreciated  the  fact  that  the  head  would 
thus  impinge  on  the  anterior  pelvic  wall,  and  Saxtorph  (1780)  recommended  that  tapes  be  put 
through  the  fenestra  of  the  forceps,  and,  while  pulling  in  the  usual  manner,  also  to  pull  downward 
on  the  tapes,  thus  making  the  head  follow  the  curve  of  the  parturient  canal.     Osiander  (1800) 


Fig.  S70. — Tarnier  Axis-tr.^ction  Forceps.     Last  Model. 


advised  to  pull  downward  toward  the  floor  with  one  hand  over  the  lock,  while  the  other  pulled 
the  forceps  straight  out — a  manosuvcr  which  is  generally  known  as  Pajot's  (Fig.  874).  In  1844 
Hermann,  of  Berne,  instead  of  the  tapes,  attached  a  straight  hook  to  the  blade  near  the  head,  and 
the  Huberts,  in  1860,  bent  the  handles  down  so  that  wlien  traction  was  made  on  the  lowest  parts 
the  force  was  transmitted  through  the  bent  lever  to  the  head  in  the  axis  of  the  inlet.  Finally,  in 
1877,  Tarnier  invented  a  forceps  which  lie  believed  poss(!ssed  tli(>se  advantages — (1)  It  allowed 
traction  to  be  made  in  the  axis  of  the  inlet;  (2j  while  the  head  was  fixed  in  the  forceps  proper  the 
traction  apparatus  was  so  jointed  that  the  head  was  given  free  mobility  and  could  follow  the 
impulses  of  the  mechanism  of  labor;  (3)  the  handles  of  the  forceps  could  be  used  as  indicators 
of  the  lines  the  head  was  following.  Tarnier  constructed  ov(n-  100  models  before  he  considered 
the  instrument  perfect  (Fig.  870).  Simpson,  MvuTay,  Lusk,  Breus,  Felsenreich,  and  many 
others  sought  to  improve  on  Tarnier's  instrument,  but  of  all  axis-traction  instruments,  in  my 
opinion  those  of  Tarnier  and  Simpson  are  the  b(;st. 

Axis-traction  for(;eps  are  not  universally  recommended  ])y  obstetric  authorities.  In  England, 
Kerr,  Milne-Murray,  Eden,  anrl  others  recommend  them;  in  Germany,  opinion  is  nearly  evenly 
divided,  the  balance  being  sliglitly  in  their  favor;  in  France,  Pajot,  Depaul,  and  others  opposed 
Tarnier,  })ut  the  large  majority  was  with  him;  in  America,  nearly  all  writers  are  in  favor  of  them. 
Vienna  is  lukewarm,  and  Bossi,  in  Genoa,  says  they  are  entirely  dispensable.  For  my  part  I 
cannot  share  the  enthusiasm  of  Williams,  Kerr,  Murray,  and  others.  By  means  of  the  Osiander 
manocuver  I  can  give  the  head  a  direction  which  a  knowledge  of  the  mechanism  of  labor  wiU 


Ol'KUATlONS    OF    DELI  VERY 


985 


indicate;  by  careful  ohscrvjiiicc  of  the  Icinlciicics  of  iiKncinciit  wliidi  (lie  Uirccs  of  iialiiro  ^ivo  the 
head  1  ciin  (Ictcnnino  in  whi<"li  way  to  apply  tiiiction,  and  1  can  aid  oik;  or  the  other,  as  recjuircd. 
With  the  axis-traction  device  there  are  so  many  joints  bet\V(!en  tlie  operating  hand  and  the  head 
that  it  is  impossible  lo  im|)ress  on  the  latter  any  specific  motion.  All  the  knowledge  one  has 
accumulated  rej^jardin^f  normal  and  abnormal  laf)or  me(!lianisms  noes  for  nauf^ht,  and  all  one 
can  do  is  to  pull  l)lindly  on  the  cross-bar.  In  this  respect  the  axis-traction  forceps  are  not  artistic. 
In  actual  practice,  wheic  I  lia\'e  applie(l  l)otii  iiisti'uments  on  tlu;  same;  case,  I  have  been  better 
satisfied  with  the  simple  Simpson  forcej)s  and  seldcnn  u.se  any  other.  Deep  injuries  to  the  maternal 
ti.ssues  are  just  as  freciuent  with  the  new  forceps,  a  fact  which  W.  A.  Freund  proved.  The  Tarnier 
instrument  has  a  murderous  cephalic  curve,  cognizance  of  which  should  be  taken  when  screwinf^ 
together  the  handles,  otherwi.sc;  a  large  number  of  dead  and  injured  children  will  be  the  result. 
In  all  axis-traction  instruments  there  is  the  po.ssibility  of  the  curved  arms  or  the  joints  bending 
or  breaking  under  the  powerful  force  applied,  having  witnessed  three  such  accidents  myself. 


Fig.  877. — Axis-tractiox  Forceps  Applied  at  the  Inlet. 


Indications  for  High  Forceps. — These  are  the  same  as  usual — danger  to  the 
motlier  or  child,  occurring  at  a  time  when  the  head  has  not  yet  passed  through  the 
inlet.  Let  it  be  well  emphasized  that  the  indication  for  forceps  here  nmst  be 
unusually  strict. 

Conditions. — These  also  are  as  usual,  and  to  be  strictly  insisted  on.  Engage- 
ment of  the  head  must  be  so  nearly  accomplished  that  the  accoucheur  feels  certain 
that  a  little  ptill  from  Ixdow  will  help  the  head  into  the  pelvis.  He  must  remember 
the  alternative  if  he  fails — craniotomy  or  hebosteotomy.  The  pelvis  may  not  be 
too  contracted — not  less  than  83^2  cm.  in  flat  and  9  cm.  in  the  justominor  types. 
Dilatation  of  the  cervix  and  retraction  of  the  pelvic  organs  above  the  inlet  must 
be  positively  complete. 


986  OPERATIVE    OBSTETRICS 

The  operation  itself  is  quite  a  little  more  complicated  than  the  low  or  midplane 
forceps,  but  the  principles  are  identical.  In  applying  the  blades  the  half  or  even 
the  whole  hand  should  be  inserted  as  a  guide.  Adaptation  of  the  blades  must  be 
to  the  sides  of  the  pelvis,  because  the  instrument,  being  pushed  in  so  far,  must  have 
its  pelvic  curve  correspond  to  that  of  the  pelvis.  The  head,  therefore,  will  be 
grasped  in  the  sagittal  diameter,  especially  in  flat  pelves,  where  the  head  enters  in 
the  transverse  diameter,  and  one  blade  will  lie  over  the  occiput,  the  other  over  the 
face  (Fig.  877).  To  prevent  serious  injury  of  the  child  the  handles  may  not  be 
tightly  screwed  together.  In  using  the  ordinary  forceps  a  finger  is  laid  between  the 
handles.  Locking  is  more  difficult  and  is  done  as  usual.  No  force  may  be  employed, 
and  the  hand  outside  may  help  adjust  the  forceps,  the  tops  of  whose  blades  may  thus 
be  manipulated  above  the  pubis.  Before  articulating  the  blades  it  may  be  necessary 
to  adjust  the  head  to  the  pelvis  by  combined  manipulation.  In  extracting,  it  is 
to  be  remembered  that  the  high  forceps  is  an  operation  of  trial — of  diagnosis. 
Traction  should  be  made,  according  to  Tarnier,  in  the  direction  indicated  by  the 
handles,  the  traction  rods  lying  1  cm.  away  from  the  shanks  (Fig.  877).  If  six,  or 
at  most  eight,  powerful,  well-directed  tractions  make  no  impression, — do  not  bring 
the  head  lower, — the  instrument  must  be  removed.  Two  or  three  of  the  tractions 
should  be  made  with  the  patient  in  the  Walcher  position.  Craniotomy  now  must 
be  done,  or  if  the  mother  and  babe  are  in  prime  condition  and  the  environment  is 
favorable,  hebosteotomy.  If  the  head  does  move  a  little  with  each  traction,  the 
operation  should  be  genth"  completed,  taking  plenty  of  time.  After  the  head  has 
entered  the  pelvis  it  may  rotate  within  the  forceps,  which  should  be  opened  to  per- 
mit this,  or  it  ma^^  be  turned  by  combined  manipulation,  the  case  now  being  simply 
one  of  arrest  at  the  midplane.  It  may  be  desiral^le  to  remove  the  axis-traction 
apparatus  and  deliver  as  in  ordinary  forceps,  or  it  may  be  best  to  leave  the  delivery 
to  nature,  or  to  follow  a  sul^sequent  indication. 

Prognosis  of  the  Forceps  Operation. — For  the  mother,  the  clangers  are  injury, 
hemorrhage,  and  infection.  Some  tearing  of  the  pelvic  organs  is  inevitable,  and  the 
nmnber  and  severity  increase  the  higher  up  the  forceps  operation  is  done.  High 
forceps  show  the  most  and  the  worst  injuries,  which  may  be  atrocious  if  the  condi- 
tion relating  to  the  dilatation  had  not  been  fulfilled.  If  rotaiy  motions  with  the 
forceps  are  made,  the  vagina  msiy  be  twisted  from  its  connective-tissue  attach- 
ments, or  the  cervix  may  be  caught  in  the  grasp  of  the  forceps  and  be  bruised  or 
torn  off  bodily;  or  the  operator,  thinking  the  blade  is  inside  the  cervix,  may  use 
force,  and  as  the  tip  of  the  instrument  is  in  the  fornix,  he  may  punch  through  this 
up,  under,  or  through  the  peritoneum. 

The  vagina  itself  may  be  torn  or  cut  by  the  blades  of  the  forceps  and  the  vulva 
also,  esi>ecially  when  the  blades  are  bent  upward  in  the  delivery  of  the  head.  The 
edges  may  cut  the  crura  of  the  clitoris  and  cause  severe  hemorrhage,  or  pressure 
necrosis  which  may  go  to  the  bone.  In  severe  forceps  operations  the  symphysis 
pubis  has  been  ruptured,  also  the  sacro-iliac  articulations,  and  the  woman  will 
have  a  pain  in  the  lower  spine  and  back,  with  more  or  less  invalidism  all  the  rest 
of  her  life.  Injury  to  the  sacro-iliac  joints  is  a  frequently  overlooked  cause  of  back- 
ache, leukorrhea,  and  many  gynecologic  conditions.  The  bladder  may  be  torn 
into,  or  may  be  pulled  off  its  pelvic  attachments  and  be  permanently  prolapsed. 
Scars  in  the  vaginal  wall  may  distort  the  bladder  sphincter,  causing  incontinence 
and  cystitis.  Injury  to  the  levator  ani  and  pelvic  floor  is  a  constant  sequel  to  forceps 
delivery.  At  autopsy  one  is  astonished  at  the  extent  and  number  of  the  tears  and 
bruises.  Postpartum  hemorrhage  results  from  the  tears  and  from  atonia  uteri. 
Infection  is  common  from  lapses  of  asepsis  and  from  the  ease  with  which  contused 
wounds  are  successfuU}^  attacked  by  the  bacteria. 

]Most  dangerous  to  both  mother  and  child  is  the  slipping  of  the  forceps.  This 
happens  in  two  ways,  according  to  Mine.  La  Chapelle:  in  the  vertical  sense,  that 


(il'KltATIOXS    or    I)KI>IVK1{Y 


!>S7 


is,  the  forceps  slide  ()(T  in  I  lie  direct  ion  of  the  line  of  tructionj  and  in  tlie  horizontal 
sense,  that  is,  the  forceps  slip  off  in  a  line  perpendicular  to  the  line  of  traction, 
the  patient  beins  iiiuisined  erect  (Figs.  878  and  879).  1  believe  the  terms  "axial" 
and  "exaxial"  slip|)in};'  would  more  clearly  express  the  conrlitions. 

The  causes  of  slippinji;  of  the  forceps  an;:  (iraspinj;  th(;  iiead  too  low,  tlie  forceps 
not  being  inserted  liigh  enougii,  under  a  mistaken  idea  of  the  degree  of  engagement; 
the  blades  feather  too  much — a  poor  instrument;  the  head  may  be  too  small  or 
too  large — hydrocephalus;  the  head  is  not  grasped  right;  the  handles  are  bent  up 
too  soon  as  the  liead  nears  the  outlet. 

The  sensation  of  slipping  of  the  forceps  is  unmistakable.  The  handles  tend 
to  separate,  and  if  the  direction  is  to  the  front  or  back  of  the  pelvis,  the  blades  seem 
to  jump  off  the  head  with  a  snapping  noise,  and  they  are  usually  disarticulated. 
If  the  forceps  slip  off  in  the  line  of  traction,  i.  e.,  axially,  one  can  feel  the  instrument 


Fig.  878. — Slippinq  of  Forceps.     Horizontal  Sense.     Exaxial. 


advance  while  the  head  seems  not  to  follow.  Slipping  of  the  forceps  is  commonest 
at  the  inlet,  because  here  the  walls  of  the  pelvis  do  not  hold  the  blades  to  the  sides 
of  the  head.  It  is  highly  essential  to  discover  the  tendency  to  slip  early,  because  the 
lacerations  caused  by  it  are  frightful.  Removal  of  the  blades  and  reapplication 
are  the  treatment.  If  the  head  is  small,  a  small  forceps  must  be  secured.  If  there 
is  a  hydrocephalus,  puncture  is  required. 

Dangers  to  the  Child. — (1)  Compression  of  the  brain,  slowing  of  the  heart, 
asph\T^ia.  (2)  Fracture  of  the  skull,  with  or  without  subdural  hemorrhage.  (3) 
Hemorrhage  from  rupture  of  the  sinuses  at  the  base  or  from  rupture  of  the  tentorium 
cerebelli.  (4)  Concussion  of  the  brain.  (5)  Crushing  of  the  orbital  plates,  with 
retrobulbar  hematoma  and  injun,'  to  nerves  and  muscles,  causing  squint,  ptosis, 
etc.  (6)  Injury  to  the  eyes,  traumatic  cataract,  abruption  of  the  choroid,  corneal 
opacity,  retinal  hemorrhage,  enucleation  of  the  eye.     (7)  Facial  paralysis,  from  com- 


988 


OPERATIVE    OBSTETRICS 


pression  of  the  nerve  as  it  comes  out  in  front  of  the  mastoid.  Usually  good  prognosis. 
(8)  Pressure  necrosis  of  the  scalp,  perhaps  to  the  bone.  (9)  It  is  said  that  idiocy 
is  more  frequent  after  forceps.  (10)  Cephalhematoma — usually  good  prognosis. 
(11)  Compression  or  cutting  of  the  umbilical  cord,  with  asphyxia.  (12)  It  is 
possible  that  deafness  may  be  due  to  injury  or  hemorrhage  into  the  organs  of  hear- 
ing, etc.  (13)  Indeed,  nearly  every  imaginable  injury  has  been  observed  and  in 
general,  forceps  babies  are  more  liable  to  infection,  pneumonia,  atelectasis,  menin- 
gitis, hemophilia,  etc. 

Dystocia  Due  to  the  Shoulders. — If,  after  delivery  of  the  head,  the  shoulders 
do  not  immediately  follow  gentle  traction,  applied  as  indicated  under  the  conduct 
of  normal  labor,  the  accoucheur  should  make  an  examination  with  four  fingers  to 
determine  the  cause  of  delay.  One  or  the  other  of  the  following  conditions  will  be 
found:    (1)   The  shoulders  are  broad  and  firm;    (2)  they  have  followed  an  unfavor- 


FiG.  879. — Slipping  of  Forceps.     Vertical  Sense.     Axial. 


able  mechanism,  the  anterior  shoulder  being  caught  on  the  ramus  pubis,  or  having 
over-rotated,  and,  the  accoucheur  not  observing  this,  he  tries  to  bring  the  shoulder- 
girdle  down  in  the  wrong  diameter;  (3)  the  cord  is  too  short;  (4)  the  chest  of  the 
child  is  too  large  (anasarca) ;    (5)  locked  twins  or  a  monster  exists. 

The  head  springs  backward  against  the  perineum,  pressing  this  well  up  into 
the  pelvis,  and  traction  serves  only  to  stretch  the  neck.  Not  a  few  children  have 
been  lost  at  this  stage  of  delivery. 

Treatment. — If  the  woman  is  conscious,  she  should  be  exhorted  to  bear  down 
strongly,  failing  which  the  assistant  makes  a  strong  Kristeller  expression.  Now, 
by  means  of  the  fingers  inside  and  the  hand  outside,  the  shoulder-girdle  is  rotated 
into  the  most  favorable  pelvic  diameter — one  of  the  oblicjucs.  Next,  the  accoucheur 
inserts  four  fingers  of  the  left  hand  into  the  vagina  in  search  of  the  posterior  axilla, 
into  which  he  puts  his  index,  and,  pulling  gently,  he  tries  to  bring  the  posterior 
shoulder  down  into  the  hollow  of  the  sacrum.     This  may  be  aided  by  crowding  the 


OPKUATIONS    OF    1)KLI\'KUY 


989 


anterior  shoulder  into  the  jx-lvis  from  above  the  jjiibis  (Fip;.  880).  After  the  pos- 
terior slioulder  has  been  brou{;ht  t(j  the  j)erineiim  tlie  hand  is  withdrawn  and  the 
child's  head  allowed  to  drop — even  a  little  j>;(mtle  traction  may  be  made  downward 
to  bring  the  anterior  shoulder  under  the  pubic  arch.  If  this  fails,  which  is  rare,  a 
trial  is  made  to  bring  the  anterior  shoulder  under  the  pubis  by  downward  traction 
on  the  head,  coml)ined  with  pressure  from  above  the  pubis.  Excessive  caution  is 
here  requinnl  because  only  too  easily  is  the  clavicle  fractured  or  the  cervical  plexus 
torn  or  pulled  out  of  the  spinal  cord. 


Fig.  880. — Brin'gin'g  Down  Posterior  Arm  in  Head  Present.\tiox. 


Failing  these  plans,  next  to  do  is  to  deliver  the  posterior  arm,  it  being  necessary 
to  insert  the  whole  hand  in  order  to  reach  it,  and  it  is  wiped  doAAai  over  the  face — 
not  over  the  back.  Now  extraction  is  always  possible  unless  there  is  some  mon- 
strosity. This  will  at  once  be  discovered  by  the  hand,  which  has  been  introduced, 
and,  of  course,  the  treatment  Avill  be  guided  by  what  is  found.  Exenteration, 
cleidotomy,  or  other  cutting  oj^eration  will  usually  be  advisable  under  such  cir- 
cumstances. 

Literature 

Davis:  Amer.  Joar.  Obstet.,  December,  1910,  p.  978. — Ingraham:   "  History  of  Forceps,"  Amer.  Jour.  Obstet.,  1911, 
vol.  ii.,  p.  830. — Reynolds  and  Newell:  Amer.  Jour.  Obstet.,  January,  1910. 


CHAPTER  LXXII 

CESAREAN  SECTION 

Cesarean  section  is  the  removal  of  the  child  from  the  uterus  through  an  in- 
cision made  in  the  abdominal  wall.  The  term  may  not  be  applied  to  the  removal  of 
the  child  from  the  belly  after  rupture  of  the  uterus,  nor  to  operations  for  ectopic 
pregnancy. 

The  term  probably  is  derived  from  the  Latin,  -partus  cesareus,  from  cedere,  to  cut.  The 
term  cesarean  section,  therefore,  is  really  a  redundancy.  There  is  no  evidence  to  show  that 
Julius  Csesar  was  thus  delivered.  Cesones  (children  dehvered  by  section  from  their  dead  mothers) 
were  kno\^-n  long  before  Caesar's  time,  and  the  operation  was  not  performed  on  the  living.  Csesar's 
mother  was  alive  at  the  time  of  his  wars,  as  is  proved  by  his  letters  to  her. 

Cesarean  section  on  the  dead  woman  has  been  done  for  ages,  possibly  even  by  the  early 
Egyptians,  and  the  operation  is  referred  to  in  the  myths  and  folklore  of  European  races.  Dionysus 
was  cut  from  the  dead  Semele.  The  Lex  Regia  of  Numa  Pompilius,  715  b.  c,  expressly  commands 
the  removal  of  the  child  before  the  burial  of  its  mother. 

Cesarean  section  on  the  living  is  of  more  recent  date,  though  it  is  more  than  possible  that  it 
was  performed  by  earlier  peoples.  "Jotze  Dofan"  was  the  name  the  ancient  Jews  applied  to 
children  delivered  through  the  flanks  of  their  mothers.  In  the  heart  of  Uganda  in  1879  Felkin 
witnessed  a  cesarean  section  performed  by  a  native.  The  operator — a  specialist — washed  his 
hands  and  the  operative  field  with  banana  wine  (antisepsis!),  the  patient  being  drunk  with  the 
same  (anesthesia!).  A  quick  incision  opened  the  uterus.  After  cutting  the  cord  and  removing 
the  placenta  the  cervix  was  dilated  from  above,  the  uterus  massaged  and  compressed,  the  peritoneal 
ca^^ty  cleaased  by  raising  the  woman  up,  then  the  abdomen  closed  by  pin  and  figure-of-8 
sutures,  the  wound  being  dressed  with  a  paste  of  crushed  herbs.  The  temperature  remained  below 
101°  and  the  wound  healed  in  eleven  days.  For  how  many  centuries  must  these  savages  have  been 
doing  this  operation  to  have  developed  so  good  a  technic? 

The  first  generally  accepted  cesarean  section  was  made  by  J.  Trautman,  of  Wittenberg,  in 
1610,  on  a  case  of  hernia  uteri  gravidi.  About  1500  J.  Nufer,  a  swinegelder  in  Switzerland,  had 
successfully  delivered  his  o^ti  wife  after  a  dozen  midwives  and  several  barbers  had  failed,  and  in 
1581  F.  Rousset  had  published  15  cases,  which  probably  were  not  all  extra-uterine  pregnancies, 
as  has  been  suggested.  Rousset's  monograph  established  the  operation,  and  in  spite  of  its  own 
frightful  mortality  and  the  resultant  oppo.sition  by  many  of  Europe's  best  accoucheurs,  it  very 
slowb'  became  an  acceptable  resource  in  those  forlorn  cases  where  the  parturient  almost  to  a 
certainty  would  have  died  without  it  The  Catholic  Church  had  much  to  do  with  the  habilitation 
of  the  operation,  since  it  enabled  the  rite  of  baptism  to  be  given  to  the  child.  Sigault's  symphysi- 
otomy for  a  few  years  only  was  a  competitor  of  cesarean  section. 

Kayser  (Copenhagen,  1844)  found  a  mortaUty  of  62  per  cent,  for  the  previous  eighty  years, 
but  Tarnier  said  that  up  to  his  time  there  had  not  been  a  successful  case  in  Paris  during  the  nine- 
teenth century,  and  Spaeth  said  the  same  thing  of  Vienna  in  1877.  Harris  collected  80  cases  in  the 
United  States,  with  a  mortality  of  52  per  cent.  The  causes  of  death  were  hemorrhage  and  infection. 
In  cesarean  sections  sutures  were  not  put  in  the  uterine  wound  because  the  ends  could  not  be  left 
long  for  the  subsequent  removal,  as  was  the  custom  in  olden  days.  As  a  result  the  women  often  died 
of  hemorrhage  into  the  peritoneal  cavity.  For  the  same  reason  lochia  escaped  into  the  belly  and  usu- 
ally set  up  peritonitis.  Further,  aseptic  technic  was  unknown,  and  all  laparotomies  were  fearfully 
dangerous.  In  1769  Lebasput  three  stitches  in  the  uterine  wound  and  left  the  ends  long,  by  which 
they  were  .subsequently  removed,  with  success,  but  a  true  efficient  uterine  suture  was  not  made  until 
Sanger  recommended  it  in  1882.  In  1877  Porro,  of  Pavia,  to  avoid  the  dangers  of  hemorrhage  and 
of  infection  from  the  leaking  of  the  lochia,  advised  the  supravaginal  amputation  of  the  uterus  after 
the  child  was  delivered,  and  for  a  short  time  this  operation  bid  fair  to  replace  the  old  conservative 
cesarean  section.  Sanger's  operation  in  1882  showed  such  good  results  that  Porro's  was  soon 
relegated  to  its  proper  place — as  an  operation  where  there  is  some  special  indication  for  sacri- 
ficing the  uterus.  The  essentials  of  Sanger's  operation  are:  median  abdominal  incision;  median 
uterine  incision,  with  or  without  eventration  of  the  uterus;  use  of  rubber  ligature  around  cervix 
to  stop  hemorrhage;  resection  of  a  strip  of  uterine  muscle  under  the  peritoneum;  interrupted 
silver-wire  seromuscular  sutures,  avoiding  the  decidua — 8  or  10;  interrupted  fine  silk  seroserous 
(Lembertj  suture,  20  to  25;   extreme  antisepsis. 

Previous  to  Sanger  the  abdominal  incision  had  been  made  in  all  possible  locations,  the  uterus 
opened  in  many  different  places  and  ways,  drainage  of  the  uterus,  of  the  abdominal  cavity,  above 
and  below,  and  many  other  devices  had  been  practised.  The  object  was  to  avoid  hemorrhage, 
seepage  of  lochia,  adhesions  of  the  uterus  to  tlie  abdominal  wall,  to  the  omentum,  with  the  danger 
of  rupture  of  the  scar  in  subsequent  pregnancies.  With  the  general  improvement  of  our  aseptic 
technic  the  results  of  Sanger's  operation  got  better,  and  it  was  found  possible  to  dispense  with 

990 


CESAHKAN    SP:CTION  901 

many  things  lie  considcnMl  necessary.  Many  v;uiefics  of  suture  liavo  been  refornrncnclc*!,— 
tlir()iiti;li-ari(l-t  liroujili  inlernii)te(l  or  continuous,  buried  nuiscular,  seromuscular,  der-idual,  tliree 
layers,  loiw  layers,  silkworin-Kut,  wire,  silk,  c-alf:;ut,  olc.  W'e  cainiot  descriho  liiem  all,  Init 
will  give  the  teciuiic  as  practised  today. 

Indications  for  Conservative  Cesarean  Section. — These  arc  absolute  anrl  rela- 
tive. Tiic  ;il)S()lute  iiKJicatioii  lor  ccsureaii  section  exists  when  the  parturient  eaiial 
is  narrowotl  so  much  tliat  the  child,  even  reduced  by  mutilating  operations,  cannot 
be  gotten  through  with  safety  to  the  mother.  Contracted  pelvis  with  a  conjugata 
vera  of  6  or  iij^o  ^"i-  "i"  ^m  immense  child  will  give  the  absolute  indication,  but  the 
narrowing  of  the  passage  may  be  produced  Ijy  exostoses,  irremovable  tumors, 
stenosis  of  the  cervix,  vagina,  and  neoplasms  of  the  uterus  and  adnexa,  prolapsed 
before  the  child.  If  these  conditions  are  discovered  earl>'  in  pregnancy,  many  may 
be  removed  before  labor,  or  at  least  abortion  may  be  done.  In  lal)or  there  is  no 
choice. 

The  relative  indication,  speaking  broadly,  will  exist  when  the  accoucheur  de- 
cides that  the  abdominal  delivery  offers  better  chances  for  both  mother  and  child 
than  delivery  from  below.     It  is  largely  subjective. 

In  contracted  pelvis,  excepting  the  absolutely  contracted,  cesarean  section  is 
considered  only  with  a  view  to  saving  the  life  of  the  child,  because  we  can,  by  means 
of  eml)ryotomy,  very  safely  deliver  from  l^elow.  The  field  claimed  for  cesarean 
section  from  the  relative  indication  is  in  pelves  with  a  conjugata  vera  of  from  63^^  to 
9  cm.,  depending  on  the  size  of  the  child.  This  is  also  the  field  claimed  by  pubiot- 
omy,  prophylactic  version,  forceps,  and  expectancy.  This  brings  us  again  to  the 
treatment  of  contracted  pelvis.  (See  pp.  709-715.)  When  the  w^oman  is  in 
prime  condition,  which  means  that  she  is  not  infected  and  not  exhausted  by  long 
labor,  and  when,  also,  the  child  is  in  good  condition,  my  preference  is  for  cesarean 
section.  If  the  woman  has  been  examined  by  questionable  hands;  if  she  has  been 
in  labor  many  hours;  if  the  bag  of  waters  has  been  open  a  long  time;  if  attempts 
at  delivery  have  })een  made — cesarean  section,  w^iile  not  always  positively  contra- 
indicated,  is  a  risky  operation,  and  I  do  not  perform  it  under  such  circumstances. 
Pubiotomy,  high  forceps,  and  craniotomy  should  be  considered.  If  the  woman  is 
infected,  as  shown  by  fever,  fetid  liquor  amnii,  tympania  uteri,  necrotic  areas  on  the 
vulva,  cesarean  section  from  the  relative  indication  is  absolutely  forbidden.  For- 
tunately, under  these  circumstances  the  child  has  nearly  always  already  succumbed, 
so  that  one  may  devote  all  his  efforts  to  save  the  mother. 

Placenta  prsevia  as  an  indication  for  abdominal  delivery  has  latterly  been  much 
discussed,  and,  as  was  already  said,  my  opinion  is  in  favor  of  it  when  the  patient 
is  at  or  near  term,  in  good  condition,  the  child  alive,  and  the  placenta  central  or  largely 
covering  the  os.  Eclampsia,  at  or  near  term,  with  the  os  tightl}'  closed,  proposed 
by  Halbcrtsma  as  an  indication,  has  received  few  supporters.  Vaginal  cesarean 
section  is  usually  preferable,  but  if  the  woman  is  at  term  or  near  it,  if  the  cervix 
is  long  and  hard,  if  the  parametria  are  edematous,  or  if  the  hemorrhage  while  operat- 
ing below  is  too  great, — as  happened  with  one  of  my  cases, — the  abdominal  route  is 
better. 

Abruptio  placentae  is  a  proper,  though  rare,  indication  for  cesarean  section  when 
the  birth-passages  arc  totally  unprepared,  if  the  woman  is  in  a  maternity  or  can  be 
gotten  there  in  time.  Prolapse  of  the  cord,  in  the  aljsence  of  contraction  of  the 
pelvis  or  other  contributing  indication,  will  hardly  be  admissible  as  a  reason  for 
the  abdominal  delivery,  though  one  can  imagine  cases  where  it  would  be  justifiable. 

Nowadays,  cesarean  section  is  so  safe  that  it  is  freely  performed,  where  formerly 
it  would  not  have  been  even  thought  of.  In  49  cases  of  my  own  the  following  were 
the  indications:  Contracted  pelvis,  32;  placenta  praevia,  3;  eclampsia,  2;  stenosis 
of  cervix,  1 ;  vaginofixation  of  uterus,  1 ;  slightly  contracted  pelvis,  scars  in  cervix, 
and  placenta  prsevia,  1;  vaginal  scars  with  pelvic  abscess,  1;  healed  vesico-uretero- 
vaginal  fistula,  1;    contracted  pelvis  and  mammoth  child,  1;    mammoth  child,  2; 


992  OPERATIVE    OBSTETRICS 

ovarian  cyst  in  small  pelvis,  1 ;  fibroids  and  infection,  1 ;  fibroids  and  contracted 
pelvis,  1;   habitual  death  of  fetus  in  labor,  1. 

Reynolds  and  Newell  in  Boston  beUeve  that  the  abdominal  delivery  is  pref- 
erable to  a  hard,  or  possibly  instrumental,  labor  through  the  natural  passages  in 
cases  where  the  woman  is  unfit,  as  regards  her  nervous  constitution  and  general 
makeup,  to  stand  the  strain  of  labor.  While  at  the  first  impression  this  seems  ex- 
treme, it  is  certain  that  every  accoucheur  of  experience  will  recall  cases  where  the 
profound  prostration  and  nervous  shock  of  even  spontaneous  deliveries  have  left 
permanent  traces  in  the  woman's  life.  In  my  opinion  the  psychic  influence  of 
labor  should  be  given  a  prominent  place  in  our  deliberations  when  selecting  a  mode 
of  delivery. 

Conditions. — For  the  absolute  indication  there  are  no  governing  conditions — 
the  child  must  be  removed  abdominally  whether  or  not  it  is  alive,  and  regardless  of 
the  condition  of  the  patient.  If  she  is  infected,  extirpation  of  the  uterus  should 
follow. 

For  the  relative  indication  to  hold,  the  mother  and  babe  should  be  in  prime 
condition.  It  is  very  important  to  make  sure  that  the  child  is  not  a  monstrosity, 
as  an  acephalus,  which  is  not  easy.  One  may  now  get  an  x-ray  picture  of  the 
child.  In  the  presence  of  kidney,  lung,  heart,  or  general  diseases  the  questions 
of  risk  of  anesthetic,  of  shock,  and-of  infection  must  receive  careful  consideration 
with  a  medical  consultant.  .  In  the  presence  of  infection  the  relative  cesarean  sec- 
tion is  contrainclicated.     Gonorrhea  comes  in  this  class. 

The  cervix  must  be  patulous  for  the  escape  of  the  lochia;  if  there  is  cicatricial 
stenosis,: the  uterus  must  be  removed.  It  is  best  to  operate  when  the  woman  has 
had  regular  labor  pains  for  an  hour  or  more.  Barnes  (1876)  advised  to  operate 
just -before  labor  began,  aii  order  to  avoid  the  disadvantages  of  emergency,  a  plan 
also  recommended  by  Bar.  The  objections  to  this  are:  Hemorrhage  from  the 
uterus  is  greater,  a  few  deaths  having  occurred  in  former  days;  the  uterus  in  prema- 
ture labor -does  not  contract  well;  the  cervix  is  closed,  and  drainage  is  poor;  it  is 
diflacult  to  .determine  the  exact  date  of  term,  and  a  premature  infant  or  premature 
twins  may  be  delivered.  The  advantages  of  operating  before  labor  has  begun  are: 
Everything  can  be  gotten  ready  without  hurry,  as  for  ordinary  laparotomy,  which 
means  much  for  the  assistants  and  nurses;  operation  by  daylight;  the  accoucheur 
can  usually  have  had  some  rest;  the  bag  of  waters  is  still  intact;  the  cord  or  ex- 
tremities will  not  have  prolapsed;  accidents  and  delays  in  transportation,  etc.,  are 
avoided. 

By  the  prophylactic  administration  of  ergot,  the  injection  of  epinephrin  and 
perhaps  pituitrin,  t>y  packing  the  uterus  with  wet  hot  pads,  brisk  kneading,  and 
compression  of  the  aorta  the  hemorrhage  is  controllable;  by  dilating  the  cervix 
drainage  of  the  uterus  may  be  provided,  and  by  careful  study  of  the  cases  the  proper 
time  for  the  operation  may  be  determined.  I  often  operate  before  labor  begins. 
When  a  Porro  is  to  be  performed,  the  element  of  danger  from  hemorrhage  and  lochial 
seepage  is  eliminated,  and,  therefore,  the  operation  may  be  undertaken  at  any  time. 

Technic. — It  is  important  to  get  the  patient  into  the  best  possible  general  health  beforehand. 
Regulated  outdoor  exercise,  care  of  the  bowels,  and  much  sleep  are  provided.  The  skin  of  the 
belly  should  be  cured  of  eczematous  and  other  eruptions.  As  a  routine  may  be  recommended  daily 
washing  of  the  belly  with  tincture  of  green  soap.  Douches,  without  special  indication,  are  for- 
bidden, and  the  patient  is  impressed  with  the  importance  of  local  cleanliness  and  the  abstinence 
from  intercourse  or  self-examination.  If  possible,  she  should  Ije  in  the  maternity  a  week  or  more 
in  axlvance  of  the  date  set.  (general  cHseases — for  example,  nephritis,  hemophilia — arc;  treated 
a.s  thoroughly  as  we  know  how.  Gentle  laxatives  are  used  a  few  days  before,  and  an  enema  the 
day  of,  the  operation. 

The  Operation. — Fig.  SSI  shows  the  instruments  required. 

Preparations  for  reviving  the  child  should  nev(?r  be  forgotten.  Four  assistants  are  needed — 
one  for  the  anesthetic,  one,  specially  trained,  to  resuscitate  the  child,  one  to  help  on  the  other  side, 
and  one  to  hand  instruments,  thread  needles,  supply  sponges — duties  whicli  in  most  modern 
liospitals  fall  tf>  the  nurse.  Another  sterile  assistant  may  be  needed  if  the  case  is  complicated  or 
requires  extirpation  of  the  uterus. 


CESAREAN    SECTION 


993 


Str;iiKl»t  otlior  is  tho  l)Ost  anosthotic.  In  (wo  cases  oporatofi  undor  tlif  Kas-oxyKcn  rrK'tliod 
tlio  cxpcricuco  was  not  satisfactory,  tiic  venous  oozing,  riKi'lily  of  tlic  alxiominal  walls,  and  strain- 
ing of  tlic  patient  heiiiK  \('ry  tioiihlesonie.  If  tiiis  inelliod  is  cniploycd,  the  {^as  may  not  he  started 
until  the  ojx'rator  is  ready  to  make  the  incision,  and  deli\(Ty  nnist  he  very  rapid  or  the  child  will 
he  as|)hyxiated.      Se\'eral  cesarean  sections  have  heen  <lone  under  local  anesthesia. 

l'"or  the  preparation  of  the  ahdonien  I  si  ill  adhere  to  tiie  old  metliod — shaving,  washing 
thoroughly  with  tincture  of  }i;reen  soap  and  hot  water,  with  bichlorid  IMOOO,  with  Oo  per  cent, 
alcohol,  and  leaving;  a  towel  soaked  in  1:1()()()  bichlorid  on  the  belly  until  the  laparotomy  sheet  is 
put  on,  then  wipinjj;  the  field  a^ain  with  Oo  p(>r  cent,  alcohol.  The  iodin  method  shows  favorably 
in  the  reports,  but  I  have  feared  that  the  fr(>e  iodin  would  get  into  the  belly  in  the  subsequent 
manipulations  and  cause  peritoneal  adhesions  and  ileus. 

Just  before  starting  the  anesthetic  a  hypodeiinic  of  aseptic  ergot  is  given  and  the  patient 
catheteriz(>d.  Tho  incision  is  made  in  the  linea  alba,  should  be  about  .'j'j  inches  long,  with  its 
middle  about  at  the  navel  and  a  little  to  the  left  of  the  latter.  In  the  Xew  York  Lj'ing-in  Hospital 
the  opening  is  ina<le  high  al)ove  the  navel.  .\s  th(>  belly-w;dl  is  .sometimes  very  thin,  one  niav  not 
cut  too  deeply.     It  is  best  to  make  a  small  opening  and  cut  the  balance  with  .sci.ssors  on  two  fingers 


Fig.  8S1. — Instruments  for  Cesarean  Sectio.v. 
Two  scalpels;  4  scissors;    2  tissue  forceps;     G  artery  clamps;    3  bullet  forceps;   2  needle-holders;   8  needles;    1 
uterine  packing  forceps;    1  sterile  hypo  syringe  filled  with  1:10,000  epinephrin;   No.  2  and  No.  1  chromicized   (tweuty- 
day)  catgut;    fine  silkworm-gut.     Second  tier,  for  extirpation  of  the  uterus:  3  retractors;  S  S-inch  pedicle  clamps;    2 
vulsellum  forceps,  Deschamps'  needle,  angular  clamps. 


inserted  into  the  peritoneal  cavity.  Now  the  uterus  is  brought  to  the  middle  line  and  steadied 
by  the  a.ssistant.  With  another  knife  a  longitudinal  incision,  5  inches  long,  corrc-^ponding  to  the 
abdominal  one,  is  made  half  through  the  thickness  of  the  uterine  wall,  and  with  lessening  strokes 
the  cavity  of  the  egg  is  opened;  then,  cutting  between  two  fingers  with  scissors,  the  opening  is 
enlarged  both  ways  to  the  size  of  the  first  uterine  cut.  Liquor  amuii  gushes  out  while  the  operator 
searches  for  one  foot,  on  which  he  makes  the  breech  extraction,  following  minutelj'  the  classic 
operation  with  Smcllie-Veit  on  the  after-coming  head.  The  assistant  presses  the  sides  of  the  belly 
against  the  retracting  uterus  to  keep  liquor  amnii  and  blood  out  of  the  peritoneal  cavity.  Clamp- 
ing the  cord  in  two  places  and  cutting  between  requires  only  an  instant,  the  operator  handing  the 
child  to  an  assistant  who  stands  at  his  elbow  bearing  a  large  tray  covered  \\'ith  an  aseptic  blanket. 
Now  the  uterus  is  dcli\ered  through  the  womid,  and  a  large  wet  towel  or  laparotomy  pad  placed 
beneath  it  to  catch  the  blood  and  to  prevent  the  exit  of  the  intestines  and  omentum,  or,  if  the 
patient  is  straining,  the  wall  may  be  temporarily  united  by  three  bullet  forceps.  The  placenta 
usually  falls  free  into  the  hollow  of  the  uterus,  but  the  membranes  must  be  pulled  otT,  gently  and 
slowly  to  get  them  all.  The  most  important  part  of  the  operation  is  the  uterine  suture.  After 
the  secundines  are  out,  ^\'ith  a  gauze  pad  the  interior  of  the  uterus  is  thoroughly  wiped  smooth, 
63 


994 


OPERATIVE    OBSTETRICS 


all  shi'eds  of  placenta  and  membranes  being  removed,  and  a  clean,  pad  is  stuffed  into  the  gaping 
cavity,  which  rapidly,  closes  as  the  organ  retracts  and  contracts.  This  is  aided  by  brisk  kneading 
and  firm  compression.  The  fii'st  row  of  sutures  takes  in  the  muscle  near  the  endometrium,  it 
being  better  not  to  puncture  tlie  decidua,  although  in  clean  cases  thei'e  is  little  objection  to  so 
doing.  The  stitches  are  placed  one-half  inch  apart  and  are  continuous — No.  2  twenty-day  catgut. 
The  hemorrhage  is  much  less  when  tliis  layer  of  sutures  is  in  place,  and  the  wall  of  the  uterus  is 
much  thicker  by  this  time.  It  is  usually  possible  to  determine  three  layers  of  muscle — one,  the 
thickest,  internal,  next  to  the  decidua,  and  darker  in  color,  probably  because  the  fibers  are  cut 
across;  another,  a  little  thinner — the  middle  coat;  and  a  third,  very  thin,  to  which  is  attached  the 
peritoneum.  The  second  row  of  sutures  should  take  in  the  middle  coat  and  is  entirely  buried. 
It  is  of  No.  2  twenty-day  catgut,  continuous,  the  stitches  being  about  1  cm.  apart.  The  knots 
should  be  particularly  well  tied,  and  not  too  much  constriction  of  the  tissues  made,  or  else  necrosis 
of  the  tissues  will  result.  The  third  or  peritoneal  suture  is  made  with  a  smooth  needle,  using  No. 
1  catgut,  and  takes  in  the  peritoneum  and  a  little  of  the  muscular  tissue.  It  is  also  continuous. 
It  may  be  made  subperitoneal,  similar  to  the  subcuticular  suture.  Each  row  of  sutures  is  begun 
at  the  end  of  the  wound  opposite  that  of  the  last.  If  the  wall  is  very  thick,  four  layers  of  stitches 
may  be  applied.     Time  taken  to  apply  an  accurate  uterine  suture  is  well  spent. 

Now  the  uterus  is  replaced,  the  peritoneal  toilet  is  made,  the  small  intestines  pulled  up  out 


Fig.  882. — Uterine    .Suture,    First    How. 
Does  not  take  in  decidua  if  avoidable. 


Fig.  883. — Uterim    Sliure,  Second 

How 

Buried. 


Fig.   884. — Uterine   Su- 
ture, Third  Tier. 
Takes  in  peritoneum  and 
part  of  muscle. 


of  the  pelvis,  the  omentum  dra\\Ti  down  behind  the  uterus,  and  the  abdominal  wall  closed  with  three 
or  four  layers  of  sutures.  I  usually  use  No.  2  chromicized  catgut,  double  thread,  for  the  fascia, 
and  continuous  silkworm-gut  for  the  skin.  Catgut  is  not  an  entirely  satisfactory  suture  for  the 
abdominal  wall,  and  it  is  a  good  plan  to  insert  2  oi'  3  tension  sutures  through  the  skin  and  fascia. 

While  cesarean  section  is  a  simple  operation,  to  attain  success  requires  a  subtle  technic  and 
close  attention  to  every  detail. 

Complications. — Adhesions  are  seldom  met  in  primary  operations,  but,  nevertheless,  it  is 
wise  not  to  cut  too  Ijoldly  into  the  belly.  After  previous  sections  adhesions  are  the  rule.  The 
most  common  are  of  the  omentum,  or  of  the  uterus  to  the  abdominal  wall,  or  the  omentum  to  the 
uterus.  Rarely  a  coil  of  gut  is  attached  to  the  uterus  muler  tlie  line  of  the  incision,  and  still  more 
rarely  the  cecum,  apj)fmdix,  or  sigmoid  may  be  adherent  beliind  and  tear  wlien  the  uterus  is  even- 
trated.  Where  adhesions  ar(!  kncjwn  or  suspected,  the  ))elly  should  Ijc  opened  at  a  spot  free  from 
them,  and  two  fingers  inserted  to  dolermint'  their  location  and  extent.  A  clear  space  on  the  uterus 
should  be  quickly  made,  and  the  child  and  placenta  delivered,  after  which  the  adhesions  are  dealt 
with  according  to  general  surgical  principles.  It  is  best  not  to  deliver  the  uterus  if  there  are  ad- 
hesions. Adherent  gut  must  be  very  tenderly  handled.  If  tlu;  onumtum  can  be  tied  off  the  uterus 
or  abdominal  wall  without  denurling  it  much,  this  should  be  done — large  rough  areas,  however, 
only  invite  new  adhesions.  If  th(;  uterus  is  intimately  bound  to  the  abdominal  fascia,  it  may  be 
best  not  to  attempt  its  separation  unless  extirpation  of  the  organ  is  to  be  performed  or  the  tubes 


CESAREAN    SECTION  905 

exsoctod.  In  the  luttor  instiinco  a  .soRmciU  of  the  uterus,  lofzicdicr  with  tlif  alKlortiinal  Hear,  may  be 
excised.  In  a  second  cesarean  section  tlu;  uterine;  incision  slicnild  he  parallel  to  and  dose  to  the 
scar  of  the  first  one,  or  in  another  part  entirely — for  example,  the  funflus,  after  Fritsch. 

If  a  liernia  of  the  old  scar  is  present,  the  sac  is  to  be  exsected  and  the  edges  of  the  fascia 
brought  together  anew. 

The  I'liirrnlii. — In  '27  of  10  cases  where  the  site  of  the  placenta  was  noted  the  organ  waa 
situated  on  the  anterior  wall  and  had  to  he  cut  to  gain  access  to  the  infant.  It  is  not  po.s.sihie  to 
he  sure  of  the  location  of  the  placenta  heforehand.  The  course  of  the  round  ligaments  (converging 
anteriorly)  and  the  prominence  of  the  veins  in  the  violaceous  surface  of  the  uterus  give  .soriK!  indi- 
cation of  it.  If  the  first  (uit  into  the  musch;  cau.ses  profu.se  hemorrhage,  anterior  insertion  may  be 
suspected,  but  the  operation  does  not  dilTer  from  the  usual  one,  except  that  the  mov(;ments  must 
he  hastened.     I  usually  ('ut  right  through  the  placenta. 

llcmorrhaqe. — Where  the  placenta  is  cut  or  torn,  bleeding  is  usually  profuse,  both  during  the 
delivery  and  afterward.  A  pnjphylactic  hypodermic  injection  (jf  20  minims  of  aseptic  ergot  is  a 
routine  before  the  anesthetic  is  started;  as  soon  as  the  child  is  delivered  the  placenta  is  to  bo  removed, 
taking  care  to  get  all  the  membranes;  then  the  uterus  is  kneaded  Ijriskly  between  the  two  hanris, 
u  hile  it  is  cox'cred  wit  h  j)ads  wrung  out  of  \'ery  hot  salt  solution.  Tli(>  inner  surface  is  wiped  smooth 
with  a  pad  wrung  out  of  hot  salt  solution,  and  the  uterus  held  tightly  in  the  grasp  for  a  minute. 
The  (luickest  wa}'  to  stop  the  bleeding  is  by  closing  the  uterine  wound,  which  should  he  done  with 
the  utmost  despatch.  Then  the  ma.ssage  is  repeated.  If  this  does  not  suffice,  four  drops  of 
epinephrin  1:  10,000  are  injected  directly  into  the  muscle  in  two  or  three  places,  making  about  ten 
drops  in  all.  While  these  manuaivers  arc  being  carried  out,  an  assistant  compresses  the  aorta, 
as  shown  in  Fig.  717.  If  these  mea.siu'es  do  not  quickly  cause  uterine  contraction  and  cessation  of 
the  i)leeding,  extirpation  of  the  uterus  must  be  considered.  The  operator  must  not  forget  that 
the  blood  may  escape  per  vaginam  also  and  in  large  quantities.  If  it  is  desirable  to  preserve  the 
uterus  and  tli(>  hein(jn'hage  persists,  uterine  tamponade  may  be  resorted  to.  Since  the  wound  has 
been  closed,  packing  is  inserted  from  below  in  the  usual  manner.  On  two  occasions  I  deemed  it 
best  to  tampon.     Recovery. 

Infection. — If  the  case  is  known  to  be  infected,  the  conservative  cesarean  section  is  contra- 
indicated,  and  if  delivery  must  be  made  abdominally,  either  the  Porro  operation  or  complete 
exliri)ation  must  be  practised.  In  cases  of  gonorrhea  conservative  section  is  very  dangerous,  a 
point  l.eopold  emphasizes,  and  it  is  best  to  consider  these,  too,  infected.  There  is  no  way  of  de- 
termining heforehand  that  the  parturient  canal  is  a.septic.  Fever,  fetid  discharge,  tympania  uteri, 
and  unhealthy  wounds  at  the  introitus  are  evidences  of  infection  of  the  uterus — at  least,  are 
danger-signals.  In  border-line  cases  the  technic  must  be  modified.  Here  the  incision  is  made 
long(>r,  the  uterus  delivered  out  of  the  belly,  and  the  latter  closed  temporarily  behind  it  by  three 
bullet  forceps  over  which  several  large  pads  or  towels  are  placed.  A  square  yard  of  dentists' 
rubber  dam  with  a  three-inch  slit,  sterilized  beforehand,  is  now  placed  aroimd  the  uterus  in  the 
same  way  as  the  tlentist  dams  off  a  tooth.  Under  these  precautions  the  uterus  is  opened  and  closed. 
Before  returning  it  to  the  belly  it  is  washed  with  salt  solution;  the  operator  and  assistants  change 
their  gloves,  and  a  clean  lap-sheet  is  spread  over  the  field.  If,  during  an  ordinary  cesarean  section, 
a  septic  focus  is  unexpectedly  opened,  for  example,  an  infected  dermoid,  the  intestine,  an  appendi- 
ceal al)scess,  it  is  best  to  remove  the  uterus  and  provide  free  pelvic  drainage. 

Ulcrinc  Drainage. — While  rubbing  the  interior  of  the  uterus  smooth,  it  is  a  good  plan  to 
pass  the  finger  down  into  the  cervix,  but  not  through  it  into  the  vagina,  to  see  if  it  is  patulous,  unless 
examination  beforehand  has  shown  that  the  os  is  open.  If  the  cervix  is  closed  bj'  scars  so  that  a 
crow's  quill  cannot  pass,  the  uterus  is  to  be  amputated.  A  normal  cer^•ix  will  open  spontaneously 
under  the  influence  of  the  after-pains.  If  the  accoucheur  fears  that  there  is  not  enough  drainage, 
he  may  pass  gauze  or  a  tube  through  the  cervix  into  the  vagina.  It  is  highly  important  not  to 
catch  the  ga>iz(>  in  the  uterine  stitches.     One  fatality  from  this  cause  is  on  record. 

After-treatment. — This  does  not  differ  from  that  after  the  usual  laparotomy.  I  give  10 
minims  of  ergot  four  times  a  day  for  a  week.  Cathartics  are  usually'  not  administered  until  the 
fifth  to  the  eighth  day,  and  then  not  vmless  required,  the  bowels  being  unloaded  by  enemata.  iSIilk 
and  molasses,  1  pint  of  each,  make  a  very  efficient  clyster,  which  may  be  repeated.  Sometimes 
camomile  tea  pz-oduccs  a  free  evacuation  of  feces  and  flatus.  The  baby  is  put  to  the  breast  at 
the  end  of  twelve  to  twenty-four  hours. 

Of  the  various  postoperative  complications,  peritonitis,  ileus,  and  uterine  abscess  only  will 
be  mentioned.  If  a  beginning  peritonitis  is  diagno.sed,  the  patient  must  be  constantly  watched, 
that  is,  hourly  observations  must  be  made,  and  if  the  pulse  grows  steadily  faster,  the  nausea  in- 
.  creases  to  emesis,  the  temperature  rises  higher,  tlie  abdominal  rigidity  increasing,  with  or  without 
leukocytosis — in  short,  if  the  ol^server  is  convinced — and  the  time  required  to  know  seldom  need 
exceed  eight  hours — that  the  infection  is  progressing,  the  belly  is  to  be  reopened  and  drained.  Ileus 
and  acute  dilatation  of  the  stomach  occur,  it  seems  to  me.  oftener  after  cesarean  section  tli:in  after 
other  ceUotomies.  For  ileus  the  usual  methods  of  treatment  are  practised.  One  that  is  service- 
able after  cesarean  section  is  to  hang  the  woman,  inverted,  from  the  shoulders  of  assistants,  and 
with  the  finger  in  the  rectum  push  the  heavy  uterus  vip  out  of  the  pelvis,  and  give  a  high  colopdc 
flushing  of  milk  and  molasses,  \\ith  the  patient  depending.  In  one  case  an  electric  vibrator  applied 
to  the  tUstended  bowel  seemed  to  help.  Eserin  had  failed.  These  measures  have  been  successful 
in  my  practice  in  the  treatment  of  gastric  dilatation;  having  the  woman  lie  on  the  stomach,  the 
foot  of  the  bed  being  elevated  IS  to  24  inches;  gastric  lavage,  repeated  every  four  to  six  hours; 
massage  of  the  stomach;  rectal  feethng.  Both  ileus  and  dilatation  may  be  caused  by  a  too  tight 
abdominal  binder,  a  point  that  I  would  emphasize  strongly.  In  all  probability  a  mild  peritoneal 
infection  is  responsible  for  most  of  the  cases,  and  bursting  of  the  fascial  suture  for  a  few  others. 
Uterine  abscess  is  a  not  infrequent  compUcation,  and  is  to  be  suspected  if  there  is  a  mild  fever, 


996  OPERATIVE    OBSTETRICS 

with  signs  of  local  peritonitis  or  partial  ileus.  Usuallj^  the  abscess  breaks  on  the  surface,  the  wound 
opening.  With  good  drainage  the  patient  quicklj'-  recovers,  but  the  uterus  is  permanently  ventro- 
fixed  and  the  scar  may  give  way  in  a  subsequent  pregnancy. 

Prognosis. — Hy  rigid  examination  of  the  cases  and  the  exclusion  of  all  that  present  even  a 
suspicion  of  infection,  the  mortality  of  the  conservative  cesarean  delivery  can  be  reduced  to  almost 
nothing.  Series  of  20  to  39  cases  without  death  have  been  reported.  Routh,  in  1910,  collected 
with  great  labor  tlie  statistics  of  Great  Britain,  comprising  1282  cases,  and  these  may  be  taken  as 
a  tj'pe  for  all  civilized  countries.  He  shows  that  there  has  been  a  steady  decrease  in  mortality 
until  now,  in  favorable  cases,  it  is  from  2  to  4  per  cent.  In  cases  where  labor  had  been  prolonged 
or  even  attempts  made  with  the  forceps,  the  death-rate  was  34  per  cent,  ancl  over.  After  labor 
had  been  in  progress  some  time  with  the  membranes  ruptured  he  found  10.8  per  cent,  mortality, 
the  best  showing  being  made  in  those  cases  where  labor  had  just  begun,  the  bag  of  waters  being 
intact — 2.2  per  cent.  It  is  generally  admitted  that  the  dangers  of  cesarean  section  increase  with 
ever}-  hour  the  woman  labors,  especially  if  the  membranes  are  opened.  The  exhaustion  of  active 
labor  diminishes  the  woman's  vital  resistance  to  infection.  Routh  gives  the  general  mortality 
of  cesarean  section  for  all  indications  as  11.6  per  cent.,  and  if  one  takes  only  the  last  five  years, 
it  is  8.1  per  cent.  In  spite  of  most  rigorous  asepsis  and  a  perfect  technic,  the  operation  has  a  high 
morbidity.  Infected  suture  material  has  caused  the  most  trouble  in  my  cases,  and  the  secondary 
union  has  been  followed  by  four  hernias  that  I  know  of.  Ten  of  the  49  cases  had  severe  febrile 
reactions,  1,  marked  peritonitis  (relaparotomy,  recovery),  3,  postoperative  pneumonia,  4,  uterine 
abscess,  ancl  there  were  2  cases  of  temporary  ileus,  2  of  dilatation  of  the  stomach  (all  4  with  alarm- 
ing symptoms).  Two  women  died,  one  from  peritonitis  and  one  had  nephritis,  the  operation  being 
done  for  eclampsia.  There  were  49  cases,  including  Porro  cesareans.  Taken  all  in  all,  it  is  not  an 
operation  to  be  lightly  ad\'ised.  The  mortality  of  the  children  should  be  zero  if  the  infant  was  well 
at  the  start.     One  baby  of  the  49  died  from  asphyxia — a  lapsus  artis. 

Repeated  cesarean  sections  have  been  done  in  large  numbers,  Nancrede  in  1875  having  done 
the  sixth  operation  on  the  same  woman.  In  such  cases  the  uterus  is  so  broadly  adherent  to  the 
belly-wall  that  it  may  be  opened  without  entering  the  general  peritoneal  cavity.  I  do  not  recom- 
mend to  try  this  because  intestines  may  be  adherent  to  the  scar.  Seven  of  my  cases  were  second 
operations.  Polak,  in  1909,  collected  150  cases  of  repeated  section,  which  showed  a  mortality  of 
less  than  5  per  cent.,  which  is  as  good  as,  if  not  better  than,  the  primary  cesareans.  In  the  olden 
times,  before  the  uterus  was  sutured,  rupture  of  the  scar  in  subsequent  pregnancies  was  not  uncom- 
mon, but  lately,  as  was  showTi  by  Brodhead,  the  accident  has  become  quite  rare,  and  this  is  because 
the  uterus  is  sewed  up  better  and  because  in  many  cases  the  patient  is  sterilized.  It  is  important, 
however,  to  have  the  woman  in  a  maternity  in  the  last  few  weeks  of  her  subsequent  pregnancies, 
and  also  to  operate  a  few  daj^s  before  the  expected  onset  of  labor  pains.     (See  Davis.) 

Sterilization  with.  Section. — Should  the  woman  be  sterilized  to  prevent  future  pregnancies? 
Authorities  differ  between  wide  extremes,  and  in  deciding  one  must  consider  the  dangers  of  sub- 
sequent pregnancies  and  labors  and  the  necessity  for  consecutive  cesarean  sections. 

If  the  woman  has  tuberculosis,  chronic  nephritis,  osteomalacia,  or  any  disease  which  in  itself 
is  a  contraindication  to  pregnancy,  she  should  be  sterilized.  Any  one  who  admits  the  propriety 
of  inducing  abortion  for  such  conditions  must  admit  the  above  postulate.  Contracted  pelvis  is 
not  allowed  in  this  category. 

The  danger  of  rupture  of  the  uterine  cicatrix  is  no  indication,  because  we  can  avoid  this  by 
properly  sewing  the  uterus,  by  placing  the  patient  in  a  good  maternity  several  weeks  before  labor,, 
and  operating  before  pains  set  in. 

If  the  first  section  is  done  for  eclampsia,  placenta  prsevia,  abruptio  placentae,  prolapse  of  the 
cord,  faulty  mechanism  of  labor,  pelvic  tumors,  in  the  absence  of  other  indications  the  woman 
should  not  be  sterilized.  If  the  woman  has  a  large  family,  the  question  is  discussable,  but  if  there 
is  only  one  child,  and  that  one  weak  or  deformed,  it  is  better  not  to  sterilize  her. 

If  the  cesarean  operation  is  done  for  contracted  pelvis,  I  earnestly  dissuade  the  patient  from 
such  a  procedure  at  the  first  section,  pointing  out  the  fact  of  the  safety  of  subsequent  operations, 
the  possibility  of  the  death  of  the  only  child,  and  the  unhappiness  of  a  one-child  family.  At  the 
second  cesarean  I  willingly  sterilize,  if  requested,  although  lately,  since  the  mortality  has  been 
so  much  reduced,  I  often  suggest  a  third  operation. 

For  many  years  the  ethics  of  sterilization  have  been  debated.  Green  created  an  extensive 
discassion  of  it  at  the  1903  meeting  of  the  American  Gynecologic  Association,  taking  an  extreme 
negative  position.  Most  American,  English,  and  Continental  authors  concede  the  right  of  de- 
cision to  the  mother  and  her  family,  after  they  have  been  given  a  fair  presentation  of  all  the  facts, 
a  position  which  I  also  take.  By  following  the  Golden  Rule  I  have  had  no  difficulty  in  arranging 
a  satisfactory  course  in  these  matters. 

Methods. — Ligation,  simple  section  or  exsection  of  a  portion  of  the  tube,  as  recommended  by 
Blundell  in  1819,  have  proved  insufficient,  pregnancy  having  occurred  in  spite  of  them.  In  osteo- 
malacia ovariotomy  is  done.  Ablation  of  the  tubes  is  safe,  as  is  also  removal  of  wedge-shaped 
pieces  of  the  uterine  horn  containing  the  tubes.  The  method  I  use  is  exsection  of  an  inch  of  the 
tube  near  the  uterus  and  burying  Ijoth  ends  securely  under  the  peritoneum  of  the  broad  ligament. 
The  peritoneum  may  be  slit  open,  an  inch  of  the  tube  itself  removed,  the  gap  being  filled  up  by  the 
connective  tissue.  It  would  be  possible,  should  pregnancy  be  later  desired,  to  reopen  the  belly  by 
anterior  colpotomy  and  anastomose  the  cut  ends  again.  Extirpation  of  the  uterus  as  a  means  of 
simple  sterilization  is  hardly  to  be  recommended,  certainly  not  in  young  women.  The  desire  to 
have  all  the  functions  of  a  woman  is  strong,  and  seldom  do  the  patients  not  regret  the  loss  of  the 
menses.  I  agree  with  \\'illiams  that  the  operation  can  be  done  in  the  same  time  as  removal  of 
the  tubes,  and  that  the  postoperative  recovery  is  prompter  and  more  satisfactory  than  in  the  con- 


CESAREAN    SECTION 


997 


servative  cesarean  section,  l)Ut  tlic  tcclmical  difFicultics  are  greater  with  amputation  of  the  utcras, 
and  piciiiaturo  nienopuu-sc  is  not  rare,  even  it'  one  or  both  ovaries  are  preserved. 

The  Porro  Cesarean  Section. — In  1876  Porro,  of  Pavia,  to  avoitl  tlio  dangors 
of  licinorrhaj^e  and  of  infect  ioii  from  the  large  uterus,  which  was  poorly  sewn  up, 
advised  the  anii)utati()ii  (jf  the  l)ody  of  the  uterus  and  tlu;  adnexa  above  an  elastic 
ligature  placed  aljout  the  cervix,  and  the  anchoring  of  the  stum[)  in  the  lower  angle 
of  the  abdominal  wound — an  operation  similar  to  supravaginal  hysterectomy  for 
fibroid,  with  extraperitoneal  treatment  of  the  stump.  The  operation  had  been 
suggested  by  Blundell  in  bSoO.  Later,  when  Schroder  dropped  the  sutured  hyster- 
ectomy stump  back  into  the  pelvis,  Isaac  E.  Taylor  did  the  same  for  the  stump  after 


Fig.  Ss.5. — Porro  Ces.*.bean  Section. 
Uoth  broad  ligaments  are  clamped,  taking  in  the  round  ligaments  if  there  are  varicosities,  which  is  usual. 

Porro's  operation.  Porro's  radical  operation  did  reduce  the  mortality  of  cesarean 
section  and  gained  some  vogue,  but  was  soon  replaced  by  the  improved  conservative 
operation  of  Sanger.  This  was  called  "conservative"  because  the  uterus  was  not 
sacrificed. 

Indications. — It  may  l)e  necessary  to  remove  the  uterus  when  myomata  are 
present,  especially  if  large  or  if  they  ])lock  the  pelvis.  ^Myomectomy  may  be  per- 
formed in  favorable  cases  if  the  woman  desires  more  children.  I  did  it  once  with 
success.  In  osteomalacia  the  uterus  as  well  as  the  ovaries  should  be  removed. 
Uncontrollable  hemorrhage  at  the  time  of  the  cesarean  may  necessitate  amputation 
of  the  fundus.  In  cases  of  ruptured  uterus,  or  one  torn  by  previous  efforts  at  de- 
livery, and  when  infection  is  present,  it  is  best  to  remove  the  organ.     In  carcinoma 


998 


OPERATIVE    OBSTETRICS 


cervicis  total  extirpation  may  be  practised.  As  a  means  of  simple  sterilization  of 
the  patient  amputation  of  the  uterus  is  hardly  recommendable,  though  in  most 
cases,  where  performed,  it  has  been  justifiable. 

There  are  no  conditions.     The  best  time  to  operate  is  before  labor  begins. 

The  technic  is  but  little  different  from  supravaginal  hysterectomy.  If  the  plan  of  operation 
is  known  beforehand,  the  abdominal  incision  should  be  nearer  the  pubis.  After  the  child  is  de- 
livered, two  clamps  are  put  on  each  broad  ligament  close  to  the  uterus.     Unless  diseased,  both 


Fia.  886. — PoRRO  Cesarean  Suction. 
After  cutting  one  side,  two  clamp.s  are  placed,  reaching  to  about  the  level  of  the  uterine  artery. 

tubes  and  ovarie.s  are  left.  Both  round  ligaments  are  also  clamped  separately,  or,  if  they  are  near 
the  tubes,  or  if  the  broad  ligamenl.s  are  full  of  varico.se  veins,  they  ai(,'  included  in  the  first  clamp. 
After  cutting  to  the  tip  of  the  clamps,  two  moi-e  are  put  on  the  broad  ligaments,  reaching  below  the 
level  of  the  uterine  arteries,  keeping  close  to  the  uterus  to  avoid  the  ureters,  and  the  tissue  is  cut 
between.  Now  a  semilunar  inr-ision  is  made  through  tlie  pei'itoneum  across  the  face  of  the  uterus 
ju.st  abo\'e  the  bladder,  extending  from  the  cut  edge  of  tlie  peritoneum  around  one  round  ligament 
to  the  other,  and  the  bladder  is  pushed  down  by  the  fingei-  ccjvered  with  a  piece  of  gauze.  Owing 
to  the  u.sual  immen.se  development  of  the  veins  of  tlie  broad  hgament,  the  varicosities  making  it 
sometimes  as  large  a.s  one's  wrist,  it  is  impractical  always  to  open  up  the  connective  tissue  to  isolate 
the  uterine  art_enes,  a.s  is  done  in  gynecologic  hysterectomies.  After  both  broad  ligaments  are 
clamped  and  the  uterus  freed,  the  latter  is  pulled  sharply  ff)rward  over  the  pubis  and  cut  off,  be- 
ginning from  behind,  just  above  the  vaginal  insertion,  the  point  being  determined  by  palpation '    It 


CESAREAN    SECTION 


000 


is  wise  to  cut  carefully  bocauso  of  the  softness  of  the  uterine  tissue  and  its  thinness  near  the  bladder. 
I  usually  cut  from  the  rifjlit  behind,  to  the  left  in  front,  then  strip  the  uterus  from  the  bladder,  if 
need  be,  formiiiK  a  new  pedicle  of  the  base  of  llie  rif^lil  broad  lifiament,  which  is  clamped  and 
severed  last.  The  lifiameiits  are  tied  o(T  imder  the  clamjjs,  usirin  So.  2  harilened  catgut.  Then 
the  larp;e  vessels  are  secin-ed  by  ,sei)arat('  individual  ligatures.  Jiefore  removing  the  clamps  it  is 
wise  to  secure  perfect  hemostasis,  because  ooziiiK  from  the  veins  in  the  soft  tissues  may  be  exceed- 
innly  troublesome.  A  few  throuKh-aiid-throuf^h  sutures  in  the  stump  may  be  required,  but  1 
usually  apply  them  in  such  a  maimer  as  to  turn  the  cut  edges  of  the  cervix  against  each  other, 


Fig.  887. — Porro  Cesarean  Section. 
A  clamp  is  put  on  the  uterine  artery,  taking  care  that  it  Kjasps  the  tissue  at  the  side  of  the  uterus 

pelvis,  to  avoid  the  ureter. 


not  toward  the 


leaving  the  cervical  canal  open  for  drainage.  Now  the  peritoneum  is  sewed  together  after  turning 
the  ligated  stumps  in  underneath  it  and  uniting  them  to  the  cervical  stump  with  a  few  sutures. 

Michaelis,  in  ISOi),  recommended  the  removal  of  the  whole  uterus,  and  Bischoflf,  in  ISSO,  first 
practised  it — a  case  of  cancer.  The  operation  is  much  more  formitlable  than  the  amputation  of  the 
fundus.  The  hemorrhage  from  the  cut  vagina  and  bases  of  the  broad  hgaments  is  less  easily 
controlled. 

Cesarean  section,  with  amputation  of  the  uterus  in  clean  cases,  and  with  an  expert  operator, 
has  the  same  mortality  as  the  conservative  operation,  and  the  morbidity  is  decidedh*  less.  In  the 
5  cases  of  my  own  recovery  was  prompter,  less  painful,  and  less  complicated  than  after  the  ordinary 
cesarean  operation.     The  reason  for  this  is  the  elimination  of  the  large,  involuting,  realh'  necros- 


1000 


OPERATIVE    OBSTETRICS 


ing  uterus,  the  clearing-out  of  the  pelvis  (less  absorption),  and  the  covering  in  of  all  raw  surfaces 
by  peritoneum.  In  septic  cases  the  mortahty  is  still  high — probably  near  20  per  cent.  _  It  is  a 
question  if  total  hysterectomy  would  improve  the  results.  If,  during  cesarean  section  in  septic 
cases,  the  abdomen  could  be  closed  tightly  around  the  ^mopened  uterus  and  the  latter  emptied  and 
amputated  without  soiling  the  peritoneal  cavity,  probably  many  cases  of  peritonitis  could  be 
prevented.     With  a  studied  technic  such  a  result  is  not  unattainable. 

Extraperitoneal  Cesarean  Section. — In  the  olden  time,  when  the  dangers  of 
opening  the  belly  were  almost  prohibitive,  the  accoucheur  sought  to  avoid  the 
necessity  of  destroying  the  living  child  by  delivering  it  from  above  the  pelvis,  but 


Fig.  888. — Porro  Cesarean  Section. 
After  the  process  has  been  repeated  on  the  right  side,  the  peritoneum  is  severed  one-half  inch  above  its  reflection 
onto  the  bladder.     The  ureter  does  not  come  into  view,  and  lies  a  short  distance  farther  away  from  the  forceps  than 
is  indicated  in  the  drawing. 


without  opening  the  peritoneum.  Joerg  suggested  it  in  1809,  Ritgen  did  it  in  1821, 
as  also  did  Physick,  of  Philadelphia,  in  1824.  In  1870  T.  Gaillard  Thomas  revived 
the  operation,  named  by  Baudelocque,  in  1823,  gastro-elytrotomy.  It  consisted  of 
making  an  incision  above  and  parallel  to  Poupart's  ligament,  blunt  dissection  under 
the  peritoneum  to  the  cervix  and  vagina,  followed  by  a  flank  delivery.  In  1906 
Frank  recommended  a  suprapubic  delivery  after  shutting  off  the  peritoneal  cavity 
by  uniting  the  supravesical  peritoneum  to  the  parietal  peritoneum.  Sellheim  tried 
to  push  the  peritoneum  upward  from  off  the  bladder,  as  was  done  by  Physick,  and 
other  operators,  mostly  German,  modified  the  operation  in  many  ways.  Up  to 
July,  1912,  over  450  operations  had  been  performed,  and  the  method  most  often 
used  was  Latzko's. 

The  patient  being  in  the  Trendelenburg  posture,  a  transverse  or  Pf  annenstiel 


CESAREAN    SECTION 


1001 


incision  is  niiulc  above  the  pubis,  the  fascia  incised  transversely  and  sewed  to  the 
edge  of  the  wound  above  and  below,  and  the  recti  separated  in  the  median  line, 
exposing  the  connective  tissue  of  the  space  of  R(;tzius.     The  bladder  is  pushed  to 


Fig.  889. — Porro  Ces.^rean  Section. 
The  large  utenis  now  hangs  only  at  the  cervix.     It  is  pulled  sharply  over  the  pubis  and  cut  off,  one-half  inch  above 
the  cervicovaginal  junction,  beginning  from  behind.     When  cutting  the  anterior  cervical  wall,  the  relation  of  the  knife 
to  the  bladder  must  be  watched.     There  is  usually  little  hemorrhage. 


the  right  side,  the  fold  of  peritoneum  of  the  vesico-uterine  pouch  is  stripped  upward 
from  the  lower  uterine  segment,  exposing  this  for  an  area  of  five  inches.  An  inci- 
sion is  made  through  the  lower  uterine  segment.     One  sees  the  head  bulging  the 


1002 


OPERATIVE    OBSTETRICS 


thin  muscle  forward.  Delivery  is  effected  by  pressure  on  the  head,  by  forceps,  or 
by  version  and  extraction,  the  placenta  removed  as  usual,  and  the  wounds  carefully 
closed,  with  or  without  abdominal  or  vaginal  drainage. 

The  dangers  and  inconveniences  of  the  operation  have  already  been  referred 
to  (p.  721). 

In(Ucatio7}s. — These  are  about  the  same  as  for  conservative  cesarean  section. 
The  hope  that  it  could  be  performed  in  septic  and  suspicious  cases,  thus  obviating 
the  painful  necessity  of  destroying  the  child  in  contracted  pelvis  with  neglected 
labor,  has  proved  illusory.  Peritonitis  and  ileus  set  in  just  the  same  as  if  the  peri- 
toneum had  been  invaded,  and  if  not  peritonitis,  a  severe  form  of  connective-tissue 
infection,  which  is  as  dangerous.     Enthusiasm  for  the  operation  is  waning  abroad. 


Fig.  890. — Porro  Cesarean  Section. 
After  raising  the  stump  with  a  vulseilum  forceps,  ligatures  replace  the  artery  clamps.     The  uterines  are  secured 
by  special  ligatures.     It  is  wise  to  guard  carefully  against  a  ligature  slipping  while  being  applied.     Most  troublesome 
oozing  would  result. 


jVIy  results  with  present  methods  of  delivery  have  been  so  satisfactory  that  I  have 
felt  no  desire  even  to  try  this  operation,  which,  a  priori,  does  not  appeal  to  me  as  a 
highly  surgical  procedure.  Bumm,  who  uses  it  freely,  admits  that  it  may  not  be 
used  in  suspected  cases,  that  injury  to  the  bladder  may  occur,  that  the  peritoneum  is 
often  opened,  unless  labor  has  been  long  in  progress  and  the  plica  is  retracted;  that 
infection  of  the  connective  tissue  must  be  feared,  and  that  a  large  percentage  of  the 
children  are  lost  in  delivery.  American  operators  have  not  accepted  the  operation, 
and  in  Great  Britain  it  has  been  performed  only  seven  times. 

Cesarean  Section  on  the  Dying  or  Dead  Woman. — A  fetus  will  live  from  five 
to  twenty  minutes  after  the  death  of  its  mother.  Reported  cases  of  longer  periods 
are  not  authenticated.     The  length  of  time  of  survival  depends  on  the  suddenness 


CESAREAN    SECTION 


1003 


of  (he  iiiotlicr's  death,  the  child  li\'iii<;'  longer  if  she  dies  of  apoplexy,  accident, 
homorrhago,  eclampsia,  or  very  acute  alTection  than  if  the  agony  is  prolonged,  as 
ill  tuberculosis,  heart  disease,  etc.,  though  in  some  of  the  latter  cases  th(,'  vitality 
of  tlie  child  is  remarkable.     Since  the  mother  uses  up  the  child's  oxygen,  the  latter 


Fig.  891. — Porro   Ce.s.vreax  Section. 
A  row  of  sutures,  not  taking  in  iho  iiiucosa,  closes  the  stump.      In  suspected  septic  cases  tliis  may  be  omitted  to  favi 

drainage,  just  the  peritoneum  being  closed. 


Fig.  S92. — Porro  Ces.\rean  Section. 

The  peritoneum  is  sewed  over  the  stump  after  uniting  to  it,  with  one  suture,  the  severed  ends  of  the  round  ligaments  and 

tubes.     If  the  tubes  and  ovaries  have  been  removed,  the  round  ligaments  are  to  be  united  to  the  stump. 


1004  OPERATIVE    OBSTETRICS 

usuall}''  dies  first.  Even  before  Numa  Pompilius,  attempts  to  save  the  child  by 
cesarean  section  after  the  death  of  its  mother  were  made,  but  the  results  were  so 
poor  that  most  men  discountenanced  the  procedure.  In  recent  times  the  operation 
has  often  been  done,  and  the  results  are  more  encouraging.  If  the  pregnancy  has 
advanced  beyond  the  twenty-sixth  week,  no  delay  is  to  be  allowed  after  life  is 
positively  extinct,  but  the  belly  opened  at  once.  It  is  not  even  necessary  legally 
to  obtain  the  consent  of  the  husband  or  the  family,  though  for  his  own  protection 
the  accoucheur  should  get  it  if  possible.  Bacon,  of  Chicago,  in  1911,  proved  this. 
Nor  should  precious  minutes  be  lost  trying  to  hear  the  heart-tones,  because  several 
children  have  been  saved  when  they  were  inaudible.    (See  Remy  and  Wyder.) 

The  Talmuclists  and  the  Catholic  law  demand  that  cesarean  section  be  per- 
formed on  the  dying  woman  to  save  the  child,  but  this  operation,  painful  to  all 
concerned,  has  rarely  been  done.  If  the  woman's  death  is  only  a  matter  of  a  few 
hours,  this  being  the  opinion  of  a  consultation  of  physicians,  and  the  child  is  living 
and  viable,  the  operation  is  indicated,  but  here,  legally,  it  is  needful  to  get  the  con- 
sent of  the  husband  or  the  next  of  kin.  In  practice  it  may  be  required  to  prepare 
for  the  operation,  and,  awaiting  the  woman's  death,  to  watch  the  heart-tones, 
operating  before  death  only  if  the  child  shows  signs  of  distress.  Naturally,  if  con- 
ditions are  right  for  a  quick  delivery  from  below,  this  is  preferable.  In  Strassburg, 
a  woman  with  mitral  disease  was  operated  on,  supposedly  in  agony,  but  it  was  only 
catalepsy,  and  she  recovered. 

Literature 

Bacon:  Trans.  Chic.  Gyn.  Soc,  1911. — Brodhead:  Trans.  Amer.  Gyn.  Soc,  June,  1909. — Cholmogoroff:  Cent.  f.  Gyn., 
1911,  p.  743,  and  Arch.  f.  Gyn.,  1911,  vol.  cxv,  Heft  1,  p.  23.  Gives  literature  of  rupture  of  cesarean  section 
scars. — Asa  Davis:  Amer.  Jour.  Obst.,  July,  1912. — -Lewis:  Amer.  Jour.  Obst.,  October,  1909,  p.  587. — Remy: 
Arch,  de  Tocologie,  vol.  xxi,  p.  819. — Kouth:  "Cesarean  Section,"  Jour.  Obstet.  and  Gyn.,  British  Empire, 
January,  191 1. — Wien.  klin.  Wochenschr.,  1909,  No.  14. — v .  Winckell:  "Cesarean  Section  on  the  Dead  and  Dying," 
Arztliche  Rundschau,  1892,  No.  5. —  Wyder:  Arch.  f.  Gyn.,  vol.  Lxxxii,  pp.  771  and  725. 


CHAPTER  LXXIII 
MUTILATING  OPERATIONS  ON  THE  CHILD 

Under  this  caption  will  be  considered  the  operations  which  reduce  the  bulk 
of  the  child.  Lessened  in  size,  it  can  be  easier  gotten  through  the  parturient  canal. 
Embryotomy  would  be  a  good  general  term  for  all  the  procedures,  but  it  has  been 
given  a  particular  significance. 

Craniotoniy  is  an  operation  which  consists  in  opening  the  fetal  head,  the  evacua- 
tion of  the  brain,  and  extraction  by  means  of  a  large  bone  forceps  or  a  sharp  hook. 

Perforation  is  the  first  step  in  craniotomy,  but  is  sometimes  applied  to  the  whole 
operation. 

Cranioclasis  is  the  third  step  in  the  operation,  and  is  also  sometimes  applied 
to  the  whole  operation.  The  instrument,  which  is  nothing  more  nor  less  than  a 
large,  strong,  especially  constructed  bone  forceps,  is  called  a  cranioclast. 

Cephalotrypsis  is  an  operation  in  which  the  head  is  crushed  by  means  of  a 
powerful  forceps  supplied  with  a  compression  screw,  no  perforation  of  the  head  being 
made.  The  instrument  is  called  a  cephalotryptor,  and  was  invented  by  Baude- 
locque,  the  nephew.     It  is  an  obsolete  operation. 

Decapitation  means  what  it  says, — section  of  the  neck, — and  is  accomplished 
either  by  means  of  a  blunt  hook  or  a  sickle-knife,  the  ecraseur,  or  scissors. 

Embryotomy  is  applied  to  decapitation,  to  the  section  of  the  fetal  trunk,  or  to 
the  opening  of  the  body  cavities. 

Exenteration  means  disemboweling  the  fetus  to  diminish  the  size  of  the  trunk. 
It  is  the  same  as  evisceration. 

Brachiotomy  means  section  of  an  arm. 

Cleidotom.y  is  an  operation  introduced  by  Phenomenoff  in  1895.  It  consists 
of  section  of  the  clavicles,  and  is  used  when  the  shoulders  are  too  broad  to  pass,  the 
head  being  delivered  and  the  child  dead. 

Spondylotomy  is  section  of  the  spinal  column. 

Before  forceps  and  version  were  known,  removal  of  the  cliild  piecemeal  was  the  only  means 
the  ancients  had  of  accomplishing  delivery  in  cases  of  mechanical  obstruction.  Fig.  893  shows 
some  of  their  crude  instruments.  Until  1830  the  sharp  hook  was  mostly  used  for  extraction,  and 
it  tore  through  the  bladder  and  rectum  as  often  as  it  safely  delivered  the  head. 

Craniotomy. — Indications — (A)  On  the  Dead  Child. — No  accoucheur  should 
have  any  compunctions  about  mutilating  a  dead  child,  yet  I  have  seen  the  most 
atrocious  operations  carried  out  by  physicians  in  order  to  avoid  the  necessity  of 
perforating  a  piece  of  lifeless  clay.  Either  they  fear  opprobrium,  or  they  overrate 
the  dangers  of  craniotomy.  Craniotomy  is  chosen,  the  fetus  being  dead,  when  an 
indication  arises  for  the  immediate  termination  of  labor.  Craniotomy  is  less  danger- 
ous than  the  forceps,  especially  if  the  child  is  large,  the  pelvis  small,  or  the  soft 
parts  unprepared.  It  is  the  rule  for  hydrocephalus.  Sentimental  reasons  advanced 
by  the  family  should  not  stand  in  the  way  of  the  accoucheur's  doing  the  best  for 
the  mother. 

When  the  child  is  surely  dead,  even  if  there  is  no  indication  for  the  immediate 
termination  of  labor,  perforation  of  the  cranium  and  reduction  of  its  size  may  be 
desirable.  This  is  true  of  primiparse — we  wish  to  save  the  levator  ani  and  pelvic 
outlet  from  overstretching,  and,  further,  it  is  thus  possible  to  shorten  the  time  of 
labor.     It  would  perhaps  be  best  in  such  cases  to  perforate  the  cranium,  evacuate 

1005 


1006 


OPERATIVE    OBSTETRICS 


a  large  part  of  the  brain,  and  leave  the  expulsion  to  nature.  In  private  practice, 
unless  the  family  is  intelligent,  objections  will  be  raised  to  the  disfigurement  of  the 
child,  or  even  its  death  may  be  ascribed  to  the  attendant.  In  delivery  of  the  after- 
coming  head,  the  fetus  having  died,  hurry  should  cease,  and  the  head  be  perforated. 
It  is  not  wise  to  delay  too  long,  since  much  blood  may  accumulate  behind  the  head. 
(B)    When  the  child  is  living,  the  indication  for  craniotomy  is  dreadfully  hard 


Fig.  893. — Types  of  Destructive  Instruments. 
a,  Ambroise  Par6;  6,  Andre  De  La  Croix;  c,  Ambroise  Par6;  d,  Levret;  e,  Burton's  perforator;  /,  Smellie's  scissors; 
!),  Meigs;    h,  Mauriceau;    i,  trephine  of  Braun;    j,  Pajot;     k,  Ambroise  Par6;    I,  Lusk's  cephalotribo;    vi,  Tarnier's 
basiotribe;    n,  C.  Braun's  cranioclast. 


to  place.  Nowhere  in  all  medicine  does  so  heavy  a  responsibility  rest  on  the  medical 
attendant.  He  is  judge,  jury,  and,  perhaps,  executioner  of  an  innocent  baby,  and 
he  can  hardly  be  blamed  if  he  shrinks  from  the  painful  task.  However,  if  he  has 
not  the  moral  courage  to  do  that  which  his  judgment  tells  him  is  the  best  for  the 
mother,  her  family,  and  the  State,  he  should  give  way  to  a  better  man.  It  is 
imperative  to  have  consultation  whenever  the  question  of  craniotomy  on  the  living 


Ml'TILATINC    OPERATIONS    ON    THE    CHILD  ]  (J()7 

fetus  arises.     The  decision  will  fcst  not  alone  on  sciiiit  i(ic  f^roiinds,  as  we  shall  show 
dii'eetly. 

Ill  practice,  craniotomy  will  come  up  lor  c(jusiderati{jn  in  cases  of  moderately 
contracted  pelves,  in  incorrigible  occipitoposterior  positions,  face  and  brow  pres- 
entations, and  tumors  blockinj^  the  passaj^c.  Re<;ardinf;-  the  c(jurs(;  of  conduct  of 
contracted  pelves,  the  reader  is  referred  to  th(!  appropriate  chapter.  The  conditions 
almost  always  met  are  these:  The  woman  has  been  in  labor  many  hours  or  even 
days,  unclean  hands  have  frequently  examined  her,  attempts  at  delivery  with  the 
forceps  have  failed,  the  vulva  is  torn  and  bruised,  the  cervix  hangs  in  shreds,  the 
urine  is  bloody,  the  child  is  injured  or  perhaps  dying.  Here  there  is  only  one  course 
— craniotomy.  The  resi)()nsibility  for  the  death  of  the  child  rests  on  those  who  con- 
ducted the  labor  up  to  this  point.  On  the  other  hand,  if  the  woman  is  not  injured, 
not  infected,  and  the  child  is  in  perfect  condition,  one  is  not  justified,  at  least  from 
a  scientific  point  of  view,  in  doing  craniotomy. 

Pinard  and  a  few  Catholic  authors  demand  the  abohtion  of  craniotomy  on  the  living  child, 
but  the  overwhelming  majority  of  obstetric  authorities  declares  this  extreme  position  untenable. 
All,  however,  agree  that  the  necessity  for  destroying  the  child  is  less  and  less  frequent  as  the 
diagnosis  of  spacial  disproportion  is  earlier  discovered,  giving  a  chance  for  cesarean  section  and 
pubiotomy.  It  follows,  therefore,  that  craniotomy  will  be  more  frequently  performed  in  home 
l)ractice.  In  a  good  maternity  the  necessity  for  sacrificing  the  babe  will  be  of  the  rarest  occur- 
rence. For  centuries  craniotomy  was  the  opprobrium  of  obstetric  art.  It  is  this  no  longer  in  the 
art,  but  remains  such  in  obstetric  practice. 

Legal!}',  the  mother  has  a  right  to  demand  that  she  be  exposed  to  no  unusual  danger  for  the 
sake  of  her  child,  antl  slie  may  refuse  to  do  so  even  at  the  request  of  her  husband.  Also,  she  has  the 
right,  c\-en  if  opposed  by  her  husband,  to  run  added  risk  for  its  sake  if  she  wishes.  The  legal  statas 
of  the  unborn  child  is  still  unsettled  (Kiernan).  At  present  it  is  part  of  its  mother,  and  has  no 
legal  existence  until  the  cord  is  cut.  The  mother  may  recover  damages  for  its  loss  bj'  wilful  or 
negligent  means,  though  itself  it  has  no  redress  if  it  siu-vives  the  injury.  The  moral  and  ethical 
aspects  of  the  question  are  too  broad  to  be  more  than  mentioned  here.  The  stand  of  the  CathoUc 
Church  has  been  alluded  to, — "Non  Occides!" — and  in  such  families  the  attendant  is  guided  by  the 
word  of  the  priest,  who  is  always  to  be  summoned.  If  the  accoucheur  is  con\inced  that  the  cesa- 
rean section  demanded  would  kill  the  mother,  he  may  retire  from  the  case.  On  the  other  hand,  if 
the  family  insists  on  the  sacrifice  of  the  child,  when  the  accoucheur  feels  that  there  are  good  chances 
for  a  successful  cesarean  section,  he  should  likewise  decHne,  but,  legally,  he  must  stay  by  the  pa- 
tient until  another  qualified  practitioner  has  assumed  charge. 

Is  consent  of  the  patient  or  next  of  kin  necessary?  Legally,  yes — indeed,  the  attendant 
could  be  held  for  malpractice  if  the  mother  suffered  injury  from  an  operation  less  safe  than  a 
craniotomj-,  performed  without  her  consent.  The  facts  of  the  particular  case  are  to  be  laid,  un- 
varnished, before  the  family  for  decision,  which  is  their  right.  Here  much  depends  on  the  atjil- 
ity  of  the  accoucheur  in  progno.sis,  for  he  has  to  evaluate  the  condition  of  the  mother  and  of  the 
babe  and  to  foretell  their  probable  chances  of  life  and  health,  admittedly  a  very  difficult  and  deli- 
cate task.  After  all,  the  family  will  usually  rely  on  the  accoucheur's  judgment,  and  he  will  be 
immensely  aided  and  comforted  by  adherence  to  the  Golden  Rule. 

In  posterior  occiput  positions  not  amenable  to  the  usual  treatment,  and  where 
the  forceps  fail,  craniotomy  may  be  necessary.  Forced  forceps  deliveries  here,  as 
well  as  in  face  and  brow  presentations  with  the  chin  posterior,  are  equivalent  to 
craniotomies  as  far  as  the  child  is  concerned,  but  have  not  the  saving  grace  of  the 
latter  in  sparing  the  woman  from  serious,  often  fatal,  mutilations.  Let  no  man  pride 
himself  on  having  accomplished  a  hard  operative  delivery  with  a  whole  but  dead 
child.     Let  him  ask  himself  if  craniotomy  had  not  been  more  humane. 

Craniotomy  is  not  a  good  operation  when  a  tumor  is  impacted  in  the  pelvis. 
Necrosis  of  the  tumor  often  ensues. 

Conditions. — The  pelvis  may  not  be  too  contracted.  Barnes  believed  it  pos- 
sible to  deliver  a  mutilated  fetus  through  a  conjugata  vera  of  less  than  two  inches, 
but  most  authors  place  the  limit  at  6.2  cm.  for  flat  and  6.5  cm.  for  generalh^  con- 
tracted pelves.  Naturally,  these  figures  must  be  raised  if  the  child  is  of  unusual 
size  or  hardness.  The  cervix  must  be  well  dilated  or  easily  dilatable — the  more  the 
better. 

Technic. — In  addition  to  the  special  instruments  for  craniotomy,  all  those  used  in  a  forceps 
operation  should  be  boiled.  Xaegele's  perforator  (Fig.  S94)  is  one  of  the  best,  but  the  trephine 
makes  a  larger  opening  in  the  skull,  and  the  vagina  is  less  hkely  to  be  injured  by  spicule  of  bone, 


1008 


OPERATIVE    OBSTETRICS 


which  is  also  true  of  the  rubber  gloves  of  the  accoucheur  (Fig.  895).  For  crushing  the  perforated 
head  the  best  instrument  is  Auvard's  cranioclast  (Fig.  896).  It  has  three  blades,  and  while  more 
difficult  to  apply  than  the  generally  recommended  Carl  Braun  instrument,  it  does  better  work. 

The  preparations  for  the  operation  are  as  complete  as  usual. 

The  head  is  steadied  by  an  assistant  from  the  outside,  or  seized  by  means  of  a 


Fig.  S94. — Naegele's  Perforator. 


strong  vulsellum  forceps  sunk  into  the  scalp.  In  some  cases  I  hold  it  with  the 
obstetric  forceps.  Under  cover  of  the  whole  hand  the  perforator  is  introduced  and 
applied  to  the  most  accessible  portion  of  the  head,  care  being  taken  that  it  does  not 
glance  off,  which  advice  is  to  be  specially  heeded  when  the  cutting  perforator  is 


Fig.  895. — Martin  Trephine. 
Made  more  easily  cleansable  by  the  author. 


used  (Fig.  898).  It  is  also  possible  to  expose  the  head  by  specula  and  do  the  opera- 
tion by  sight.  After  the  opening  is  made,  one  finger  is  hooked  into  it,  then  the  brain 
matter  is  thoroughly  broken  up  by  means  of  a  long  forceps,  taking  special  care  to 
tear  the  tentorium  and  destroy  the  medulla,  this  to  avoid  the  painful  experience  of 


Fio.  SOG. — Author's  Cranioclast — A  Modified  Auvard. 


seeing  the  child  gasp  after  delivery.  Two  cases  are  recorded  where  the  child  lived 
a  while  in  spite  of  the  mutilation.  Now  the  cranium  is  washed  out  with  a  stream 
of  sterilized  water.  The  third  step  of  the  operation  is  crushing  the  empty  skull. 
Under  the  same  rules  as  those  of  forceps  one  outer  blade  of  the  cranioclast  is  laid 
over  the  face  of  the  child,  and  while  this  is  held  by  an  assistant,  the  solid  blade  is 


Ml  Tir.ATIXG    OPERATIONS    ON    THE    CHILD 


1009 


y)iislic<I  into  the  skull  to  the  base.  By  moans  of  the  compression  screw  the  two  are 
l)r()u<;lit  slowly  tofiictlicr,  hut  after  theij  are  locked  and  before  they  are  tightened  the 
arcourhenr  should  assure  himself  that  nothing  is  caught  in  the  grasp  of  the  jaus.  When 
the  handles  arc  in  contact,  the  two  are  lockccl  willi  the  hasp,  then  the  third  blade 
ai)plietl  and  also  screwed  down  tight.  Tlic  lourtli  act — extraction — is  done  with 
the  same  care  and  gentleness  as  the  forceps  operation,  and  the  proper  mechanism 
of  labor  shouUl  b(>  followed.  There  is  no  occasion  for  liurry.  Frequent  examina- 
tions ar(>  made  to  determine  if  the  head  is  following,  to  preserve  the  parts  from  injury 
by  si)i(uhE  of  bone,  which  may  be  sharp  and  piercing,  and  to  aid  in  stripping  the 
cervix  back  over  the  head.  If  the  instrument  is  well  applied,  it  will  not  slip  off; 
if  it  does,  it  is  to  be  reapplied,  and  higher  up,  grasping  the  face.  Spicule  or  sharp 
edges  of  l)oni'  are  removed  by  means  of  the  Mesnard-Stein  bone  forceps  (Fig.  899). 


Fig.  S97. — Instruments  for  Embryotomy. 
The  same  instruments  as  for  forceps,  plus  the  destructive  instruments. 


The  perineum  is  to  be  preserved  by  slow  delivery — at  least,  the  woman  should  be 
spared  injury  of  this  structure. 

In  many  cases,  after  the  head  is  delivered,  the  shoulders  are  arrested.  It  is 
not  prudent  to  use  force.  The  size  of  the  shoulder-girdle  is  reduced  by  the  operation 
of  cleidotomy.  One  hand  searches  for  the  more  accessible  of  the  two  clavicles,  and 
under  the  guidance  of  this  hand  the  tip  of  the  decapitation  scissors  is  passed  to  a 
point  on  the  neck  of  the  child  adjacent  to  it.  With  tiny  snipping  motions  the  points 
of  the  scissors  are  pushed  under  the  skin  of  the  neck,  and,  guided  by  the  fingers,  a 
clavicle  is  reached  and  cut.  The  other  is  treated  the  same  way.  It  is  now  possible 
to  deliver  the  trunk  of  the  child.  In  very  exceptional  cases  the  sternum  must  be 
bisected  and  the  chest  emptied — this  in  cases  of  monsters  or  anasarca.  If  delivery 
of  the  trunk  still  causes  difficultv,  one  arm  may  be  brought  down  and  traction  made 
64 


1010  OPERATIVE    OBSTETRICS 

on  it,  or,  better,  the  blunt  hook  is  passed  into  the  axilla  and  combined  traction  made 
on  it  and  the  head. 

If  the  craniotomy  is  performed  in  face  presentation,  the  perforation  is  made 


Fig.  S98. — Perfoeatiox  t\-ith  Trephine. 


through  the  glabella  or  through  one  eye,  using  the  Naegele  instrument.     If  on  the 
after-coming  head,  the  opening  is  to  be  made  through  the  nasopharynx,  via  the 


Fig.  899. — Mesnakd  Stein  Bone  Forceps. 


mouth,  to  avoid  disfigurement  of  the  child,  or,  if  this  fails,  through  the  more  accessi- 
ble side  of  the  head.     Xaegele's  perforator  is  the  best  here,  and  a  large  opening  is 


MUTILATING    OPERATIONS   ON    THE    CHILD 


1011 


to  be  obtained.     Thorough  evacuation  of  the  brain  by  irrigation  is  essential,  and  it 
usually  is  not  necessary  to  crush  the  skull,  slow  traction  causing  it  to  collapse. 

It  is  not  wise  to  cut  the  body  off  the  head  under  the  notion  that  thus  the  latter 


Fig.  900. — Instruments  for  Decapitation. 

a,  Arabian;   6,  Ambroise  Par6;   f,  Abulcasis;   f/,  Baudelocque;   f,  Van  der  Ecken;  /,  Tarnier's  embryotome;   p,  Jacque- 

mier;   A,  Braun's  hook;    i,  Dubois  scissors;  j,  Ribemont  Dessaignes. 

will  be  more  accessible.  One  loses  a  good  handle  on  the  head.  If  this  accident  has 
happened,  the  floating  head  may  be  steadied  with  a  strong  vulsellum  forceps,  then 
firmly  seized  with  a  pair  of  obstetric  forceps,  perforated  with  a  trephine,  crushed 
with  a  cranioclast,  and  extracted.     If  the  pains  are  strong  and  the  accoucheur  is 


Fig.  901. — Decapitation  Scissors. 


certain  that  blood  is  not  accumulating  in  the  uterus,  the  delivery  of  the  head  may 
be  left  to  nature.     I  usually  do  not  wait. 

In  all  cases  as  soon  as  the  mouth  of  the  child  is  accessible  the  throat  is  to  be 
stuffed  full  of  wet  cotton,  because  sometimes  the  elasticity  of  the  chest  causes  the 


1012 


OPERATIVE    OBSTETRICS 


child  to  make  a  sort  of  inspiration  which  the  by-standers  mistake  for  a  gasp  and 
evidence  of  hfe.  x4.fter  craniotomy,  a  hot  uterovaginal  douche  of  sterile  water  is 
given  and  it  is  my  custom  to  tampon  the  uterus  lightly. 

Decapitation.— Hippocrates  did  decapitations,  using  a  curved  knife.     It  is 


Fig.  902. — Decapitation  Hook. 


Fig.  903. — Dixapitatino  with  Jahdine's  Hook. 


MUTILATINf!    OPKUATIONS    ON    THE    fHILI)  1013 

the  rarest  of  all  operations,  nowadays,  owing  to  the  general  improvement  of  obstetric 
practice.  Neglected  transverse  presentation  is  the  usual  indication,  but  sometimes 
it  is  needed  to  decapitate  the  first  of  interlocked  twins,  and,  still  more  rarely,  in 
the  treatment  of  double  monsters.  The  conditions  for  the  operation  are  the  same 
as  for  craniotomy,  and  the  same  (juestion  will  arise  as  to  the  propriety  of  performing 
it  when  the  child  lives.  In  neglected  transverse  presentations,  however,  it  is  most 
exceptional  for  the  child  to  be  found  alive.  Of  prime  importance!  in  these  cases 
is  an  accurate  knowledge  of  the  state  of  the  uterus.  If  the  lower  uterine  segment  is 
excessively  thinned,  indeed,  on  the  point  of  rupturing,  decapitation  should  be 
supersecU^l  by  evisceration,  because  this  operation  will  not  increase  the  distention — 
rather  the  opposite.  If  the  shoulder  is  wedged  deeply  into  the  excavation,  the  neck 
IxMUg  stretched  almost  parallel  with  the  long  axis  of  the  fetal  body,  evisceration  is  a 
better  operation.  If  the  neck  is  readily  accessible  and  the  uterus  not  dangerously 
thinned,  decapitation  is  a  very  satisfactory  operation.  Fig.  900  shows  some  of  the 
instruments  used  for  severing  the  neck.  Carl  Braun's  hook  has  been  modified  by 
Jartline  by  making  the  inside  somewhat  sharp — an  improvement.  I  have  usually 
])erf()rmed  the  operation  as  here  described,  all  under  the  guidance  of  the  hand,  but 
I  can  see  advantages  in  doing  it  with  the  aid  of  sight,  the  field  loeing  exposed  by 
broad  specula  and  the  neck  being  pulled  down  with  the  hook  or  powerful  vulsella. 

First  Act. — To  make  the  neck  more  readily  reached,  traction  is  put  on  the  arm.  Passing 
the  whole  hand  into  the  vagina,  the  neck  is  encircled  by  two  fingers  and  the  thumb.  Guided  by 
the  latter,  the  hook  is  passed  over  the  neck,  where  it  is  firmly  pulled  into  the  soft  parts.  No 
attempt  to  twist  should  be  made  until  the  hook  is  well  placed  and  the  fingers  are  apposed  to  the 
thumb,  thus  cncirchng  the  neck  and  guarding  the  mother's  tissues  from  injury.  Now  the  handle 
is  twisted,  slowly  pulling  at  the  same  time,  turning  the  knob  in  the  direction  of  the  head.  The 
first  ludf-turn  breaks  the  cervical  spine,  after  wliich  the  hook  takes  a  deeper  hold  on  the  muscles, 
and  a  full  tvu-n  severs  these.  The  skin  now  remains,  and  this  is  packed  into  the  hook  by  means  of 
the  fingers,  and  a  few  complete  turns  cut  it  with  the  cleanness  of  a  knife.  Sometimes  a  few  tough 
shreds  must  be  severed  with  the  scissors  (Fig.  901). 

Sccottd  Act. — Extraction  of  the  trunk  is  made  on  the  prolapsed  arm;  only  rarely  is  it  neces- 
sary to  open  the  chest  or  apply  the  hook  to  the  trunk.  The  neck  must  be  covered  by  the  fingers 
during  delivery  to  protect  the  vagina  from  being  pierced  by  spicula^  of  bone. 

Third  Act. — Delivery  of  the  head  is  accomplished  by  expression  from  above,  traction  on  the 
jaw  from  below,  or,  if  need  be,  by  forceps  or  even  craniotomy.  In  the  latter  instance  the  head 
must  be  firmly  fixed  either  by  the  forceps  or  by  strong  vulsella.  Sharp  projections  of  bone  may 
do  much  damage  if  unobserved. 

Evisceration. — In  cases  of  arrested  delivery  of  the  child,  in  complicatio  corpora 
(see  p.  618),  the  neck  is  inaccessible  to  the  hook  or  the  scissors.  Exenteration  is 
the  best  operation.  A  large  hole  is  made  in  the  chest  with  the  scissors,  several 
ribs  being  resected.  With  the  fingers  the  entrails  are  pulled  out — first  out  of  the 
chest,  then,  after  boring  through  the  diaphragm,  out  of  the  abdomen.  Usually 
the  body  collapses,  and  the  child  can  be  easily  extracted,  but  if  there  is  the  least 
resistance,  the  spinal  column  should  be  cut  through  with  the  scissors  (spondylotomy), 
a  perfectly  safe  procedure,  since  the  instrument  operates  inside  the  bod}'  of  the  child, 
the  maternal  soft  parts  being  protected.  Now  the  extraction  maj'  be  made  by 
pulling  on  the  arm  or  pulling  do^\Ti  the  feet  of  the  child,  or  b}'  hooking  the  blunt 
hook  over  the  spinal  column. 

Literature 

Kerr:  Operative  Midwifery. — Kicrnayi:  The  Alienist  and  Xeurolofrist,  May,  1911. 


CHAPTER  LXXIV 
INDUCTION  OF  PREMATURE  LABOR 

This  means  the  artificial  interruption  of  pregnancy,  after  the  child  has  become 
viable,  but  before  term.  Louise  Bourgoise,  midwife  to  Mary  of  Medici,  in  1608 
introduced  the  operation  of  inducing  labor  prematurely  as  a  therapeutic  measure. 
In  1756  Denman  reported  20  cases  of  induced  premature  labor  for  contracted  pelvis. 
In  all  probability,  according  to  Kleinwachter,  the  ancient  Greeks  performed  abor- 
tion for  the  same  reason.     Soranus  of  Ephesus,  in  the  second  century,  mentions  it. 

Indications. — There  is  hardly  any  condition  affecting  the  pregnant  woman  that 
ma}'  not  give  the  indication  for  emptying  the  uterus.  The  most  common  are — 
first,  contracted  pelvis,  the  idea  being  that  a  small  fetus  will  pass  through  easily; 
and,  second,  diseases  which  affect  the  health  of  the  woman  so  deeply  that  it  is  feared 
she  will  not  survive  until  term,  or  that  the  inroads  on  her  constitution  will  be  such 
as  materially  to  shorten  her  life.  The  indications  may  be  grouped  under  five 
headings:  1.  Contracted  pelvis.  2.  Diseases  which  are  incidental  to  pregnancy. 
3.  Diseases  accidental  to  pregnancy.  4.  Habitual  death  of  the  fetus  after  viability, 
but  before  term.     5.    Prolonged  pregnancy  and  overgrowth  of  the  child. 

For  contracted  pelvis  see  p.  713.  Under  diseases  incidental  to  pregnancy  see  the 
chapters  on  Eclampsia,  Toxemia,  Chorea,  Pernicious  Vomiting,  Pernicious  Anemia, 
Placenta  Prsevia,  Abruptio  Placentae,  Psychoses,  Multiple  Neuritis,  Impetigo 
Herpetiformis,  Polyhydramnion,  Hydatidiform  Mole,  etc.  The  keynote  of  the 
treatment  is  to  stop  the  gestation  at  a  point  before  either  mother  or  child,  or  both, 
are  in  danger,  either  to  life  or  to  health. 

Under  diseases  accidental  to  pregnancy  see  the  chapters  on  Bright's  Disease, 
Tuberculosis,  especially  of  larynx.  Heart  Disease,  Diabetes,  Retinitis,  Psychoses. 

A  very  interesting  condition  is  the  habitual  death  of  the  child  after  viability, 
but  before  term.  In  apparently  healthy  women  successive  children  die,  either 
just  before  labor  or  directly  after.  The  causes  are  mostly  unknown.  Syphilis  is 
the  most  common,  and  my  practice  is,  even  if  no  history  of  the  same  is  forthcoming, 
and  even  if  the  seroreaction  of  both  parents  is  negative,  to  submit  both  to  a  mild 
mercurial  treatment.  An  occasional  success  has  encouraged  me  to  continue  this 
plan.  Bright's  disease  in  a  latent  form  explains  a  few  cases,  anemia  and  constitutional 
disorders,  diabetes,  adiposity,  and  hypothyroidism  a  few  more.  Often  enough  no 
cause  can  be  found.  Without  doubt  the  husband  is  sometimes  to  blame,  and  I 
am  convinced  that  some  men  cannot  produce  a  spermatozoicl  capable  of  giving  the 
normal  ovum  sufficient  life  impetus  to  carry  it  through  a  full  gestation.  This  has 
been  observed  in  alcoholism,  lead-poisoning,  in  tobacco-workers,  rr-ray  operators, 
and  even  without  apparent  reason.  The  treatment  of  such  cases  is  causal,  and  in 
addition  to  this  good  results  have  been  observed  in  a  complete  reversal  of  the  usual 
mode  of  life.  For  example,  a  man  overloaded  with  business  cares  may  be  sent,  with 
his  wife,  to  spend  six  months  in  camp  on  the  plains  or  in  the  mountains. 

If  the  exact  time  when  the  children  usually  die  is  known,  labor  may  be  brought 
on  a  few  weeks  before  this.  In  some  of  these  cases  every  alternate  child  dies,  or 
the  habit  is  broken  up  from  some  cause  or  other.  It  will  be  noticed  that  this  indica- 
tion is  precarious,  but  most  authors  allow  it. 

Prolonged  Pregnancy  and  Overgrowth  of  the  Child. — Some  women  habitually 
go  over  the  usual  period  of  pregnancy,  and  not  seldom  the  child  dies  or  suffers  so 

1014 


INDrrTIOX    OF    PREMATURE    LABOR  1015 

much  (luriuji  (l('li\'('ry  tliat  it  su('('Uinl)s  shortly  after.  In  thoso  casos  the  (Taniiiiii 
is  usually  hard  and  angular,  the  bones  stilt'  and  unmohlable,  the  fiesh  firm  and  un- 
pliable,  and  the  body-length  increased.  In  some  instances  the  child  as  a  whole  is 
of  greater  size  than  ordinarily,  and  the  mechanical  labor  difficulties  are  pronounced. 
I  have  already  (p.  G36)  discussed  this  subject,  and  stated  that  my  practice  is  not  to 
allow  the  women  to  go  too  far  beyond  term.  Some  women  come  to  the  accoucheur 
giving  a  history  of  difficult  labors  with  immense  children.  It  is  wise  to  accept  the 
story  with  much  reservation,  because  often,  for  various  reasons,  the  previous 
attendant  will  exaggerate  the  size  of  the  child,  and  again  the  patient  herself  will  do 
the  same,  sometimes  forgetting.  Nevertheless,  such  a  pregnancy  requires  watching, 
and  if  th(>  child  actually  does  grow  too  large,  it  is  best  to  interrupt  it. 

Conditions. — The  child  must  be  living  and  viable  in  all  cases  where  the  preg- 
nancy is  terminated  in  its  interests.  It  may  not  be  deformed.  A  child  delivered 
before  the  thirtieth  week  of  gestation  has  but  little  chance  of  survival.  Speaking 
broadly,  with  every  week  of  gestation  after  this  period  the  child's  chances  improve 
10  per  cent.  In  determining  the  size  of  the  child  by  palpation  the  possibility  of 
twins  is  to  be  borne  in  mind. 

The  pelvis  may  not  be  too  markedly  contracted,  it  being  generally  conceded 
that  in  pelves  below  7  and  l}/2  cm.  the  outlook  for  an  infant,  even  at  the  thirty- 
second  week,  is  dubious. 

The  condition  of  the  mother  must  be  such  that  she  will  probably  live  through 
the  operation.  Although  several  cases  are  on  record  of  the  operation  being  done 
on  a  moribund  woman,  actual  practice  seldom  justifies  it.  The  consent  of  the 
mother  or  next  of  kin  must  be  obtained,  and  in  all  cases  a  consultation  is  essential, 
first,  because  human  judgment  is  fallible,  and,  second,  to  avoid  legal  entanglements 
later.     A  written  statement  is  desirable. 

The  Prognosis. — In  a  collection  of  2200  cases  Sarwey  found  a  maternal  mor- 
tality of  1.-4  per  cent. — 0.6  per  cent,  due  to  infection,  but  part  of  this  may  have  been 
due  to  causes  not  inherent  in  the  operation  itself.  Nowadays,  with  our  perfected 
technic,  the  induction  of  labor  should  be  without  mortality  ascribable  to  infection 
carried  in  by  the  accoucheur,  but  it  is  not  possible  always  to  avoid  infecting  the 
woman  with  virulent  bacteria  already  present  in  the  genitalia,  for  example,  in 
gonorrhea,  in  the  urine  from  a  ureteropyelitis,  even  those  of  the  ordinary  vaginal 
flora.  If,  as  not  seldom  happens,  the  operation  requires  repeated  internal  manipu- 
lations extending  over  several  days,  the  streptococci  in  the  vagina,  given  blood, 
bruised  tissue,  and  a  depressed  woman,  acquire  invasive  virulence;  therefore  it  is 
not  uncommon  in  prolonged  cases,  in  spite  of  the  most  painstaking  aseptic  technic, 
for  the  patient  to  have  fever,  and  in  a  few  cases  fatal  sepsis  may  arise. 

The  morbidity  is  not  small.  Dilatation  of  the  cervix  is  usually  imperfect 
and  lacerations  are  common,  which  is  also  true  of  the  pelvic  floor  to  a  less  degree. 
Operative  termination  of  the  labor  is  oftener  required,  which  carries  T^"ith  it  the 
dangers  so  often  referred  to.  If  the  uterus  is  ver}-  sluggish,  the  various  operations 
have  to  be  repeated  day  after  day.  Such  cases  act  badly  on  the  nervous  system  of 
the  patient.  In  a  few  cases  on  record  the  attempt  to  get  the  uterus  to  act  had  to 
be  abandoned,  and  the  pregnancy  went  to  term.  Some  of  the  methods  employed 
are  not  without  danger — the  insertion  of  a  bougie,  for  instance,  may  detach  the 
placenta. 

For  the  child,  the  general  mortality  is  from  30  to  GO  per  cent.,  depending  on  the 
period  of  pregnancy  and  the  indication  which  demanded  the  interference.  The 
child  of  a  sickly  mother  will  have  less  chance  of  survival  than  one  from  a  healthy 
parent.  The  dangers  besetting  the  child  in  passing  a  narrowed  pelvis  are  to  be 
carefully  weighed.  Nowadays,  specialized  obstetric  nursing  and  the  scientific 
incubator  have  done  much  for  the  premature  infant.  The  presentation  of  the  child 
has  much  to  do  with  the  prognosis,  that  of  the  breech  being  particularh'  unfavorable. 


1016  OPERATIVE    OBSTETRICS 

It  is  best  to  secure  cephalic  presentation  before  operating — at  least,  perfect  dilata- 
tion of  the  parturient  canal — to  make  the  exit  of  the  tender  child  the  easiest  possible. 

Technic. — Of  the  20  or  more  methods  that  have  been  recommended,  only  a  few 
are  practised,  and  the  selection  will  depend  on  the  urgency  of  the  case,  the  rapidity 
with  which  it  is  necessary  to  empty  the  uterus,  and  individual  preference. 

Puncture  of  the  Bag  of  Waters. — This  is  the  oldest  method,  mentioned  by 
Demnan  in  1756,  as  the  generally  known,  probably  only,  one.  Any  long-pointed 
instrument  may  be  used,  as  a  scissors,  but  where  obtainable,  a  thin  trocar  is  better. 
By  forcing  the  head  down  into  the  cervix,  by  allowing  the  water  to  trickle  away, 
not  to  rush  out  in  a  stream,  perhaps  using  the  Sims'  position,  prolapse  of  the  cord 
may  be  prevented.  If  the  head  is  movable  and  prolapse  of  the  cord  likely,  it  is 
better  to  substitute  another  method.  In  primiparse,  with  a  closed  cervix,  the  dis- 
advantages of  a  dry  labor  are  to  be  borne  in  mind.  Puncture  of  the  membranes  is 
the  most  certain  of  all  methods,  and  may  be  used  when  older,  milder  means  fail. 

Bougies. — Krause,  in  1855,  introduced  one  or  two  elastic  solid  bougies  into 
the  uterus  between  the  membranes  and  the  wall.  Though  the  method  is  quite 
popular,  I  hardly  ever  use  it,  finding  it  inefficient  (the  pains  seldom  come  on  within 
forty-eight  hours)  and  somewhat  dangerous.  In  two  cases  of  my  own  the  placenta 
was  encroached  on,  with  severe  but  controllable  hemorrhage.  The  bag  of  waters 
may  be  punctured,  and  I  think  the  danger  of  infection  is  higher  than  with  other 
methods.  In  a  case  seen  in  Berlin  necrosis  of  the  track  of  the  bougies  was  found 
postmortem. 

By  the  light  of  broad  specula  the  cervix  is  exposed,  and  two  No.  24  French  size, 
soft-rubber  bougies  passed  into  the  uterus,  going  to  either  side,  behind,  in  the  direc- 
tion of  the  least  resistance.  If  the  least  blood  appears,  both  are  to  be  removed  and 
the  vagina  packed.  Next  day  another  method  of  induction,  usually  puncture  of 
the  membranes,  is  to  be  practised. 

Dilatation  of  the  Cervix. — Hydrostatic  dilatation  of  the  cervix  is  often  used  to 
hasten  labor  and  in  the  treatment  of  placenta  prsevia.  A  bag  in  the  cervix  both 
dilates  it  and  stimulates  the  pains.  The  technics  have  already  been  described. 
A\Tien  the  bags  are  used  simply  to  start  labor  pains,  the  small-sized  ones  are  selected. 
Pains  usually  come  on  within  six  hours,  but  often  subside  immediately  the  bag  is 
expelled,  requiring  the  insertion  of  another.  Sometimes  the  pains  do  not  come  on 
for  several  days,  even  if  larger  and  larger  bags  are  put  in  every  twenty-four  hours. 
It  cannot  be  denied  that  sometimes  the  bag  displaces  the  head  and  allows  mal- 
presentations  and  prolapse  of  the  cord  to  occur. 

Packing  the  cervix  and  lower  uterine  segment  with  gauze  is  a  favorite  method 
of  the  author.  It  is  illustrated  in  Fig.  792.  Under  the  guidance  of  the  fingers, 
or  in  the  view  provided  by  broad  specula,  and  with  the  cervix  drawn  down  by 
vulsellum  forceps,  a  strip  of  gauze  three  to  five  yards  long  and  three  inches  wide  is 
snugly  and  evenly  placed  in  the  lower  part  of  the  uterus  and  the  cervical  canal. 

Sometimes  the  separation  of  the  membranes,  by  swinging  the  finger  around  the 
lower  pole  of  the  uterus,  is  enough  to  bring  on  contractions  (Hamilton).  I  have 
used  this  method  at  term  with  labor  imminent. 

Only  exceptionally  are  we  required  to  use  great  haste,  as  in  eclampsia,  threaten- 
ing edema  of  the  lungs  from  heart  or  lung  disease,  and  in  such  instances  vaginal 
cesarean  section  is  the  method  of  choice,  though  occasionally  the  abdominal  route 
is  to  be  selected. 

In  cases  of  sufficient  urgency,  but  less  than  the  last,  puncture  of  the  membranes 
and  the  insertion  of  a  balloon  dilator  will  be  the  methods  of  choice,  followed  later 
by  manual  dilatation  of  the  cervix  and  delivery. 

Where  there  is  no  great  hurry,  my  practice  is  as  follows:  The  patient  is  pre- 
pared as  for  any  major  obstetric  operation.  Under  the  strictest  aseptic  precautions 
the  cervix  is  dilated  with  the  finger-tip  and  straightened,  then  the  region  just  above 


IXDT'CTION    OF    I'HKMATURE    LABOR  1017 

tlio  internal  os  is  loosely,  and  the  eervical  eanal  tislitiy,  packed  with  gauze,  as 
deserihed  on  p.  908,  leaving  no  ends  hanging  out  the  vulva.  I  usually  do  this 
about  5  P.M.  The  patient  is  allowed  a  light  supper,  and  one  hour  after  this  a  single 
dose  of  castor  oil  is  administered.  Pains  usually  come  on  by  3  or  5  o'clock  the 
next  morning,  and  as  soon  as  they  are  well  established,  the  gauze  may  Ik;  removed. 
If  pains  do  not  come  on  l)y  .5  p.m.  the  next  evening,  the  same  procedure  is  re- 
peated, or  a  medium-sized  Voorhees  bag  is  inserted.  A\'hile  the  uterus  may  not 
have  gotten  into  regular  action,  some  pains  always  have  occurred,  and  they  have 
softened  the  cervix  and  jiroduced  some  effacement.  If,  next  morning,  regular  pains 
have  not  set  in,  the  membranes  are  ruptured,  and  now,  with  very  few  exceptions, 
the  lal)or  goes  on  cjuickly.  I  am  using  pituitrin  in  5  and  10  minim  doses  to  aid  the 
uterine  action,  with  fair  success. 

Irregular  uterine  action,  abnormal  contraction  rings,  malpresentat ions  and  mal- 
positions of  the  fetus,  insufficient  dilatation  of  the  cervix,  nervous  exhaustion,  sleep- 
lessness, prolonged  anxiety  of  the  patient,  fever,  prolapse  of  the  cord,  lacerations 
of  the  soft  parts,  operative  interference,  postpartum  hemorrhage,  and  many  other 
grave  and  less  grave  complications  must  be  expected  when  you  induce  labor. 

Premature  children  suffer  severely  from  the  traumatism  of  labor.  Breech  de- 
liveries are  especially  faial  to  them,  therefore  version,  as  a  rule,  is  contraindicated. 
They  are  especially  prone  to  fracture  of  the  bones,  cerebral  hemorrhage,  and  ate- 
lectasis pulmonum. 

If  delivery  is  effected  by  forceps,  episiotomy  is  desirable  to  spare  the  head  the 
perineal  pressure.  After  delivery  it  is  essential  that  the  lungs  be  well  inflated,  that 
the  infant  be  kept  warm,  and  that  it  l^e  placed  in  a  properly  ventilated  and  disin- 
fected incubator.  Mother's  milk  and  good  nursing,  however,  are  more  important 
than  the  incubator.     The  best  results  are  obtained  by  combining  the  three. 

For  the  sake  of  completion-  a  few  obsolete  and  dangerous  methods  may  be 
named:  Puncture  of  the  membranes  high  up  in  the  uterus  with  a  trocar;  intra- 
uterine injection  of  water,  hot  and  cold,  of  glycerin,  milk,  etc.;  the  Kiwisch  douche 
— a  stream  of  hot  water  against  the  cervix;  carbon  dioxid  water  irrigations  of  the 
vagina;  vaginal  tamponade;  colpeurysis;  electricity;  the  a;-ray;  irritation  of  the 
nipples;  medicines,  as  'quinin,  cimicifuga,  ergot,  cathartics,  etc.  (Literature  in 
Williamson,  Jour.  Obst.  and  Gyn.,  Brit.  Empire,  August,  1905,  p.  254.) 

Following  a  suggestion  of  Heide,  Rongy  injects  fetal  blood-serum  for  the  in- 
duction of  labor  with  good  results  (Amer.  Jour.  Obstet.,  July,  1912). 

Induction  of  Abortion. — This  operation  has  been  done  since  remotest  anti- 
quity, and  in  savage  as  well  as  civilized  lands.  By  some  it  was  done  to  prevent 
overpopulation,  and  was  a  recognized  procedure;  by  others  to  avoid  the  discomforts 
and  dangers  of  the  function  of  reproduction,  or  even  the  disfigurement  of  the  person 
wrought  by  gestation,  as  in  decadent  Rome.  The  child  was  considered  to  be  with- 
out a  soul — only  a  groA\i:h  on  its  mother.  As  a  therapeutic  measure,  abortion  was 
done  long  before  Christ;  indeed,  the  production  of  abortion  by  a  physician  for 
other  reasons  was  considered  unethical,  as  witness  the  oath  of  Hippocrates.  The 
ancient  Jews  considered  abortion  a  great  sin,  but  admitted  it  as  a  means  of  cure  of  dis- 
ease affecting  the  mother.  The  promulgation  of  Christian  principles  did  much  to 
stop  the  practice,  at  least  openly,  and  soon  the  law  made  it  a  punishable  offense, 
(See  Lecky,  History  of  European  ^Morals.) 

One  of  the  saddest  commentaries  on  our  modern  "civilization,"  in  a  so- 
called  religious  and  ethical  era,  is  the  prevalence  of  criminal  abortion.  A  young 
physician  is  not  long  in  practice  before  he  is  approached,  in  a  hundred  ways,  open 
or  concealed,  to  perform  a  criminal  abortion.  Not  alone  the  single  woman,  l^ut 
the  married,  will  come.  All  arguments  will  be  brought  to  bear — that  of  friend- 
ship for  a  stricken  family,  the  disgrace  of  a  child  under  untoward  circumstances, 
the  impossibility  of  caring  for  a  large  number  of  children,  ill  health,  even  gold  will  be 


1018  OPERATIVE    OBSTETRICS 

offered.  The  physician  should  allow  none  of  these  things  to  influence  him  to  do  an 
abortion,  because,  first,  it  is  murder,  and  conscience  will  make  his  later  days  mis- 
erable ;  second,  it  is  a  criminal  offense,  and,  performed  in  the  way  most  of  such . 
operations  have  to  be  done,  infection  will  likely  follow,  and  perhaps  death  of  the 
patient,  with  a  prison  term  for  the  perpetrator,  in  the  perspective;  third,  acci- 
dents, like  perforation  of  the  uterus  and  anesthetic  deaths,  are  not  uncom- 
mon; fourth,  if  he  does  it  once  he  is  a  lost  man;  the  woman,  no  matter  how 
firml}'  she  has  been  bound  to  secrecy,  will  tell  her  friends,  and  soon  his  reputation 
as  an  abortionist  will  be  established.  There  are  other  reasons,  but  the  conscientious 
physician  will  not  need  any  at  all.  A  word  of  warning:  Let  the  inexperienced 
physician  beware  of  simulated  disease.  A  woman  will  read  up  on  some  disease 
which  she  knows  sometimes  gives  the  indication  for  abortion,  and  will  try  to  impress 
the  doctor  that  she  is  deathly  ill. 

Therapeutic  abortion  is  rarely  indicated,  and  lately  our  general  therapy  has 
improved  so  much  that  few  affections  justify  its  performance.  (1)  Contracted 
pelvis  with  a  conjugata  vera  below  6  cm.,  mentioned  by  Soranus  of  Ephesus  in  the 
second  century  a.d.,  and  by  Cooper  in  1772,  to  avoid  the  terrific  mortality  of 
cesarean  section.  Nowadays,  with  the  safety  of  cesarean  section,  the  accoucheur 
should  refuse  to  perform  abortion  for  this  indication  unless  there  are  other,  scienti- 
fic reasons,  e.  g.,  heart,  lung,  or  kidney  disease.  (2)  Hyperemesis  gravidarum 
and  other  forms  of  toxemia.  Without  doubt,  here  is  a  real  indication  for  abortion, 
but  a  restricted  one.  In  cases  of  toxemic  vomiting,  with  the  evidences  of  real  in- 
volvement of  the  structure  of  the  liver  and  kidneys,  one  should  not  wait  too  long 
before  emptying  the  uterus.  (See  Hyperemesis.)  (3)  Incarceration  of  the  retro- 
flexed  gravid  uterus  is  usually  better  treated  by  laparotomy.  (4)  Advancing 
tuberculosis,  as  shown  by  loss  of  weight,  evening  fever,  hemoptysis,  etc.  Most 
authorities  believe  that  the  progress,  while  not  always  stayed,  is  rendered  less 
fulminant  by  interrupting  pregnancy.  A  combination  of  hyperemesis  gravidarum 
and  tuberculosis  is  a  positive  indication  for  abortion,  as  also  is  tubercular  laryngitis. 
(5)  Heart  disease  is  only  an  indication  when  the  muscle  is  badly  inefficient,  as  ad- 
vanced myocarditis  and  discompensation.  (6)  Diabetes  and  other  constitutional 
diseases,  as  under  induced  labor.  (7)  Diseases  of  the  kidneys,  especially  if  com- 
plicated by  retinitis.  (8)  Other  diseases  which  seriously  jeopardize  the  mother,  as 
Basedow's  disease,  leukemia,  pernicious  anemia,  chorea,  etc.  (9)  Diseases  of  the 
ovum — polyhydramnion,  hydatidiform  mole,  death.  In  the  last-mentioned,  hemor- 
rhage from  the  uterus  usually  indicates  interference,  and  then  the  procedure  cannot 
be  called  true  abortion;  rather  we  are  simply  completing  a  process  nature  has 
begun.  Hemorrhage  during  the  early  months  of  pregnancy  may  come  from  pla- 
centa praevia,  placenta  marginata,  cornual  placenta,  and  chronic  abortion,  and 
may  require  interference.  Repeated  bleedings  are  almost  always  followed  by 
complete  abortion.  Sometimes  the  pregnancy  continues  to  term,  and  trouble 
arises  in  the  placental  stage  from  placenta  accreta  and  postpartum  hemorrhage. 
Again,  a  placenta  praevia  will  show  itself  in  the  seventh  or  eighth  month.  While 
a  few  of  my  cases  have  gone  to  term — as  a  rule,  I  regard  frequent  hemorrhages  in  the 
early  months  sufficient  indication  for  therapeutic  abortion. 

In  one  case,  a  neurotic,  highly  bred,  "overcivilized"  (Reynolds)  woman,  the 
psychic  shock  of  the  pregnancy  was  so  great  that  the  question  of  therapeutic  abor- 
tion was  seriously  considered.  I  refused  to  do  it,  advising  mental  treatment,  and 
the  woman  disappeared,  but  had  she  not,  in  my  hands,  quickly  recovered  from  the 
continuous  nervous  excitement,  the  sleeplessness,  the  almost  maniacal  fear  of  preg- 
nancy, which  reminded  me  very  much  of  the  overwhelming  terror  some  people  have 
of  thunder-storms,  I  am  sure  that  abortion  would  have  been  justified. 

The  conditions  for  the  operation  are  about  the  same  as  for  induced  labor.  Al- 
ways insist  on  a  consultation,  draw  up  a  written  statement  of  the  facts  in  the  case, 


INDUCTION    OF    PREMATURE    LABOR  1019 

and  have  it  signed  l)y  the  woman,  her  next  of  kin,  and  all  the  physicians  in  charge. 
Every  appearance  of  mystery  and  secrecy  must  be  sedulously  avoided.  It  is  best 
to  perform  the  operation  in  a  hospital. 

Technic. — The  oponitions  may  be  divided  into  those  done  during  tlie  first  c'ttihi  weeks,  those 
done  froni  the  eighth  to  the  sixteenth  week,  and  those  from  this  time  until  the  ehild  is  viable. 

In  the  hrst  eight  weeks  the  uterus  usually  can  be  emptied  all  at  one  sitting.  An  anesthetic 
is  not  always  required,  but  the  accoucheur  nuist  be  able  to  do  everything  with  the  greatest  delibera- 
tion and  comfort.  A  careful  biinaiuial  examination  is  made  to  discover  an  ectopic  pregnancy  or 
a  retroflexion.  The  cervix  is  dilated  with  CSoodell  dilators  of  increasing  sizes,  this  part  requiring 
from  fifteen  to  twenty-fi\-e  minutes.  Then  the  contents  of  the  uterus  are  removed  with  the  curet 
and  polypus  forceps,  after  which  the  cavity  is  lightly  filled  witli  a  strip  of  gauze.  This  stops  the 
l)lceding,  and  when,  next  day,  it  is  removed,  it  brings  with  it  shreds  of  decidua  which  may  have 
been  oNcrlookcd.  In  rare  cases  tlie  cervix  is  so  hard  that  it  is  impossible  or  unsafe  f(ji-ciblv  to  dilate 
it.  Here  the  cer\-ix  may  be  packed  with  iodoform  gauze  for  twenty-four  hours,  when  it  will  be 
found  softened  and  tlilatable.  Perhaps  a  tent  may  be  put  in,  but  I  have  never  used  one,  since  I 
consider  them  dangerous.     When  haste  is  not  demanded,  the  two-stage  method  maybe  chosen. 

During  the  third  and  fourth  month  the  abortion  is  done  in  two  stages.  On  the  first  day  the 
OS  is  openecl  a  little  with  a  Cloodcll  dilator,  then  with  a  curet  the  ovum  is  broken  up,  making  cer- 
tain that  the  amnion  has  been  punctured;  then  the  cavitj'  of  the  uterus  is  lightly,  and  the  cervix 
tightly,  packed  with  gauze  by  means  of  the  tubular  packer  shown  on  p.  908.  Pains  almost  alwaj's 
start  up  within  twelve  hours,  and  if  the  packing  is  not  expelled,  at  least  the  cer\-ix  is  opened  enough 
to  put  in  one  finger.  If  it  is  not,  the  packing  may  be  repeated — this  time  I  usually  use  a  piece 
of  weak  iodin  gauze.  At  the  end  of  another  twenty-four  hours  the  uterus  may  be  emptied,  as 
described  under  Abortion. 

During  the  fifth  and  sixth  months  the  process  resembles  the  induction  of  premature  labor  more. 
The  bag  of  waters  should  be  ruptured,  and  a  small-sized  Voorhees  bag  inserted.  In  cases  of  great 
urgency  vaginal  cesarean  section  should  be  performed.  Let  me  warn  the  accoucheur  against  the 
removal  of  a  small  fetus  piecemeal  through  a  long,  narrow  cervical  canal.  It  will  tax  his  skill  to 
the  utmost,  especially  if,  as  so  frequently  happens,  the  bod}'  is  torn  off  the  head,  which  bobs  around 
in  tlu^  blood  in  the  uterine  cavity.  If  he  attempts  this  operation,  every  bit  of  the  body  of  the  fetus 
should  l)e  laid  out  on  a  clean  towel,  and  he  may  not  call  the  work  complete  until  all  the  parts  of 
the  fetus  are  accounted  for.  After  the  placenta  is  removed,  the  whole  interior  of  the  uterus  is 
lightly  cureted,  and  finally  the  cavity  is  filled  with  gauze,  which  is  removed  the  next  day.  Where- 
erir  possible,  the  fingers  are  to  be  used  instead  of  the  curet  or  ovmn  forceps. 

There  is  no  medicine  which  will  safely  bring  on  abortion,  though  many  are  vaunted  for  the 
purpose.     Other  methods  of  inducing  abortion  have  been  named  under  Induced  Labor. 

After-treatment. — Ergot  and  hydrastis,  of  each  10  minims,  are  administered  thrice  daily  for  a 
week.  Douches  are  not  used — only  external  washings  with  a  weak  antiseptic  solution.  The 
woman  should  lie  abed  for  one  week  and  only  gradually  assume  her  duties. 

Prognosis. — The  induction  of  abortion  is  attended  by  a  certain,  though  in 
proper  hands  small,  mortality.  The  dangers  are  infection,  which  is  not  always 
avoidable,  since  the  woman  m&y  have  it  within  her,  and  perforation  of  the  uterus. 
I  consider  the  operation  of  induced  abortion  one  of  the  most  dangerous  in  obstetrics. 
The  most  painstaking  asepsis  does  not  always  guarantee  an  afebrile  convalescence. 
Perforation  of  the  uterus  by  the  curet  is  sometimes  very  easy.  It  has  happened  to 
every  accoucheur  of  experience — either  the  cervix  tears  into  the  broad  ligaments 
or  peritoneal  cavity,  or  the  curet,  even  the  finger,  goes  through  the  wall  of  the  uterus. 
In  one  recorded  case  the  uterine  muscle  was  so  soft  that  the  weight  of  the  curet  held 
vertically  on  the  extirpated  uterus  sufficed  to  make  it  go  through  to  the  table 
underneath.  I  confess  I  use  the  curet  only  ^\^th  the  greatest  distrust,  and  dispense 
with  it  entirely  if  the  finger  can  gain  access  to  the  uterus.  The  ovum  forceps,  too, 
are  dangerous,  and  many  cases  are  reported  annually  of  the  drawing  out  of  coils 
of  gut  and  omentum  through  perforations  in  the  uterus.  Spiculte  of  bone  from  a 
dismembered  fetus  may  also  puncture  the  uterine  wall,  and  the  lower  uterine  seg- 
ment may  be  torn  during  forced  attempts  to  draw  the  fetus  through  it.  In  view  of 
all  this  the  operation  is  not  to  lie  lightly  undertaken,  and  is  to  be  performed  with  the 
greatest  gentleness  and  circumspection. 


APPENDIX 

Sterilizing  Rubber  Gloves. — Author's  Mtihod. — First,  o\'on  now  gloves  are  testpff  for  imper- 
fcf'tioiis  \)\  (illiiiji;  tliciii  up  uilli  very  liot  water  and  drying  the  outside.  The  minutest  perforation 
will  thus  he  (hscovered.  All  imperfect  gloves  are  discarded.  The  gloves  are  now  thoroughly 
washe(l  inside  and  out  with  .soap  and  water,  dried,  and  generou.sly  powdered  with  plain  pure  talcum. 
They  are  then  suspended  in  a  tall,  low-pressure  sterilizer  by  means  of  clips.  Thirty  pairs  an;  done 
at  one  time,  and  with  tliem  are  sterilized  enough  paper  for  wrappers  ('(>()  sheets),  .'iO  litlle  bottles  of 
corn-starch,  and  o  towels.  Hanging  thus,  the  gloves  are  exposed  to  flowing  steam  for  forty-five 
minutes.  While  still  warm,  they  ai'c  removed  from  the  sterilizer  with  sterile  hands,  laid  on  the 
towels,  then  each  pair  is  wi':ii)pe(l  up  in  tlie  paper  wrappers,  using  two  sheets,  together  with  a 
bottle  of  starch.     The  packages  are  labeled  and  then  put  back  in  the  sterilizer  for  another  forty- 


FiG.  904. — Glove  Sterilizer. 


Fig.  90.5. — Showing  how  the  Gloves,  the  Paper 
Wr.\ppebs,  the  Bottles  of  Cornst.\rch  and  Towels 
ARE  Hung  in  the  Sterilizer. 


five  minutes"  steaming.  They  are  laid  on  the  steam  radiator  for  six  hoius,  to  be  thoroughlj-  di'ied 
out,  and  stored  in  a  covered  box. 

Before  using  the  gloves  the  hands  are  disinfected,  dried,  and  powdered  with  the  corn-starch, 
and  the  glo\'es  are  drawn  on.  Corn-starch  is  used  on  the  hands  before  drawing  on  the  gloves,  and 
it  is  preferred,  because  it  does  not  parch  the  skin  as  much  as  talcum.  Talcum  must  be  used  during 
the  sterilization — corn-starcli  glues  the  gloves  together.  Bj-  means  of  a  Uttle  pure  lysol  all  the 
talcum  is  dissolved  off  the  outside  of  the  gloves,  then  they  are  thoroughly  rinsed  in  sterile  water 
to  remov(>  all  traces  of  lysol.  The  object  of  this  lysol  bath  is  twofold — first,  it  removes  the  tal- 
cum, which  even  though  sterile  may  cause  aseptic  suppuration  if  it  gets  into  the  wound;  second, 
the  lysol  kills  any  germ  that  might  possibly  have  gotten  on  the  gloves  from  the  time  they  were 
steriUzed  until  they  enter  the  wound. 

Most  hospitals  sterilize  gloves  in  high-pressure  apparatus.  Unless  they  are  exposed  to  the 
superheated  steam  full  thirty  minutes'  absolute  sterilization  is  not  sure,  but  such  a  method  spoils 

1021 


1022 


APPENDIX 


the  rubber.  Gloves  so  treated  do  not  last  long,  and  their  elasticity  suffers  even  from  the  first. 
Glo^■es  may  be  sterilized  by  boiling  in  plain  water  for  thirty  minutes.  They  should  be  wrapped  in 
a  thick  cloth  to  avoid  scorching. 

Gloves  may  not  be  put  in  a  sterilizer  near  a  flame  or  near  the  entry  of  superheated  air — they 
scorch  very  readily  and  become  brittle. 

Lysol  Gauze  for  Tamponade. — Two  widths  of  gauze  are  required  for  packing  the  uterus, 
depending  on  the  time  of  pregnancy.  For  use  in  the  early  months  a  strip  about  three  inches 
wide  is  best,  the  gauze  being  cut  into  five-yard  lengths  and  loose  threads  carefully  removed  from 
the  edges.  A  woven  bandage  may  be  bought  from  surgical  supply  houses,  and  I  use  it  instead 
of  cut  muslin.     For  packing  the  uterus  at  or  near  full  term  these  narrow  strips  would  be  useless. 

For  uterine  packing  the  gauze  is  cut  one-half  yard  wide,  into  lengths  of  12  yards.  The 
selvedge  and  cut  edge  are  folded  in,  and  each  length  is  made  into  a  bundle.     The  bundles  are  then 


Fig.  906. — Gauze  for  Uterine  Tamponade. 
Shows  tlio  method  of  pafking  into  the  jar  in  layers  from  the  bottom. 


thoroughly  rinsed  in  running  water,  wrung  dry  by  hand,  and  boiled  for  twenty  minutes  in  0.25  per 
cent,  lysol  solution.  A  pair  of  rubber  gloves,  two  sheets,  and  a  metal  clothes-wringer  are  now 
sterilized  by  steam  or  boiling.  Wearing  the  gloves,  the  bundles  arc  run  through  the  wringer, 
using  considerable  pressure.  Then  the  strijis  arc  packed  into  sterilized  Mason  jars  or  others  that 
arc  large  enough,  packing  smoothly  in  cii-cles  from  below  upward.  Thus  the  tamponade  can  be 
made  directly  from  the  jar.  The  gauze  may  not  be  rolled  and  then  placed  in  a  jar.  The  mouth 
of  the  jar  is  filled  with  a  layer  of  cotton,  the  lid  is  screwed  down  tight,  and  the  jars  are  put  in  the 
sterilizer.  They  are  sterilized  on  two  successive  days,  two  hours  each  time.  The  jars  are  then 
wrapped  in  three  layers  of  paper,  sterilized  again,  and  put  away  in  a  clean  place.  Thus  prepared, 
gauze  will  keep  sterile  for  years. 

Plain  sterilized  gauze  is  prepared  by  cutting  the  gauze,  as  it  comes  from  the  surgical  supply 
houses,  into  the  requi.site  lengths,  as  just  given,  packing  into  the  jars  as  described,  and  sterilizing 
in  the  steam  chamber  every  day  for  three  days,  two  hours  each  time. 


APPENDIX 


1023 


UIAUNUSIS, 


Chicago  Lying=In  Hospital  ""-j  Dispensary  '°"' 


STATION 

LABOR  RECORD 


Ho.  of  Cudi, —  - 


Name  of  Paticot  - 


Date  of  ApplicAtloTir- 
—       Floor, 


BlnhpUcc, 

Previout  Dlaeases,  date  of  each,- 


.•  Married,        Single,        Widow,        Age, 


Fint  MenitniftUon,  (tr^'}- 
Family    History 


Signs  of  Rachilii  7— 


Character  of  Menstruation, 


Character  of  Previous  Pregnancies,  Labors,  Puerperiui 


.„. „„. . , — Miscarriages,  ■]  "^^'^'^,   ._,        [ 

First  Labor,  {at  what  age) —     Last  Labor,  {da'-\ Last    Menstruation    \  jau 


Quickening.  Uate\ 

Month  of  Gestation  - 


.— •         Health  in  present  Prcgnancyr- 


PREPARATORY  STAGE. 


Uterine  Contractions, 

(  effatemmt,  1  ~ 
C«rvii,  \  tonJUion,    \ 


FIRST  STAGE, 


Date,  {ifgan)   {  f^'/i^i ^„„^.,\  - 


Character  of  Cry, 


-19    ■     ,  hour __„A.M.    Arrival  of  Attendant  {JafA- 

Frequency  of  Pains 


EXTERNAL  EXAMINATION,  Ovoid,   {'fJ^^^'^J-  }- 
Back, Small  Pans, - 


Tempeiaiuie — 
Over  Inlet 


-  {::x }  - 


Height  cf  Fundus, — 

Uterine  Ccntractions,  ^-j^eni.'r- 


Engagement  of  Presenting  Part,  ■.  "l]j        } 

AUSCULTATION.      Fetal  Heart,    {r^fidHy) 

Fuiuc  SoufHe,  {^'Jflf^'  ] 

PELVIS.     Interspinouf 


PRESENTATION, 

^ Round  Ligaments,  <ieuit.    j-- 


.-Estimated  Weight  of  Child— 


^.{r^gu/anfj')- 


..C/..,V.V«).- 


Uterine    Souffle,    {^t/rf^'-j 

Intercristoua, Bi-Troch —- -    Baudelocque, 

Sacrum,  ■f^Jj''^'/''| Pubis,—— — — — — Stature,— 


Circumference C.  D. 

Height, C.  M. 


INTERNAL  EXAMINATION.  {g-^^_  }    D  D  D^ 

1.  Cervix,  (ffaeemmt) 

2.  Membranes,  "I  itenlaotey  rif/nrc.  •  Uimt) 


E<iB=.{w:-«}- 


3.     Engagement  of  Presenting  Part, -.■ 

S.    Sacrum, Ischiatic  Spines, . — . 

Hemonhage, —    Vaginal  Secretion 

Second   Internal  'Examination.   -  r.V*.-u^Jr  • _____ 


'•{^-}- 


Conjugata  Diagonalts 
-     Bladder, . — 


General   Observalic 


1            2.         3          4         Is          fc          7          6           8        llO        11         li        15         14       |l5        16        17        18         19      ho  CM 
_, , 1 1 1 1 1 1 1 1 L- 1 1 ■ 1 1 1 1 > 1 

Fig.  907. 


1024 


APPENDIX 


Poaition  of  Pitient,  <J»rtaJ.   > 

EXTERNAL  EXAMINATION,    Ovoid.. 


SECOND  5TA0e. 


p.'  S:       Attendance,    {^Z"/  crrhml. }  ' 

Bladder, Rectum, 

Fundua». 


Inlet. 


Charactei  of  Cry,. 


Uterine  Contractions, 


Enc*EC°^ci>t  of  Preaentinc  Paitt 


{^n- 


AUSCULTATION.  Fetal  Heart,  {nuin^tr) {rfsularily).. 

Funic  Souffle, — Uterine  Souffle,.. .„ 

INTERNAL  EXAMINATION.         {By  v^kom,  time) 

Cervix,  {effacent^t) 0»,  {site) 

Uembnaea.  \tfOMt^»*tm4  mptmrr  n''W) „__._..™ ™ 


{fotilion) 

Pelvis,  (/«  Firsl  Stage)^ 


{.hard,  tie., 
Uq  Amnli.,      {£!^Mm.  }"-" 


Enfagemenl     ( 

of  \ 

Pteacnting  Part,  ( 


■  >*fe»v 


SBCOKD  EXAMINATION.         A  t,-=>hffm. 


Pelvis.  {lee Firsl  Stage)- 


CcDezal  Observatioits,  ■ 


I.  a/Ure»miMf  k»od,  \ 
Shotlldeis,  {diameter  in  -whith   they  are  deiivend)- 

Protection  of  the  Perineum,      {  J^^  \ 

Corf  Around  Neck, 

ANESTHETIC.        \  '^^I^'  \ 


J-r^u/ir 


ESecton  Pains. 

Degree  of  Anesthesia,   {^sut^/i'a/.} - 

BABY.     Condition, 


TIME  OP  DELIVERY,^-. 


-{tren/ment) — ~ -— Chill.... 

---..  {'./.en   leg.,,.)  {'^'^^i'.T]" 


.  Weight, Lcnfeth; ..C.  M.     Mature?.. 


THIRD  STAQB. 


After  Pains,     <  sntriiy.         \ 

Uterus,  {psiition) 

Cord  Advances,   {i^/""""} - 

(  tpomiatuOMt,  "I 

Expulsion   of  PlacenU,      ^  nrlr  **pr***i9m.   >- 

Method  of  Treatment  of  Third  Stage, 

Vaginal  Manipulations,      {j^wj^ji^*^'} 

twmdUiam.  1 „.„ 


^{cfffitittenty) 


(  k»3)/ar,  ) 
I  Abdomen,  <  lid*,        >— 


Hemonhage  After  Third  Stage, 


Ptacentm. 
{c^fUten 


Retzoplacental  Blood  Clot.    {jj^^,.  } 

Cota,{/enffA) C.M.(«/rr/r«i,)« 

Mcfflbcanes.     {   '"j^Jj;  [  («/w/////) 

Uterus  After  Delivery  of  Placenu,  {^w^Z/iVh),.. 

Length  of  Third  Stage. hour*,.. 

Perineum,  \ittrmtts.       > „ _™™ 


..Estimate  of  Am't  of  Blood  Lost. . 


^.{0pmit.s)~ 


..{thitk) „_ 

-  {fuight) C.  M. 


{e:U- 


Length  of  First  SUge,^ fcoun 


Temp. 


SUriMARY  OF  LABOR. 


nin.       Second  Stage. 

(  hti£kl  atott  /•>//,'[ 

,       Uterus,  -icoiutttt^tj;  >- 


Third  St«g», hours,.. 


Fig.  908. 


APPENDIX 


1025 


COMPLICATIONS  OR   OPERATIONS 


RECORD  OF  THE  PUERPERIUM 


Date, ... 
t  fe«ls. 


4.  BUddet,    - 

10.  BreastSt   {condition)  ~ — . 

11.  Uierus,    {height  above  /uiir) 

12.  Abdominal  tcndemesa 

K.  Lochia,    (/mjw/jV^) ■—' 

15.  Treatment  —  Remaiks, 


2.    Sleep, 

5.  Stomach,  (die/) 

6.  Tempetatuie,    A.  M, 

■•■- f: 


13.     Genitals,  {candilion)- 


Countenance,    — 

Pulse,  A.  M 

~{nippUs)~~ 

{oflerpains)— 


Patient  feels.— 

Bladder, 

Tonffue,   


10.  Breasts,    {tandition) — - 

11.  Utcrxjs,     {height   above  fuiii) 

12.  Abdominal  tenderness -—- 

14.  LochU,    i^uantily) 

15.  Treatment  —  Remarks, 


Sleep , 

Stomach,  {diet) — 


S.     Tempcratxire,    A.  M. 


13.     Genitals,  {condition)^ 


Z.    Bowels.  ™— ~ 

6.    Cotintenance,    — 

9.    Pulae,  A.  M 

{nipples)— 

{aflerpains)- 


Date, 

1.     Patient  feels, 

4.     BUdder,    

7.  'Tongue, —^ 

10.  Breasts,    {condition) 

11.  Uterus,    {height  ahn-e  puiit) 

12.  Abdominal  tenderness 

14.  Lochia,    {quantity) 

15.  Treatment  —  Remarks,  ~— — . 


Stomach,  {diet) 

Temperature,    A-  M 


13.     Genitals,  .{condition)  ~ 


Countenance,   — ~ 

Pulse.  A.  M 

{mippra)  — 

—^{a/terfcnm).. 


Dite, 

1.  Patient  feels, 

4.  Bladder.    — ~ 

7.  Tongue,    

10.  Breasts,    (condieian) 

11.  Uterus,     {height   aiove  puiit)   ■ 

12.  Abdominal  tendemeas 

14.  Lochia.    {juanHty) 

15.  Treatment  —  Remarks,  — ~ 


5.    Stomad),  {diei)- 

8.    Tempeiatuie,    A.  M^ 


3,     Bowels, 

6.     Countenance,    - 

9.    Pttlae,  A.  U.  — 

_i -.{mppUi)- 


.11.    Genitals.  {e»n£ti^~ 


Fig.   909. 


65 


1026 


APPENDIX 


Date, 

1.  Patjeot  feels, 

4.  BlAdder,    

7.  Tongue, 

to.  BreaitB,    (fcndifitm)  . — - 

II.  Uterus,     (AiTfA/    aicr^e   ^ 

13.  Abdomma]  tenderness — 

14.  Lochia,    {quantify) 

13 .  Treatment  —  Remarks, 


5.     Stomach,  {diet) 

8.    Temperature,    A.  M.- 


P.  M S 

,«).„-„ 

13.     Genitals,  {c(mefition) - 


Countenance,    — 

PulBc,  A.  M 

(nipfUs)— 

{c/l^faim)... 


Date, 

1.  Patient  feels. ~~_ 

4.  Bladder, 

7.  Tongue,  —. . 

10.  Breasta,    {(ondition)  ■ — ~— — . 

U.  Uterus,    {heighl   above  pubis)   — 

12.  Abdominal  tendemesa < — ~ 


2.     Sleep,- — _ 

S.     Stomach,  [diet) 

8.    Temperature,    A.  M. — 


6.    Countenance,    — > 
9.    Pulse,  A.  M.  - 

(«'>//«) 

[o/Urpatm).: 


14,  Lochia,    {quantity) 

15.  Treatment  —  Remarks,  • 


13.     Genitals,  {condition)  ■■ 


Date,  — 

1.  Patient  feels, 

4.  Bladder, 

7.  Tongue, 

10.  Breasts,    {eondilion) 

11.  Uterus,    {height   above  pubis) 

12.  Abdominal  tenderness 

14.  Lochia,     {quantity) 

15.  Treatment — Remarks, 


2.    Sleep, ^ _... 

5.    Stomach,  {diet) 

8.    Temperature,    A.  M 

,.....-_.-_. — ...____  {eondition)- 


3.    Bowels, 

£.     Countenance,    

9.     Pulse,  A.  M 

• {nippUs).^^ 

— {aftlrpains) :.- 


13.     Genitals,  {condition)- 


Date, 

1.  Patient  feels, 

4.  Bladder,    . — 

7.  Tongue, 

10.  Breasts,    {condition)  — ~ — _-_. 

11.  Uterus,    {height  above  pubis)   . 

12.  Abdominal  tenderness 

14.  Lochia,    {guanlily)  — 

15.  Treatment  —  Remarks, 


2.    Sleep, — ~ • • 

5.     Stomach,  {diet) 

8.    Temperature,    A.  M.— — —-.-P.  M- 
__, {secretion) 


{condition)-" 


3.     Bowels, 

6.  Countenance,  >■-- 
9.     Pulse,  A.  M 

"" {nippies)--. 

{afterpains)... 


13.     Genitals,  {condition).- 


1.     Patient  feels, 

4.     Bladder. 


10.  Breasu,    {condition)  — 

11.  Uterus,    {height   above  pubis)   

12.  Abdominal  tenderness 

14.  Lochia,    {quantity) 

15,  Treatment  —  Remarks, 


—Day         Signatures,- 


0.     Bowels, ' 


5.     Stomach,  {diet)- 

8.     Temperature,    A.  M. 


{condition)— 


6.     Countenance - -■ 

9.     Pulse,  A.  M P.    M.- 

- (ni/ftis)..- 

(«A"/>««..) -.. 


13.     Genitals,  {condition) 


1.  Patient  feeli, 

4.  Bladder, 

7.  Tongue,   — -__ _ — __ 

iC.  Breasts,   {condititm) 

11.  Ulcrus,    {height   ah<rve  puHt)   ■ 

12.  Abdominal  tenderness-— 

14.  Lochl*,    {quantity) 

13.  Treatment  —  Remarka. 


_19  -— Day         Signature! 

5.    Stomach,  {diet) ~ 

8.     Temperature,    A.  M -P.  M... 

{secretion) 


3.     Bowels, - -.." — 

6.    Countenance,    — ... — 

9.     PuJbc.  a.  M - P.   M... 

{"ipp/^i).- 


■  {eondilieit):. 


13.    Genitals,  {eonditten)  ■■ 


{a/terpains)— 


Uterus,  {moHtiiy)- 


IP  „ Day        Signatures, 

EXAHDNATION  ON  DAY  OF  DBCHAHGE. 

{nipples) 


{vagina)-. 

■■{ttntitivemti — - 


.-   Parametria,.. 


Fig.  910. 


APPENDIX 


1027 


APPLICATION  No 


CONriNEMENT  No.. 


Chicago  Lying=in  Hospital  and  Dispensary,    hoc. 


RECORD  OF  CHILD. 


Name  of  Mother,. 


Previous  History  of  Mother, 

Condition  during  Pregnancy, 


Month  of  Gc3Ution,. 


LABOR.     Character.    ]  *f^l^^,\ 
Date   of  Child's  Birth,. « 


Presentation  and  Position,... 


Duration  of  Labor, hours,.^ 


Time  of  Ligotion  of  Cord....... _ min.     Treatment  of  Eyes,.. 

Treatment, — 


Primary  RcspirationSi 


Capillary  Ciiculal 


s;;',r'      ) 


Temperature  {juit  after  binh  ),- 


GENERAL  CONDITION.      Living,....- Asphyxiated,  {^(;^,, } Still-bom. Not  Viable, Macerated.. 

Sex... - ~.    Development,-,.- ._ Fat, Cry,    Jft'ST.*""'}- 

( sihininr.  ) 

Skin. — — Vemix  Caseosa. „-.~.~~      Lanugo. 

HEAD.     Configuration, ™ ~, OssiBcalion. 


Size  of  FontancUes,... 


Sutures,.. 


IDJU 


Caput  Succedaneum,  |  [°j^'^"' }  _ 


CepbalhematDma ,  _ 


nEASUREHENTS. 

X.^mph, r.  M.      Weight..., lbs.       DIAMETERS.       Bi-parictal C.  M.       Bi-temporaJ. 

Suboccipito-brcgmatic, C.  M.        Occipito-frontal. C.  M.      Occipitcmental, C.  M.      Bisacromial, C.  M.      Bisiliac._ 

Right  Oblique  of  Head, C.  M.       Left  Oblique  of    Head, ..-- C.  M. 

CIRCUMFERENCES.    Suboccipito-bregraatic, C.  M.     Occipito-fronul . C.  M.     Bisacromial C.  M.     Chest 


-C.  M. 
..C.  M. 


REMARKS.     Anomalies,. 


SUBSEQUENT  RECORD. 


Slcep,_ 
Eycs,_ 


Umbilicus,  {^^';^*^-}_ 

Stools,  {mimter,   t«/cr),. 


Temperature, A.  M... 


...Day,     Signatures. ,... 


Sldn,  [ephr,  frufficn)^ 


Genitals,, 


_P.  M.        Remarks,^ 


..19      ,    Day. -. Signatures,- 

N  urslng,  ._„ . „ — 


Sldn,(fc/<>r,  trufticn)- 


UmbilicuB,  \y^f''^'\ 

Stools,  {numfier,  (olfir) 

Temperature,-™ A.  M.. 


'.  M.         RemarksH- 


Fig.  911. 


1028 


APPENDIX 


„19  Day,.. 

Nursing, _„ — 


Eyesr- 


Sldn.{.'i7/tfr,  eruption)^ 


UmbOicus.    j^^f'^'f 

Stools,  [rmmbfr,  eohr) 

Tcmpciatuic, A.  M.., 


,,-P.  M^  -       Remarks,™ 


Sleep,, 
Eyes^ 


Umbilicus,  \'/jf/^'\ 

Stools,  (numier,  eofor) 

Temperature, A.  M.„ 


19       ,     Day,.. 

Nursing, 


Sldn,(«/l>r,  ernpti(m)^. 


Genitals,-. 


P.  M.         Remarks,- 


Eyes.. 


UmbUicus,    {^Zl^^'l 

Stools,  {nuni^^r,  cohr) 

Temperature, .,., A.  M.. 


^)dn,{co/or,  eruption)^ 


'.  M.         Remaiks,.. 


Eyes,- 


S)sia,Uohr,  eruption) 


UmbiUcus,   j^^^^-^'[_ 

Stools,  {numier,  mfir)  ,._,.,  ,....,,,  , 
Temperature, A.  M.. 


'.  M.         Remarks,. 


Sleep,- 
Eyes^ 


...._ _19      ,    Day,.. 

Nursing, , _ 


^]txn,{(olor.  erupiion)^^ 


Cry, 


Umbilicus,    {fZl^^'i 

Stools,  {numier,  color) 

Temperature, A.  M.., 


_.J».  M.  Remarks,- 


19       ,     Day, 

Nursing..^.™ ,_. 


Eyes^ 


Skin,(f<7/or,  eruption)^. 


Umbilicus,    {  ^^  ''^'  \ 

Stools,  [number,  tohr) 

Temperature, „_ A.  M._ 


GcnitalSr^ 


P.  M.         Remarks,. 


SiMp, 

Eyw, ; ™. 

Umbilicus,    {j^f*^'f 

Zxo(ibt,\ftOinber,  ielor) 

Tempeianire,-. A.  M.. 


19      ,    Day,., 

Nursi  ng. 


Sl£m,(fo/<»r,  erupiian)^. 


GenitalSr- 
Urine,™ 


„P.  M.         Remarks,. 


EXAMINATION  ON  DISCtlAR<lB»       Day, „ _. ._.     Date. 

Note, , Eyea, 'Mouth,. 


Navel,  ^^,.   -•     \ 

Weight, 


Subcutaneooa  Fat,_ 


OeneraJ  CotididoiV 


Discharged  by  (Si^nafn-r). 


Fig.   912. 


INDEX 


Abdomen,  distention  of,  dys- 
tocia duo  to,  t)41 
lines  on,  in  pregnancy,  99 
pain  in,  in  jiregnancy,  533 
pendulous,  in  pregnancy,  83, 
398 
treatment,  399 
physics,   in   pregnancy,    100 
Abdominal     binder    in    puer- 

perium,  327 
examination,  .  diagnosis     of 
position    and    presenta- 
tion by, 279 

in  labor,  279 
hernia,  539 
muscles  in  labor,  151 
palpation  in  labor,  279 
powers,  anomalies,  in  labor, 
5G9 
treatment,  571 
pregnancy,  381 

secondary,  384 
pressure  in  labor,  151 
supporter,  Patterson's,  400 
walls,   changes   in,   in   pucr- 
perium,  212 

in  pregnancy,  99 
Abortion,  41() 

as  termination  of  retroflexcd 

pregnant  utenis,  406 
blood  mole  in,  434 
cervical,  421 
changes  in  ovum  after  death 

of  fetus,  434 
criminal,  1017 
definition,  114 
diagnosis,  423 
etiology,  416 

fetal,  417 
,  from    placental    diseases, 
417 

maternal,  417 

paternal,  418 
extra-uterine  pregnancy  and, 

differentiation,  389 
fleshy  mole  in,  435 
frequency,  416 
from  death  of  fetus,  417 
from  diseases  of  amnion,  417 

of  chorion,  417 

of  fetal  body,  417 

of  umbilical  cord,  417 
from   endometritis,   417 
from  plac{>nta  pra;via,  449 
habitual,  419 

etiologj-  of,  419 

treatment  of,  434 
hematoma,  mole  in,  435 
in  progress,  422,  423.     See 

Abortion,  inevitahle. 
incomplete,  422,  423 

diagnosis,  424 

treatment  of,  433 


Abortion,  induction  of,  101 
after-treatment,  1019 
indications,  1018 
prognosis,  1019 
technic,  1019 
inevitable,  422 

curetage     of     utei*us     in, 

427 
De  Lee's  treatment,  426 
diagnosis,  424 
emptying  uterus  in,  428 
accidents  in,  431 
acute     dilatation     of 

uterus  in,  432 
hemorrhage  in,  431 
incomplete,  432 
perforation  of  uterus 
in,  431 
treatment  of,  425 
mechanism,  420 
first  period,  421 
second  period,  422 
medicolegal  aspects,  435 
missed,  417,  423,  435 
prognosis,  424 
septic,  433 
svmptoms,  422 
therapeutic,  1018 
threatened,  422,  423 
diagnosis,  423 

differential,  424 
treatment  of,  425 
treatment,  425 

summary,  434 
tubal,  383 

treatment  of,  395 
Abruption    of    placenta,    437. 
See  also  Placenta,  abruption 
of. 
Abscess  of  breasts,  892 
ti'eatment,  895 
of  fixation  in  puerperal  fever, 

881 
parametritic,  in  pregnancy, 

532 
submammarj^,  894 
uterine  intramural,  in  puer- 
peral fc^•er,  862 
Absence  of  sacrum,  689 
Acardiacus,  465 
acephalus,  541 
acormus,  541 
Accidental    hemorrhage,    437, 

445 
Accouchement  force,  910.  915 

in  placenta  pra^via,  460 
Acephalocystis   racemosa,    544 
Acetonuria  in  pregnancy,  108 
Acne  in  pregnancy,  534 

in  puerperium,  377 
Acrania,  539 

Acromegalic  changes  in  preg- 
nancj-,  104 

1029 


Acute  yellow  atrophy  of  liver 
in  pregnancy, 
370 
diagnosis,  371 
pathologj',  370 
prognosis,  371 
symptoms,  370 
treatment,  371 
Adhesions  in  cesarean  .sections, 

994 
Adrenalin  in  hyperemesis  grav- 
idarum, 351 
in   postpartum   hemorrhage, 
787 
Adrenalinemia    in    pregnancy, 

104 
After-coming  head,  deliverj'  of, 
bj^  forceps,  956,  957 
Mauri  ceau-  SmelUe-Veit 

method,  955,  956 
Van    Hoorn's    method, 

960 
Wiegand-Martin  meth- 
od, 950 
After-pains,  128,  131 
in  puerperium,  324 
Agalactia,  213,  887 
sjTnptoms,  888 
treatment,  888 
Agglutinins,  827 
Aggressins,  827 

Ahlf eld's   hot-water-alcohol 
method  of  sterilization  of 
hands,  273 
method    of    expressing    pla- 
centa, 314 
table  of  infant  feeding.  338 
Air-embolism  as  cause  of  sud- 
den death  in  labor,  793 
Air-passages,    clearing,    in 
phyxia  neonatorum,  805 
Albuminuria  in  labor,  135 
in  new-born  infant.  331 
in  pregnancy, 108,  369 
Alcohol  in  pregnancy,  225 
Alimentary  tract,   diseases 

pregnancy,  492 
Alkahs  in  eclampsia,  367 
Amblyopia  in  pregnancy,  506 
Amnion  of,  52 
anomalies  of,  562 
development,  44 
diseases   of,   abortion 

417 
navel,  334 
Amnionitis,  562 
Amniotic  caAnty,  37,  44 

fetus  outside,  475 
Ampullary    layer    of    uterine 
decidua,  35 
pregnancy,  385 
Amputation      of      breasts     in 
eclampsia,  368 


as- 


in 


from, 


1030 


INDEX 


Amyl  nitrite  in  eclampsia,  367 
Anaerosis  of  new-born  infant, 
797.       See     also     Asphyxia 
neonatorum. 
Anchoring  villi,  40,  41,  42 
Anemia  in  pregnancy,  374 
pernicious,     in     pregnancy, 
374 
Anencephalus,  539 
Anesthesia  a  la  reine,  295 
cliloral,  in  labor,  295 
chloroform,  in  labor,  294 
ether,  in  labor,  294 
in  inducing  labor  in  eclamp- 
sia, 364 
in  labor,  293 

choice  of  anesthetic,  294 
conditions,  294 
history,  294 
indications,  294 
method  of  administration, 

294 
objections  to,  293 
obstetric  degree,  293 
surgical  degree,  293 
in  operations,  898 
morphin,  in  labor,  295 
nitrous   oxid   gas,   in  labor, 

295 
regional,  in  labor,  295 
scopolamin-morpliin,   in    la- 
bor, 295 
Anesthetics     in     hyperemesis 

gravidarum,  350 
Angioma  of  placenta,  557 
Angular    pregnancy,     extra- 
uterine pregnancy  and,  dif- 
ferentiation, 391 
Anorexia  in  labor,  134 

in  pregnancy,  107 
Antefixation       of       pregnant 
uterus,  401 
treatment,  403 
Anteflexion  of  pregnant  uterus, 
398 
treatment,  399 
Antenatal    therapeutics,  249 
Antepartum  bath,  276 

douche,  276 
Anteversion        of        pregnant 
uterus,  398 
treatment,  399 
Antisepsis  in  labor,  273 

in  second  stage  of  labor,  317 

in  third  stage  of  labor,  317 

Antistreptococcus     serum     in 

puerperal  fever,  880 
Anus,    feces    issuing   from,    in 
operations,  care  of,  905 
fissure  of,  in  labor,  650 
in  puerpcrium,  896 
Aorta,  compression  of,  in  post- 
partum   hemorrliagc,    781 
Appendicitis,      ectopic      preg- 
nancy    and,     differentia- 
tion, 393 
in  pregnancy,  493 
diagnosis,  493 
treatment,  494 
pyelo-ureteritis     and     stone 
and,  differentiation,  500 
Appendix,  1021 
Appetite  in  pregnancy,  107 
Applicators,  323 


Arcus  tendineus  fasciae  pelvis, 

160 

musculi  levatoris  ani,  161 

Areola  in  pregnancy,  101,  253 

Arm,  prolapse  of,  in  shoulder 

presentation,  626 
Arms  and  feet,  prolapse  with 
head,  634,  635 
treatment  634 
in  nape  of  neck,  635 
Arteries  of  uterus,  74 
umbihcal,  44,  51,  52 
Artery,  cervicovaginal,  75 
puerperal,  75 
uterine,  74 
Articles,    list    of,    needed    for 

labor,  232      _      _ 
Artificial     respiration    in    as- 
phyxia neonatorum,  807 
Asepsis  in  labor,  273 
in  puerperium,  321 
in  second  stage  of  labor,  317 
in  tliird  stage  of  labor,  317 
of  environment  in  labor,  277 
of  patient  in  labor,  275 
of  physician  in  labor,  273 
Asphyxia  in  breech  presenta- 
tion, 613 
Hvida,  801 
neonatorum,  797 
after-treatment,  809 
artificial  respiration  in,  807 
catheterization  of  trachea 

in,  805 
clearing    air-passages    in, 

805 
De  Lee's  treatment,  808 
diagnosis,  800,  802 
etiology,  798,  799  _ 
external    stimulation    in, 

805,  806 
inouth-to-lung  insufflation 

in,  807 
pathology,  799 
Prochownick's  method  of 
resuscitation     in,     806, 
807 
prognosis,  803 
Schultze's    swingings    in, 

807,  808 
symptoms,  800 

after  delivery,  801 
before  delivery  of  child, 
800 
treatment,  after  delivery, 
804 
before  birth,  804 
of  fetus,  706 
causes,  477 
pallida,  801 
Assimilation  pelvis,  679 
asymmetric,   682 
diagnosis,  683 
high,  680 
low,  680 
lower,  079 

midplanc  contracted,  682 
transversely      contracted, 

681 
upper,  679 
Assistants  for  operation,  898 
Asymmetry  of  Stadtfeld,    144 
Asynclitism,    182 
anterior,  182 


Asynclitism,  posterior,  182 
Atelectasis  of  placenta,  556 
Atony  of  placental  site,  759 
uterine,   770 
in  labor,  567 
Atrophy,  acute  yellow,  of  liver 
in  pregnancy,  370 
diagnosis,  371 
pathology,  370 
prognosis,  371 
symptoms,  370 
treatment,  371 
lactation,  in  puerperium,  212 
Attitude  of  fetus,  169 
definition,  173,  579 
deflexion,  174,  585 

etiology,  586 
improving,  932 
in  shoulder  presentation, 

617 
military,  583 
Auscultation  in  labor,  284 
Auscultatory  signs  in  diagnosis 

of  pregnancy,  260 
Autoinfection      in      puerperal 

fever,  821 
Autotransfusion  in  postpartum 

hemorrhage,  790 
Axis  of  parturient  canal,  166 
of  uterus  in  pregnancy,  83 
pressure,  fetal,  150 
Axis-traction  forceps,  983 
application,  986 
conditions  for,  985 
indications,  985 
principle  of,  983 
Tarnier's,  984 


Baby,  blue,  64 

Bacillus,    colon,    in    puerperal 
fever,  829 
tetanus,  in  puerperal  fever, 

830 
typhosus  in  puerperal  fever, 
830 
Back   presentation,    615.     See 
also  Presentation,  transverse. 
Bacteremia  in  puerperal  fever, 
828,  852 
pathology,  853  * 

symptoms,  854 
metastatic,      in      puerperal 
fever,  853,  856 
Bacteria  in  causation  of  puer- 
peral fever,  821 
in  liquor  amnii,  53 
in  vagina,  211,  822 
Bacterial  endometritis  in  preg- 
nancy, 519 
Bacterium    coli    commune    in 

puerperal  fever,  829 
Bacteriuria  in  pregnancy,  501 
Bag  of  waters,  121 

puncture  of,  induction  of 
premature     labor     by, 
1016 
rupture,  122,  291 
determining,  286 
in   transverse  presenta- 
tion, 624,  625 
Balloon  dilators,  911 
Ballottement,  259 


INDEX 


1031 


Bandage  of  limbs  in  posti):ir- 

tuni  hcinorriiagc,  790 
Bandl'.s   cuutnictioii   riajj;,   74S 
Barnes'    hag   for  tlilatation  of 
cervix,  911 
forceps,  9<S:3 
Bartholinitis  in  pregnancy,  514 
Basedow's     disease    in     preg- 
nancy, 491 
treatment,  491 
Basiotribe,  Tarnier's,  lUOG 
Bath,  antepartum,  27G 

of  new-born  infant,  336 
Bathing  in  pregnancy,  228 
Battledore  i)lacenta,  51 
Baudelocque-Breisky  pelvime- 
ter, 233 
Baudelocquc's  diameter,  meth- 
od of  obtaining,  235 
Baumers'  forceps,  962 
Bed  for  symphysiotomy,  926 

in  labor,  277 
Bernheim  cannulae,  790 
Biischiatic  diameter  of  pelvis, 

measurement,  242 
Bimanual  version,  936 

in  transverse  presentation, 
936 
Binder,    abdominal,    in    puer- 

perium,  327 
Biparietal  diameter,  169 
Bipolar  version,  934 
Birth-canal,    advancement    of 
head    along,   internal    ex- 
amination for  determining, 
28S 
preparation  of,  164 
Bisacromial  diameter  of  fetus, 

169 
Bisiliac  diameter  of  fetus,  169 
Bitemporal  diameter,  169 
Bituberal   diameter   of   pelvis, 

measurement,  242 
Bladder,    calculi    in,    dystocia 
due  to, 649 
in  pregnancy,  532 
diseases  of,  dystocia  due  to, 

649 
dislocation  of,  in  labor,  763 
full,  dystocia  due  to,  649 

in  labor,  763 
gangrene,  in  retroversion  of 
pregnant  uterus, 
408 
treatment,  413 
in  labor,  134 

care  of,  291 
in  pregnancy,  82,  96 
in  puerperium,  221 
care  of,  322 

catheterization  of,  method, 
322 
in   retroflexion   of   pregnant 

uterus,  407 
injuries  to,  in  labor,  763 
irritable,  725 

as  sign  of  pregnancy,  253 
pressm-e  necrosis  of,  in  labor, 

763 
tumors  of,  dystocia  due  to, 
649 
in  pregnancy,  532 
worms,  544 
Blastodermic  vesicle,  30 


IMastomo-deciduo-cliorion  cell- 

ulare,  548 
Blastula   formation   of    ovum, 

30 
Hlazek  twins,  540 
lilindness  in  ])regnancy,  505 
Blood,    changes    in,  in    preg- 
nancy, 103 
in  i)uerperium,  220 
diseases  in  pregnancy,  374 
fetal,  61 

in  new-born  infant,  329 
mole,  434 

transfusion    of,   in    postpar- 
tum hemorrhage,  790 
Blood-corpuscles  of  fetus,  61 
Blood-sui)ply  of  uterus,   74 
Blue  babies,  64 

Bluish  discoloration  of  vulva, 
vestil^ule,     and     vagina     in 
pregnancy,  254 
Bone  forceps,   Mesnard-Stein, 
1010 
frontal,  shape  of,  169 
Bone-marrow,    changes   in,    in 

pregnancy,  104 
Bones,    changes    in,    in    preg- 
nancy, 109 
of  extremities  of  fetus,  frac- 
tures, in  labor,  814 
of  fetus,  changes  in,  due  to 

syphilis,  487 
parietal,  shape  of,  169 
pehdc,  injuries  of,  in  labor, 

765 
softening  of,  in  pregnancy, 

504 
Wormian,  168 
Bonnaire's      classification      of 
bony  pelves,  654 
method  of  manual  dilatation 
of  cervix,  910 
Bossi's  dilator,  914 
Botalh's  duct,  63 
Bougies,   induction   of  prema- 
ture labor  with,  1016 
Bowels  in  labor,  care  of,  291 
in  new-born  infants,  care  of, 

337 
in  pregnancy,  226 
in    puerperal    fever,    treat- 
ment, 878 
in  puerperium,  care  of,  322 
Brachiotomy,  1005 
Brachyccphalus,  169 
Brain,  changes  in,  in  eclampsia, 
358 
compression  of,  as  cause  of 
asphj'xia  neonatorum,  799 
hemorrhage  of,  in  new-born 

infant,  811 
of  fetus,  injuries,  706 
Braun's  bag  for  dilatation  of 
cervix,  911 
cord  repositor,  632 
cranioclast,  1006 
hook,  1011 
trephine,  1006 
Braxton     Hicks'     method     of 
bipolar  version  in  shoul- 
der presentation,  625 
sign  of  pregnancy,  259 
version,  942,  944 

in  placenta  priBvia,  454 


Breasts,  abscess  of,  892 
treatment,  895 
aMii)utation,     in     eclampsia, 

3(i8 
caked,  890 

care  of,  in  pregnancy,  230 
changes   in,  in   diagnosis  of 
pregnancy,  253 
in  puerperium,  213 
diseases  of,   in  puerperium, 

884 
engorgement  of,  884 
symptoms,  884 
treatment,  885 
enlargement,  in  puerperium, 

213 
functional    disturbances,    in 

puerperium,  884 
in  pregnancy,  100 
in  puerperium,  care  of,  323 
inflammation  of,  892 
injection  of  air  and  oxygen 

into,  in  eclampsia,  368 
massage  of,   885,   886,  888, 

889 
of  new-born  infant,  335 
secretion    of,    in    new-bom 

infant,  335 
shape,  in  pregnancy,   102 
striai  on,  in  pregnancy,  101 
supernumerary,  102 
Breech  delivery,  946,  947 

abnormal  rotation  in,  958 
during  fourth  act,  960 
during  third  act,  959 
anterior  liip,  951 
arms,  952,  953,  954 
complete,  948 
compUcations  dm'ing  first 
act,  951 
fourth  act,  955 
second  act,  952 
third  act,  952 
offered    by    soft    parts, 
961 
first  act,  948 

complications    during, 
951 
manual  method,   947 
Pinard's  method,  951 
posterior  hip,  952 
retraction  of  perineum  in, 
958 
presentation,   174,   176,  603 
abnormal  rotation  of  back 

in,  609 
asphj-xia  in,  613 
cephalic  version  in,  942 
clinical  coui-se,  610 
complete,  176,  605 
descent  in,  606 
deviated,  615 
diagnosis,  612 
double,  605 
etiolog}',  603 

external  restitution  in,  607 
flexion  in,  606,  607 
■)foothngs,  605,  608 

prolapse     of     cord     in, 
treatment,  634 
frequency, 178,  603 
incomplete,  176,  605 
internal  anterior  rotation 
in,  606 


1032 


INDEX 


Breech     presentation,     latero- 
flexion  in,  607 
mechanism,  603,  605,  606 

unusual,  60S 
molding  in,  612 
plastic  changes  in,  612 
prognosis,  613 
prolapse  of  cord  in,  treat- 
ment, 634 
single,  176,  605,  610 
symptoms,  610 
treatment,  614 

manual  aid  in,  615 
WTy-neck  in,  612 
Bregma,  fetal,  168 
Breisky's  method  of  measuring 
sacropubic     diameter,     243, 
244 
Breus'  forceps,  983 
Broad  hgaments  in  pregnancy, 

95 
Brow  presentation,  176,  589 
correction  of,  932 

De  Lee's  method,  933, 
934 
diagnosis,  591 
forceps  in,  982 
frequency,  589 
mechanism,  589,  590 
molding  in,  592 
prognosis,  600 
treatment,  592 
Brushing   surface   of   endome- 
trium in  puerperal  fever,  876 
Budin's  classification  of  bony 

pelves,  656 
Bulbocavernosus    muscle,    161 
Burton's  perforator,  1006 


Cadxjca,  33 
Caked  breast,  890 
Calcification  of  placenta,   556 
Calculi,   vesical,   dystocia  due 
to,  649 
in  pregnancy,  532 
Cannula,  Bernheim,  790 
Caput    ballitabile,     177,     193, 
196,  584 
mobile,  177,  196 
ponderosum,  177,  196 
succedanc^lim,  143,  144,  809 
cephalhematoma  and,  dif- 
ferentiation, 810 
in  contracted  pelvis,  708 
Carcinoma  of  cer\'ix  in  preg- 
nanc}',  527 
diagnosis,  528 
treatment,  528 
of  rectum  in  pregnancy,  532 
syncytiale,  548 
Caries,   dental,  in   pregnancy, 

492 
Caruncula;      myrtiformes      in 

puerperium,  210 
Carus,  curve  of,  166 
Catamenia,  11 
Cathartics  in  eclampsia,  366 
Catheter,  tracheal,  804 

method  of  introducing,  805 
Catheterization   of  bladder  in 
puerperium,    method,  322 
of  trachea  in  asphyxia  neo- 
natorum, 805 


Caul,  122 

Ceinture  eutocique,  624 
Cells,  decidual,  32,  35 
giant,  syncytial,  36 
lutein,  7 
SertoU's,  20 
Cellulitic  mastitis,  893  _ 
Cellulitis,  pelveocrural,  in  puer- 
peral fever,  860 
Centi-um  perineale,  162 

tendineum  perinei,   162 
Cephalhematoma,  809 

caput  succedaneum  and,  dif- 
ferentiation, 810 
Cephahc  presentation,  174, 176. 
See  also  Head  'presenta- 
tion. 
version,  934 

breech  presentation,  942 
in  transverse  presentation, 
624 
Cephalometer,  Ferret's,  268 
Cephalotribe,  Lusk's,  1006 
Cephalotrypsis,  1005 
Cephalotryptor,  1005 
Cerebral  hemorrhage  in  new- 
born infant,  811 
hernia,  539 
Cervical  abortion,  421 

canal,    artificial    dilatation, 
910.     See  also  Cervix,  dila- 
tation of. 
ganglion,  great,  78 
muscles  of  fetus,  injuries,  in 

labor,  812 
pregnancy,  421 
Cervicovaginal  artery,  75 
Cervix,  carcinoma  of,  in  preg- 
nancy, 527 
diagnosis,  528    ■ 
treatment,  528 
changes  in,  in  pregnancy,  78, 
79,  86 
in  puerperium,  208 
dilatation    of,    by   hysteros- 
tomotomy,  914 
degree,  in  labor,  286 
Harris'  method,  910 
in  labor,  120 
incisions  for,  914 
induction     of     premature 

labor  by,  1016 
machine,  914 
manual,  910 
vaginal    cesarean    section 

for,  916 
with  colpeurynter,  911 
with  metreurynter,  911 
edema  of,  in  labor,  415 
effacement  of,  in  labor,  120 

degree,  286 
enlargement     of,     in     preg- 
nancy, 415 
erosions  of,  in  pregnancy,  516 
forceps,  De  Lee's,  746 
hypertrophic   elongation,   in 

labor,  414 
hypertrophy     of,     in     preg- 
nancy, 516 
incisions  in,   for  purpose  of 

dilatation,  914 
laceration  of,  in  labor,  745 
prognosis,  745 
treatment,  745 


Cervix,  location,  at  term,  91 
machine  dilatation,  914 
manual  dilatation,  910 
median  portion,  87 
opening,  operations  for,  907 
packing,  909 

relation,    to    lower    uterine 
segment,     in    pregnancy, 
91 
rigidity  of,  dystocia  due  to, 
644 
diagnosis,  646 
treatment,  646 
in  labor,  577 
softening  of,  in  pregnancy, 

87,  255  _ 
spasm  of,  in  labor,  577 
stricture  of,  in  lalaor,  577 
supravaginal  portion,  87 
tapir-nosed,  648 
vaginal  portion,  87 
Cesarean  section,  990 
adhesions  in,  994 
after-treatment,  995     , 
complications,  994 
conditions,  992 
definition,  990 
drainage  of  uterus  in,  995 
extraperitoneal,  1000 
in  contracted  pelvis,  721 
indications,  1002 
for  prolapse  of  cord,  634 
hemorrhage  in,  995 
historic  sketch,  990 
in  abruption  of  placenta, 

444,  991 
in  contracted  pelvis,  991 
in  eclampsia,  991 
in   placenta  praevia,   460, 

991 
indications,  991 
infection  in,  995 
instruments  for,  993 
on  dying  or  dead  woman, 

1002 
placenta  in,  994 
Porro,  997 

indications,  997 
technic,  998 
prognosis,  996 
Sanger's,  990 
sterilization  in,  996 

methods,  996 
technic,  992 
vaginal,  916 
dangei-S  of,  919 
in  abruption  of  placenta, 

444 
in  placenta  praevia,  461 
indications,  920 
preparations  for,  916 
technic  of,  916 
Chadwick's  sign  of  pregnancy, 

253 
Chamberlen  forceps,  962 
Champetier  de  Ribes'  bag  for 

dilatation  of  cervix,  911 
C'hange  of  life,  18 
Chart,  child,  1027,  1028 
labor,  1023-1025 
puerperium,  1025,  1026 
Chassagny's  bag  for  dilatation 
of  cervix,  911 
forceps,  962 


INDEX 


1033 


Chest  of  fcdis,  circuiiifcrciHic, 

If)!) 
Chief  pliuic  of  pelvis,  I'jC) 
Child,   iiceidents   to,    in   hibor, 
797 
dangers  of  i)l;iceiit;i  pni'via 

to,  44<) 
injuries  to,  in  labor,  .S09 
organism,  effect  of  labor  on, 

138 
pregnancy  and,  223 
stone,  3S7 
Chills  in  labor,  127,  133 

in    puerperal    fever,     treat- 
ment, 879 
nervous,  in  puerperium,  324 
physiologic,   in   puerperium, 
218 
Chin,    arrested    rotation,    for- 
ceps in,  981 
position,      persistent      pos- 
terior, 596 
Chloasma  uterinum,  110 
Chloral  anestiu'sia  in  labor,  295 

in  eclampsia,  3()tJ 
Chloranciuia  in  pregnancy,  103 
Chloroform  anesthesia  in  labor, 
294 
in  eclampsia,  366 
Queen's,  295 
Chlorosis  in  pregnancy,  374 
Cholecystitis     in      pregnancy, 

493 
Cholera  in  pregnancy,  478 
Chondrocraniiun,  167 
ChontlrotlystrophiafoctaUs,  535 
Chorea  gravidarum,  371 
prognosis,  372 
treatment,  372 
Chorio-angiomata,  557 
Chorio-epithelioma,  548 
clinical  course,  550 
diagnosis,  550 
etiology,  548 
pathology,  549 
prognosis,  550 
symptoms,  550 
treatment,  551 
Chorion,  diseases  of,  544 
al)ortion  from,  417 
epithelioma,  548 
frondosum,  39 
h\'datidiform    degeneration, 

'  544 
Iteve,  39,  49 
Chromatin,  29 
Cilia  of  syncytium,  38,  39 
.  Circulation  after  birth  of  child, 
64 
fetal,  61 

changes  in,  after  liirth,  140 
in  lal)or,  133 
in  ne\v-liorn  infant,  330 
placental,  scheme  of,  42 
vitelline,  61 
Circulatory  system,  changes  in, 
in  eclampsia,  359 
changes  in,  in  pregnancv, 

104 
diseases,     in     pregnane^-, 
487 
Cirrhosis  of  placenta,  551 
Clavicle  of  fetus,  fractures,  in 
labor,  814,  815 


Cleansing,  1 1 
Cleidolomy,  1005,  1009 
Climacteric,  18 
("liseometry,  244 
("losing     ring     of     Nitabuch- 
W  inkier,  36 
of  Waldeyer,  43,  48 
Coccygodynia  in  lai)or,  7()7 
Coccyx,   injuries  of,   in   labor, 
766 
treatment,  767 
Coiling  of  umbilical  cord,  558 

diagnosis,  559 
Coitus  in  pregnancy,  224,  227 
Colil)acillose  gravidique,  829 
Colic,  prostitutes',  382 
Collai)se  in  lal)or,  793 
diagnosis,  795 
symptoms,  795 
treatment,  795 
Collargol    in    puerperal    fever, 

879 
Colles'  law,  485 
Colon    bacillus    in    puerperal 

fever,  829 
Colostrum,  102,  214 

corpuscles,  214 
Colpeurynter,  dilatation  of  cer- 
vix with,  911 
in  placenta  pra3\'ia,  456 
Colpohysterotomy,  916 
Compact  layer  of  uterine  de- 

cidua,  32,  34,  47 
Compression  of  aorta  in  post- 
partum hemorrhage,  781 
of  brain  as  cause  of  asphyxia 

neonatorum,  799 
of     uterus     in     postpartum 
hemorrhage,  783 
Concealed       hemorrhage       in 
abruption    of    placenta,  439 
Conception,  20 

influence  of  season  of  year 

on,  27 
time  of,  26 

when  most  Ukely  to  occur, 
26 
Cone  d'attraction,  28 
Confinement,      prediction      of 

day,  267 
Congestion,  pelvic,  as  sign  of 

pregnancy,  253 
Conglutinatio    orificii   externi, 

dystocia  due  to,  644 
Conjugata  diagonahs,  154 

vera,  153 
Conjugate  diameter,  obstetric, 
154 
of    pelvis,     measurement, 
242 
Conjuncti^■itis,   gonorrheal,   in 
new-born       infant, 
308 
prevention,  308 
Constipation,    fever    from,    in 
puerperium,  896 
in  pregnancy,  107 
treatment,  226 
in  puerperium,  222 
Contraction,  passive,  of  uterus, 
619 
ring,  93 

in  transverse  presentation, 
621 


Contraction     ring     of     I'aiidl, 

(^'onvulsions  in  pregnancy,  353. 

Sec  also  Ecldini/aifi. 
Co[)ulation,  22 
Cord,  umbilical.     See   Umhili- 

ad  ami. 
Coronary  suture,  167 
Corpus  albicans,  8 

luteum,  formation,  7 
functions,  9 
true,  9 
verum,  9,  10 
Corpuscl<;s,  colostrum,  214 
(Dorset  in  pregnancy,  225 
Cotton  spitting  in  pregnancy, 

107 
Cotyledons,  48 
Coutouly's  forceps,  962 
Coxalgic  pelvis,  670 
Cradle,  phlegmasia,  861 
Cramp  pains,  573 
treatment,  576 

in  leg  in  labor,  134 
Cranioclasis,    1005.     See    also 

Craidotonijj. 
Cranioclast,  Braun's,  1006 

De  Lee's,  1008 
Craniopagus,  541 
Craniorachischisis,  538,  539 
Cranioschisis,  539 
Craniotomj^,  1005 

conditions  in,  1007 

in  contracted  pelvis,  722 

in  pelvic  contraction,  713 

indications,  1005 

on  dead  child,  indications, 
1005 

on  hving  child,  indications, 
1006 

technic,  1007 
Cravings  in  pregnancy,  107 
Crede's  method  of  expressing 
placenta,  312,  313 

ointment  in  puerperal  ievev, 
879 

treatment   of   eyes   of   new- 
born infant,  308 
Criminal  abortion,  1017 
Crista  lactea,  100 
Cross  of  death,  850,  869 
Crying  of  fetus,  801 
Cumulus  oophorus,  4 
Curage  of  uterus  in  puerperal 

fever,  876 
Curet,  De  Lee's  uterine,  427 
Curetage   of    uterus   in   inevi- 
table abortion,  427 
in  puerperal  fe\'er,  876 
Curve  of  Cams,  166 
Cycle,  menstrual,  13 
Cj'clocephalus,  539 
Cyclops,  539 

Cystitis  in  pregnancy,  501 
Cystocele,  dystocia  clue  to,  649 

in  labor,  740,  763 

in  pregnane}-,  414 
Cysts,   echinococcus,   in   preg- 
nancy, 532 

of  placenta,  .557 

of  umlDilical  cord,  560 

ovarian,  in  pregnancy,  529. 
See  also  Ovarian  tumors  in 
-pregnancy. 


1034 


INDEX 


Dammerschlaf,  295 
Deafness  in  pregnancy,  106 
Death   of    fetus    as    cause    of 
abortion,  417 
causes,  476,  477 
changes  in  o^nim  after,  in 

abortion,  434 
diagnosis,  265 
s^^nptoms  and  signs,  265 
of  mother,   effect   on  fetus, 

536 
sudden,  in  labor,  793 
etiology,  793,  794 
symptoms,  795 
Decapitation,  1005,  1012 
hook,  1012 
instruments  for,  1011 
scissors,  1011 
technic,  1013 
Decapsulation,       renal,       in 

eclampsia,  368 
Decidua,  33 

ampullary  layer,  35 
basahs,  33,  35 
capsularis,  33,  35 
compact  layer,  32,  34,  47 
glandular  layer,  35 
gi'a\4ditatis,  32 
menstruationis,  32 
reflexa,  33,  35 
serotina,  33,  35 
spongy  layer,  32,  35 
subchorialis,  43,  48 
vera,  34 

at  term,  36,  37 
growth,  36 
Decidual  cells,  32,  35 
endometritis,  516 
catarrhal,  517 
diagnosis,  518 
glandular,  517 
interstitial,  517 
polyposa,  517 
treatment,  518 
tuberosa,  517 
Deciduoma   malignum,    548 
Deep  transverse  arrest,  forceps 

in,  974 
Deflexion  attitudes,  174,  585 

etiology,  586 
Deformities,  congenital,  537 

of  parturient  canal,  509 
Degeneration,  hydatidiform,  of 

chorion,  544 
De  Lee's  cervix  forceps,  746 
cranioclast,  1008 
method    of    changing    occi- 
pitolajva     posterior    to 
occipitolajva       anterior 
position,  931 
of  correcting  brow  presen- 
tation, 933,  934 
face  presentation,   933, 
934 
of  st  orilizing  rubber  gloves, 

1021 
of  treating  asphyxia  neo- 
natorum, 808 
obstetric  satchel,  270 

specula,  741 
operating  telescope,  903 
packing  forceps,  776 
portable  douche-can,  776 
sterilizer,  903 


De  Lee's  treatment  of  inevit- 
able abortion,  426 
uterine  curet,  427 
Dehvery,     breech,     946,    947. 
See  also  Breech  delivery. 
of  head,  302 

of  placenta,  Crede's  method, 
312,  313 
Duncan's  mechanism,  200, 

201 
hemorrhage    in,    mechan- 
ism of  control,  203 
mechanism,  199 
Schultze's         mechanism, 
200,  201 
of  shoulders,  304 
operations  of,  946 

examination     of     patient 

after,  898 
general  conditions,  946 
in     private     houses,     ar- 
rangement of  room, 
900 
preparations,  899 
of  patient,  900 
indications,  946 
preparing  vagina  and  pel- 
vic floor  for,  920 
postmortem,  795 
Denman's  method  of  sponta- 
neous evolution,  620 
Denominator,  579 
Dental  caries  in  pregnancy,  492 
Depression,  groove,  of  skull  of 

fetus,  707 
Descent  in  occipital  presenta- 
tion, 183 
Destructive  moles,  545 
Determination  of  sex,  68 
Deviated  breech  presentation, 
615 
head  presentation,  615 
Diabetes,  effects  of,  on  preg- 
nancy, 502 
effects  of  pregnancy  on,  502 
in  pregnancy,  502 
diagnosis,  502 
prognosis,  503 
treatment,  503 

after  viability  of  child, 

503 
before    child   is   viable, 
503 
physiologic,    of    pregnancy, 
108 
Diagnosis  before  operation,  897 
Diameter,   Baudelocque's   me- 
thod of  obtaining,  235 
biischiatic,   of  pelvis,  meas- 
urement, 242 
biparictal,  169 
Ijisacromial,  169 
bisiliac,  169 
bitemporal,  169 
bitubcral,  of  pelvis,  measure- 
ment, 242 
conjugate,    of   pelvis,   meas- 
urement, 242 
obstetric  conjugate,  154 
occipitofrontal,  169 
occipitfnnental,  169 
Diameters  of  fetal  head,  169 
of  pelvic  inlet,  153 
of  pelvic  outlet,  156 


Diameters,  sacropubic,    Breis- 
ky's  method  of  measm'- 
ing,  243,  244 
measurement  of,  242 
suboccipitobregmatic,  169 
Diaphoretics  in  eclampsia,  367 
Diaphragm,  urogenital,   161 
Diaplu'agma  pehds  rectale,  160 
Diastasis  recti  in  puerperium, 

213 
Die  Wechseljahre,  18 
Diet  in  eclampsia,  362,  363 
in  hyperemesis  gra\ddarum, 

350 
in  labor,  291 
in  pregnancy,  225 
in  puerperal  fever,  879 
in  puerperium,  321 
Prochownick's,    to    restrain 
growth  of  fetus,  715 
Digestion,  fetal,  physiology,  67 
Digestive  tract,  changes  in,  in 

pregnancy,  106 
Dilatateur  intrauterin,   911 
Dilatation  of   cer\dx  by  hys- 
terostomotomy,  914 
degree,  in  labor,  286 
Harris'  method,  910 
in  labor,  120 
incisions  for,  914 
induction     of     premature 

labor  by,  1016 
macMne,  914 
manual,  910 
vaginal    cesarean    section 

for,  916 
with  colpeurynter,  911 
of  uterus  in  emptying  uterus 
in  inevitable  abortion,  432 
sacciform,  of  pregnant  ute- 
rus, 407 
vital,  259 
in  labor,  150 
Dilator,  Bossi's,  914 
Dilators  for  dilatation  of  cervix, 

911 
Diphtheria  in  puerperal  fever, 

863 
Direction,  point  of,  579 
Discus  prohgerus,  4 
Disengagement     in     occipital 

presentation,  187 
Dislocation  of  bladder  in  labor, 
763 
of  hips,  double,  688 
diagnosis,  689 
of  ribs  in  labor,  767 
Displacements    of   pregnant 
uterus,  398 
anterior,  398 
posterior,  404 
Disposition,  change  in,  in  diag- 
nosis of  pregnancy,  252 
Disproportion  between  pelvis 
and  child  in  contracted  pel- 
vis, diagnosis,  709 
Distention   of   abdomen,    dys- 
tocia due  to,  641 
Distortion  of  pregnant  uterus, 

414 
Diuretics  in  eclampsia,  367 
Diverticula  of  uterus  in  preg- 
nancy, 514 
Dizziness  in  pregnancy,  533 


INDEX 


1035 


Dodorlcin's  nicfliod  of    lichos- 

tcotoiny,  '.)2;i 
Doli(:hoceplialii>,  HI'.) 
Dolores,  117 
ad  ptirtum,  131 
ad  .socundiun  partuin,  131 
coiKiuassantcs,  131 
post  partuin,  131 
I)ra'i)araiite.s,  131 
pra'sa^iiciitos,  131 
Double    brooch    presentation, 
605 
dislocation  of  hips,  688 

diagnosis,  089 
monsters,  537,  539 
uterus,  513 
vagina,  513 
Douche,  antepartum,  276 
hoi    uteriiu",    in   postpartum 

hemorrhage,  782 
intra-uterine,     in    puerperal 

fever,  876 
vaginal,  in  pregnancy,  228 
Douclie-can,     De    Lee's    por- 
table, 776 
Douglas'  method  of  spontane- 
ous evolution,  620 
Douleurs,  117 

Drainage  of  uterus  in  cesarean 
section,  995 
in  puerperal  fever,  877 
Dress  in  pregnancy,  225 
Drug    eruptions     in    puerper- 

ium,  377 
Drugs  in  human  milk,  216 
Dry  labor,  120,  122 
Drying  up  milk,  890 
Dubois'  scissors,  1011 
Ducamp's  cord  repositor,  632 
Ductus  Botalh,  63 

omphalomesentericus,  45 
venosus  Arantii,  62,  63 
Dudan's  cord  repositor,  632 
Di'ihrssen's   incisions,    914 
operation    of    vaginal    cesa- 
rean section,  916 
Duncan's  method  of  expressing 

placenta,  129,  200,  201 
Duration  of  labor,  132 
Dusee's  forceps,  962 
Dwarf  pelvis,  658,  659 
Dynamic  action  of  forceps,  963 
Dystocia  due  to  anomalies  of 
bonj-  pelvis,  651 
of  parturient  canal,  644 
of  pelvic  incUnation,  656 
to     conglutinatio     orificii 

externi,  644 
to  contracted  pelvis,  657 
to  cystocele,  649 
to  diseases  of  l)ladder,  649 
of  pelvic  organs,  649 
of  rectum,  649 
to  distention  of  abdomen, 

641 
to  enlargement  of  parts  of 

fetus,  638 
to  excessively  large  fetus, 
636 
course,  636 
diagnosis,  637 
etiology,  636 
prognosis,  637 
treatment,  637 


Dystocia  due   l<>   full    bladder, 
()49 
rectum,  649 
to  hydrocephalus,  638 
course,  ()39 
diagnosis,  640 
treatment,  641 
to  infantile  genitals,  648 
to  rigidity  of  cervix,  644 
diagnosis,  64(j 
treatment,  (546 
of  pelvic  floor,  647 
diagnosis,  647 
treatment,  648 
to  rigor  mortis  in  fetus,  638 
to  shoulders,  988 
treatment,  988 
to  stenosis  of  vagina,  646 
diagnosis,  647 
etiology,  646 
treatment,  647 
of  vulva,  648 
treatment,  648 
to  too  large  pelves,  656 
to  tough  membranes,  641 

treatment,  642 
to  tumors  of  bladder,  649 

of  rectum,  650 
to  vesical  calculi,  649 


Ear,    diseases,    in   pregnancy, 
506 
presentation,   posterior,   697 
Ears,  ringing  in,  in  pregnancy, 

106 
Ecarteur  uterin,  914 
Eccyesis,  381.     See  also  Extra- 
uterine pregnancy. 
Echinococcus    cysts    in    preg- 
nancy, 532 
Eclactisma,    354.      See    also 

Eclampsia. 
Eclampsia,  353 

after-treatment,  368 
alkalis  in,  367 

amputation  of  breasts  in,  368 
amyl  nitrite  in,  367 
attack  of,  354 
cathartics  in,  366 
cesarean  section  in,  991 
changes  in  brain  in,  358 
in  circulatory  system  in, 

359 
in  fetus  in,  360 
in  kidnej's  in,  359 
in  liver  in,  359 
in  lungs  in,  360 
chloral  in,  366 
chloroform  in,  366 
chnical  course,  354 
convulsions  in,  cause,  358 
diagnosis,  360 
diaphoretics  in,  367 
diet  in,  362,  363 
diuretics  in,  367 
elimination  in,  366 
epilepsy  and,  differentiation, 

360 
etiology,  356 

of  the  con^'ulsion,  358 
excretion  in,  method  of  in- 
creasing, 363 
forms  of,  353,  356 


Eclampsia,  hirudin  in,  368 

history,  354 

hot  packs  in,  367 

hysteria  and,  differentiation, 
3(50 

in  contracted   pelvis,   treat- 
ment, 724 

induction   of  labor  in,  363, 
364,  3(55 
anesthesia  in,  3(54 

injection  of  air  and  oxygen 
into  breasts  in,  368 

lumbar  puncture  in,   367 

morphin  treatment,  366 

narcotics  in,  366 

nephritic,  356 

oxygen  in,  367 

pain  in  epigastrium  in,  354 

parathyroid  extract  in,  367 

parturientium,  353 

pathologic  anatomy,  358 

poisoning    and,    differentia- 
tion, 360 

prevention,  362 

prodromes  of,  354 

prognosis,  360 

prophylaxis,  362 

refiectorica,  356 

renal  decapsulation  in,  368 

salt  solution  in,  367 

skin  in,  care  of,  363 

thi'omboses  in,  360 

thyroid  extract  in,  367 

treatment,  362,  364 
adjuvant,  365 
preventive,  362 

trephining  skull  in,  367 

uremia  and,  differentiation, 
360 

venesection  in,  367 

veratrone  in,  367 

veratrum  \nride  in,  367 

without  con^^alsions,  356 
Eclampsisme,  354 
Ectoblast,  30 
Ectoderm,  3(),  37 
Ectopia  cordis,  539 

vesics,  539 
Ectopic  pregnancy,  381.     See 

also  E.vira-uterine  pregnancy. 
Eczema  in  pregnancy,  534 

in  puerperium,  377 
Edema  in  pregnancy,  106,  376, 
534 

of  cervix  in  labor,  415 

of  placenta,  556 
Effacement  of  cer^-ix  in  labor, 

120,  286 
Egg  balls,  3 
Elongation,    hjTjertrophic,    of 

cer\'ix  in  labor,  414 
Embolism,    air-,    as    cause    of 
sudden  death  in  labor,  793 

pulmonary,  as  cause  of  sud- 
den death,  793 
Embrj^o,      development,      54. 

See  also  Fetus,  development. 
Embryonal  nucleus,  29 
Emhrvotome,  Tarnier's,  1011 
Embryotomy,  1005,  1012 

instruments  for,  1009 
Emotions,     influence     of,     on 

quantity  and  quality  of  milk, 

216 


1036 


INDEX 


Endoblast,  30 

Endocarditis,  septic,    in   puer- 
peral fever,  856 
Endometritis  as  cause  of  abor- 
tion, 417 
decidual,  516 
catarrhal,  517 
diagnosis  of,  518 
glandular,  517 
interstitial,  517 
polyposa,  517 
treatment  of,  518 
tuberosa,  517 
in     pregnancy,     gonorrheal, 
519 
syphihtic,  519 
in  puerperal  fever,  834 
diagnosis,  839 
pathology,  835 
symptoms,  838 
Endometrium,    brushing    sur- 
face of,  in  puerperal  fever, 
876 
changes    in,   in    pregnancy, 
34 
in  puerperiima,  208 
Endotoxins,  827 
Engagement,     degree     of,     in 
presentation,  177 
criteria  of,  196,  981 
in  occipital  presentation,  181 
of  head,  177 

deeply,  177 
of  obstetric  nurse,  248 
of  presenting  part  in  labor, 
283 
Engorgement  of  breasts,  884 
symptoms,  884 
treatment,  885 
Enlargement  of  cervix  in  preg- 
nancy, 415 
of  fetus,  excessive,  dystocia 

due  to,  636 
of  parts   of  fetus,   dystocia 

due  to,  638 
of   pelvic   canal,    operations 
for,  921 
Entei'ocele,    vaginal,    in   preg- 
nancy, 414 
Entoderm,  30,  37 
Environment,    asepsis    of,    in 

labor,  276 
Epi blast,  30 

Epigastrium,    pain    in,    in    ec- 
lampsia, 354 
Epilepsy,   eclampsia  and,   dif- 
ferentiation, 360 
Episiotomy,  305 
indications  for,  305 
repair  of,  737,  738 
Epistaxis  in  pregnancy,  507 
Epithelioma,  chorion,  548 
Epithelium,  germinal,  of  ovary, 
3 
of  Waldcyer,  3 
Ergot   in   postpartum    liciiior- 

rhage,  782 
Erosions    of    cervix    in    preg- 
nancy, 516 
Eruptions,   skin,   in   new-born 

infant,  333 
Erysipelas  in  pregnancy,  478 
Erythema  multiforme  in  puer- 
perium,  377 


Erythrocytes  in  new-born  in- 
fant, 329 
in  pregnancy,  103 
Ether  anesthesia  in  labor,  294 
Eversion   of   vaginal   walls   in 

labor,  414 
Evisceration,  1005,  1013 
Evolution,  spontaneous,  619 
Denman's  method,  620 
Douglas'  method,  620 
Roederer's  method,  619 
Examination,    abdominal,    di- 
agnosis of  position  and 
presentation  by,  279 
in  labor,  279 
final,    in   puerperium,  327 
first,  in  labor,  278 
internal,  in  labor,  285 
of    patient    after    operative 

delivery,  898 
physician's,     in    pregnancy, 

233 
rectal,  in  labor,  288 
Excavation  of  pelvis,  155 
Excretion  in  eclampsia,  meth- 
od of  increasing,  363 
Excretory    functions    of    pla- 
centa, 68 
Exencephalus,  538 
Exenteration,  1005,  1013 
Exercise  in  pregnancy,  227 

in  puerperium,  326 
Exhaustion  psychoses  in  puer- 
perium, 896 
Exocelom,  44 
Exotoxins,  827 

Extension  in  occipital  presenta- 
tion, 187 
Extraction.     See  Delivery. 
Extraperitoneal   cesarean   sec- 
tion, 1000 
indications,  1002 
Extra-uterine   pregnancy,   381 
abortion  and,  differentia- 
tion, 390 
and     intra-uterine     preg- 
nancy, combined,  387 
angular    pregnancy    and, 

differentiation,  390 
appendicitis    and,    differ- 
entiation, 393 
changes  in  uterus  in,  387 
classification,  381 
clinical  course,  387 
course,  later,  386 
diagnosis,  389 
differential,  390 
direct,  after  first  trimes- 
ter, 390 
first  trimester,  389 
etiology,  381 
frequency,  382 
hematocele  in,  383 
hematoma  in,  384 
intra  -  uterine     pregnancy 
and,  flifferentiation,  389 
pathology,  382 
pregnancy   in   rctroverted 
uterus     and,      differen- 
tiation, 391 
prognosis,  394 
pyosalpinx   and,   differen- 
tiation, 392 
repeated,  387 


Extra-uterine  pregnancy,  rup- 
ture in,,  384 
treatment,  395 
symptoms,  387 
treatment,  394 
x-rays  in  diagnosis  of,  394 
Eyelids,    darkening,    in    preg- 
nancy, 111 
Eyes,  diseases  of,  in  pregnancy, 
505 
of  new-born  infant,  care  of, 
303,308,336 
injury  to,  during  labor, 
811,  987 


Face  presentation,  176,  592 
changing  of,  to  occipital, 

930,  931,  932,  933 
clinical  course,  596 
correction,  932 

De  Lee's  method,  933, 
934 
diagnosis,  597 
forceps  in,  980 
frequency,  178,  592 
mechanism,  593 

of  labor  in,  592 
plastic  changes  in,  600 
prognosis,  600 
treatment,  600 

after  _  engagement,    601 

before  engagement,  601 

Facial   paralysis   in   new-born 

infant,  811 
Facies    Hippocratica  in   peri- 
tonitis   in    puerperal   fever, 
849 
Fainting  spells  in  labor,  134 
in    pregnancy,    105,    111, 
533 
Fallopian  tubes  in  pregnancy, 

96 
False  corpus  luteum,  9 
fontanel,  168 
knots  in  umbilical  cord,  52, 

558 
pains,  279,  567 
pelvis,  152 
Fat  umbihcal  cord,  61 
Favereau's  cord  repositor,  632 
Feces,  expulsion,  in  labor,  care 
of,  302 
in  operations,  care  of,  905 
Fecundation,  20 
Feeding  new-born  infant,  337 
Feet  and  arms,  prolapse,  with 
head,  634,  635 
treatment,  634 
Fehling's  theory  of  pulse-rate 

in  puerperium,  220 
Femoral  veins,  thrombosis,  in 

puei-peral  fever,  859 
Femur   of   fetus,    fracture,    in 

labor,  815 
FertiUzation,  20 
Fetal  axis  pressure,  150 
blood,  61 

body,      diseases,      abortion 
from,  417 
palpation,  in  diagnosis  of 
pregnancy,  260 
circulation,  61 

changes  in,  after  birth,  140 


INDEX 


1037 


Fetal  (lip;ostion,  physiology,  07 
envelops,  diseases,  544 
head,     advancenieid,     along 
birth-caiial,  internal  ex- 
amination     for     deter- 
mining, "iSS 
asynclitic,  182 
bregma,  168 
changes    wrought    on,    by 

labor,  142,  11:^ 
eomprt'ssion  of,  from  for- 
ceps, 903,  904,  905 
(leli\-ery,  302 

descent,  in  occipital  pres- 
entation, 183 
determining  size,  710 
diameters,  109 
disengagement,     in     occi- 
I)ilal    presentation,    187 
engagement,  177 
deeply,  177 

in     occipital     presenta- 
tion, 181 
extension,  in  occipital  pres- 

entation,  187 
external     restitution,     in 
occipital     presentation, 
188 
flexion,  in   occipital  pres- 
entation, 183 
floating,  177 
groove  depression,  707 
in  mechanism  of  labor,  107 
injuries   to,   in  labor,  809 
molding,    in    breech  pres- 
entation, 612 
in    brow    presentation, 

592 
in  labor,  143 
median    vertex   presen- 
tation, 588 
in  occipitoposterior  po- 
sition, 582 
occiput,  168 
on  perineum,  177 
period   of   disengagement, 

177 
reduction  in  size,  in  labor, 

172 
regions,  168 

rotation,  in  occipital  pres- 
entation, 183 
internal  anterior,  in  oc- 
cipital    presentation, 
184 
shape,  169 
sinciput,  168 
sutures,  107 
synclitic,  182 
vertex,  109 
heart,  effect  of  labor  pains 
on,  138 
sounds,  58 

in    diagnosis    of    preg- 
nancy, 200 
hiccup,  59 

movements,  active,  in  diag- 
nosis of  pregnancy,  259 
passive,    in    diagnosis    of 
pregnancy,  259 
respiration,    physiology,    07 
skull.     See    Fclal    head. 
souffle  in  diagnosis  of  preg- 
nancy, 201 


Fetal  triangle,  282 
Fetus,  accidents  to,  in  labor, 
797 
asphyxia  of,  706 

causes,  477 
at  term,  56 

length,  57 

weight,  57 
attitude  of,    169.     See  also 

Attiliidc  of  fetus. 
blood,  01 

blood-corpuscles,  01 
bones  of,  changes  in,  due  to 

syphihs,  487 
cervical  muscles,  injuries,  in 

labor,  812 
changes  in,  in  eclampsia,  300 

result  of  labor,  171 
chest  of,  circumference,  109 
circulation,  61 
clavicle     of,     fractm-es,     in 

labor,  814,  815 
crying  of,  in  utero,  801 
dangers  of  placenta  prsevia 

to,  449 
death  of,  as  cause  of  abor- 
tion, 417 

causes,  476,  477 

changes  in  o\aim  after,  in 
abortion,  434 

diagnosis,  205 

symptoms  and  signs,  205 
deflexion  attitudes,  585 

etiology,  585 
delivery  of,  postmortem,  795 
development,  54 

at  term,  50 

at  various  periods,  55 

in  eighth  month,  50 

in  fifth  month,  50 

in  first  month,  55 

in  fourth  month,  50 

in  ninth  month,  50 

in  second  month,  55 

in  seventh  month,  56 

in  sixth  month,  51 

in  tenth  month,  50 

in  third  month,  50 
digestion  of,  pliysiology,  07 
diseases  of,  535 
effect  of  death  of  mother  on, 

530 
enlargement  of  parts  of,  dys- 
tocia due  to,  638 
evidences  of  life,  58 
excessively    large,     dystocia 

due    to,     630.     See    also 

Dystocia  due  to  excessively 

large  fetus. 
femur  of,  fracture,  in  labor, 

815 
fractures    in,    in    contracted 
pelvis,  708 

of  bones  of  extremities,  in 
labor,  814 
growth,  54 

restraining,  Procho'^\Tiick's 
diet  for,  715 
head.     See  Fetal  head. 
heart  sounds,  58 
hiccup,  59 
humerus     of,     fracture,     in 

labor,  S15 
in  mechanism  of  labor,  167 


Fetus,  injuries  of  brain  of,  700 

in  labor,  S09 

medicolegal  a.spect,  816 
internal  super-rcjtation,  584 
inversion  of,  178 
kidneys,  phj'siology,  68 
length,  54 

at  term,  57 
lengthening  of,  in  labor,  171 
leukocythemia,  01 
life  of,  diagnosis,  205 

preservation,  in  labor,  295 
long  l)ones,   fracture  of,   in 

labor,  810 
mental  state,  59 
military  attitude,  583 
mobihty  of,  178 
movements,  58 
mucous  membranes  of, 

changes  in,  due  to  syphi- 
hs, 485 
mutilating     operations     on, 

1005 
nourishment,  07 
organism  of,  effect  of  labor 

on,  138 
outside  amniotic  ca^^ty,  475 
overgrowth  of,  induction  of 

premature  labor  in,  1014 
paralysis  of  muscles   of  ex- 
tremities of,  in  labor,  813 
physiology,  01 

special,  GO 
plastic  changes  wrought  on, 

by  labor,  142 
position   of,    172.     See   also 

Position. 
presentation    of,    172.      See 

also  Presentation. 
prognosis  of  life  of,  in  con- 
tracted pehis,  700 
respiration,  physiology,  67 
respirator}'  action,  59 
rigor  mortis  in,  536 

dystocia  due  to,  038 
scalp   of,    pressure  necrosis, 

707 
shoulders  of,  circumference, 

109 
skin  of,  changes  in,  due  to 

syphilis,  485 
skull  of,  groove  depression, 

707 
sternocleidomastoid    muscle 

of,  rupture,  in  labor,  812 
sternomastoid  muscle,  hema- 
toma   of,    in    labor,    812, 

813 
sj-phihtic  changes  in,  485 

osteochondritis  in,  487 
trunk   of,   in  mechanism   of 
labor,  109 

injuries,  in  labor,  812 
tuberculosis  of,  480 
viscera  of,  changes  in,  due  to 
sj-pliilis,  485 

injuries,  in  labor,  813 
weight,  54 

at  term,  57 
Fever  dm"ing  labor.  796 

treatment.  790 
from   constipation   in   puer- 

perium,  890 
milk-,  213,  219,  843,  884 


1038 


INDEX 


Fever  of  pregnancy,  519 

puerperal,     817.     See     also 

Puerperal  fever. 
retention,    in   puerperal   in- 
fection, 839 
Fibers,  Luschka's,  161 
I'ibro-elastic  tissue  of  uterus, 

72 
Fibroids  of  uterus,  effects  of 
on  pregnancy,  523 
in  pregnancy,  521 
diagnosis,  524 

differential,  525  _ 
pregnancy    and,    differ- 
entiation, 525 
prognosis,  525 
treatment,  525 

in    early    pregnancy, 

525 
near  term  or  in  labor, 
526 
twins  and,  differentiation, 
469 
Fibroma    molluscum    gravida- 
rum, 376 
Fissure  in  ano  in  labor,  650 

in  puerperium,  896 
Fistula  in  labor,  763 

rectovaginal,  in  labor,  763 
Flat  pelvis,  662 

generally  contracted,  667 

mechanism,  695 
labor  in,  findings,  697 
parietal     bone     presenta- 
tion in,  696,  697 
rachitic,  663 
simple,  662 
Fleshy  mole  in  abortion,  435 
Flexion  in  occipital  presenta- 
tion, 183 
Floating  head,  177 
Flowers,  11 

FcEtus  compressus,  435,  465 
papyraceus,  435 
sanguinolentis,  435 
Follicle,  graafian,  ripening  of, 
5 
primordial,  3 
Fontanel,  anterior,  168 
false,  168 
large,  168 
posterior,  169 
small,  168 
Fontanels,  167 
lateral,  168 
Foods,  influence  of,  on  quantity 
and  quality  of  milk,  217 
to  be  avoided  in  puerperium, 
322 
Footling  presentation,  60S 

prolapse  of  cord  in,  treat- 
ment, 634 
Forceps,  961 
adaptation,  971 
application  of  blades,  970 
axis-traction,  983 
application  of,  986 
conditions  for,  985 
indications  for,  985 
principle  of,  983 
Barnes',  983 
Baumers',  962 
Breus',  983 
cephalic  curve,  963 


Forceps,  conditions  for,  966 
Chamberlen,  962 
Chassagny's,  962 
compression   of  head  from, 

963,  964,  965 
Coutouly's,  962 
De  Lee's  cervix,  746 

packing,  776 
definition,  961 
description,  963 
diameter  for,  966 
Dusee's,  962 
dynamic  action,  963 
extraction  of  head,  971 
first  act,  970 
fourth  act,  973 
front  of,  966 
function  of,  963 
Galabin's,  983 
Gregoire's,  962 
Hamon's,  962 
Hermann's,  983 
high,  966,  983 

conditions  for,  985 
in  contracted  pelvis,  718 
indications  for,  985 
technic  of,  986 
historic  sketch,  961 
in   after-coming   head,    956, 

957 
in  arrested  rotation  of  chin, 

981 
in  brow  presentation,  982 
in    deep    transverse    arrest, 

966,  974 
in  face  presentation,  980 
in  impaction  of  head,  974 
in  occipitoposterior  position, 

979 
in  transverse  arrest  in  O.  D. 

P.,  976 
in  unusual    mechanisms    of 
occipitoposterior     presen- 
tation, 974 
indications  for,  965 
injuries  to  child,  987 
injuries  to  mother,  986 
inlet,  966,  983 
Japanese,  962 
Leroyenne's,  983 
Levret's,  962 
locking,  971 
low,  966,  973 
medium,  966 

Mesnard-Stein  bone,  1010 
method  of  turning  blade,  977 
midplane,  966,  983 
Osiander's  maneuver,  982 
outlet,  966,  973 
ovum,  429 

Pajot's  mana'uver,  982 
Paifyn's,  962 
Plan's,  962 
pelvic  curve,  963 
prognosis,  986 
I'cinoval,  973 
Ritgen's  manoeuver,  973 
Rudford's,  962 
Sanger's,  983 
Santarelli's,  962 
Saxtorph's,  962 
Scanzoni-Fritsch   m  c  t  h  o  d , 

980 
second  act,  971 


Forceps,  Simpson's,  963 
shpping  of,  986,  987,  988 
axial,  987 
exaxial,  987 
Smelhe's,  962 

Tarnier's   axis-traction,   984 
technic,  966 
third  act,  971 
tissue,  729 
traction  on,  971 
two-stage  operation,  978 
varieties,  962 
Vedder's,  983 
Vienna  School,  963 
Forces  involved  in  labor,  149 
Forehead  presentation,  589 

mechanism  of  labor  in,  589 
Fossa  ovarica,  2 
Fractures  in  fetus  in  contracted 
pelvis,  708 
of   bones   of   extremities   of 

fetus  in  labor,  814 
of  clavicle  of  fetus  in  labor, 

814,  815 
of  femur  of  fetus  in  labor,  815 
of  humerus  of  fetus  in  labor, 

815 
of   long   bones    of   fetus   in 

labor,  816 
of  sternum  in  labor,  767 
Freezing  point  of  liquor  amnii, 

52 
Fritsch's   method    of   treating 
postpartum  hemorrhage,  787 
Fritsch-Scanzoni     method     of 

forceps  delivery,  980 
Frontal  bone,  shape,  169 

suture,  168 
Funic   souffle  in   diagnosis   of 

pregnancy,  261 
Funnel  inversion  of  uterus  in 
labor,  759 
pelvis,  677 
diagnosis,  678 
labor  in,  diagnosis,  701 
mechanism,  701 
Fiirbringer's  method  of  sterili- 
zation of  hands,  273 
Furunculosis    in    puerperium, 
377 


Gait  in  pregnancy,  110 

Galabin's  forceps,  983 

Galactophoritis,  893 

Galactorrhea,  886 
treatment,  887 

Gall-stones  in  pregnancy,  492 

Ganglion,  cervical,  great,  78 

Gangrene  of  bladder  in  retro- 
version of    preg- 
nant uterus,  408 
treatment,  413 
of  umbilical  cord,  334 

Gas-forming  bacteria  in  puer- 
peral fever,  831 

Gastric  indigestion  in  preg- 
nancy, 492 

Gastro-elytrotomy,  1000 

Gastroschisis,  689 

Gastrula,  30 

Gauze,  gelatinized,  packing 
uterus  with,  in  postpartum 
hemorrhage,  786 


INDEX 


1039 


Gaiizo,    lysol,    for    (uiupoiuulo, 
1U22 
sterilization,  1022 
Gelatinized      ^jauze,      packing 
uterus  with,  in   postpartum 
heniorrhaizie,  7S0 
Genitals,  external,  changes  in, 
in  puerperiuni,  209 
infantile,    dystocia    due    to, 
048 
Germinal  epithelium  of  ovary, 
3 
of  \N'aldeyer,  3 
Giant-cells,  syncytial,  36 
tJigli  saw,  924 

Gingivitis  in   pregnancy,    107, 
353 
treatment,  3")o 
Girdle,  pelvic,  in  pregnancy,  98 
Glandular     layer     of     uterine 
decidua,  35 
mastitis,  893 
Gloves,  rubber,  in  labor,  274 
sterilization  of,  1021 
De  I.ee's  method,  1021 
Glycosuria  in  pregnancy,    108 
Gonococcus  in  puerperal  fever, 

829 
Gonorrhea  in  pregnancy,   514 
diagnosis,  516 
treatment,  516 
in  puerperal  fever,  862 
symptoms,  862 
Gonorrheal    conjunctivitis    in 
new-born,  308 
pre\-ention,  308 
Graafian  follicle,  ripening,  5 
Graves'  disease  in  pregnancy, 

491 
Graviditas  exochorialis,  475 
Gravity  in  labor,  151 
Great  cervical  ganglion,  78 
Gregoire's  forceps,  962 
Groove  depression  of  skull  of 

fetus,  707 
Grossesse  angiilaire,  256 
nerveuse,  251 


Habitual  abortion,  419 
etiology,  419 
treatment,  434 
Hair,  changes  in,  in  pregnancy, 

111 
Halsted's  method  of  steriliza- 
tion of  hands,  273 
Hamon's  forceps,  962 
Hands,  steriUzation  of,  273 
Ahlfeld's     hot-water-alco- 
hol method,  273 
Fiirbringer's  method,  273 
Halsted's  method,  273 
HareUp,  539 
Harris'     method     of     dilating 

cervix,  910 
Head,    fetal.      See  Fetal  head. 
labors,  unusual  mechanism, 

579 
presentation,  deviated,  615 
frequency,  causes  of,   178 
Pajot's  law  of  accommo- 
dation in,  178 
prolapse  of  arms  and  feet 
in,  634,  635 


Head  presentation,  version  in, 
940 
conditions  necessary  for, 

941 
double  manual  method, 

941 
indications,  940 
methods,  941 
Heart,    changes    in,    in    preg- 
nancy, 104 
disease,  effect  of  pregnancy 
on,  488 
effects  of,  on  pregnancy, 

489 
in  labor,  488 

treatment,  490 

in  pregnane}',  487 

prognosis,  489 

treatment,  489 

in  puerpcrium,  488 

fetal,  effect  of  labor  pains  on, 

138 
hypertrophy,  in  pregnancy, 

104 
sounds  of  fetus,  58 
Heart-tones,  fetal,  in  diagnosis 

of  pregnancy,  260 
Hebosteotomy,  921,  923 
after-treatment,  927 
complications,  925 
conditions,  928 
Doderlein's  method,  923 
hemorrhage  in,  control,  925 
in  contracted  pelvis,  719 
indications,  927 
instruments  for,  923 
lacerations  in,  927 
needle,  924 
prognosis,  929 
subcutaneous,  925 
Hegar's  sign  of  pregnancy,  78, 

255 
Hematocele    in    extra-uterine 

pregnancy,  383 
Hematoma     in     extra-uterine 
pregnancy,  384 
mole  in  abortion,  435 
of   sternomastoid  muscle  of 

fetus  in  labor,  812,  813 
of  vagina  in  labor,  743 
etiology,  743 
prognosis,  744 
symptoms,  743 
treatment,  744 
of  vulva  in  lal)or,  743 
etiology,  743 
prognosis,  744 
symptoms,  743 
treatment,  744 
retroplacental,  199 
Hematuria  in  pregnancy,  501 
Hemophilia  in  pregnancy,  374 

treatment,  375 
Hemorrhage,    accidental,    437, 
445 
cerebral,  in  new-born  infant, 

811 
concealed,    in   abruption    of 

placenta,  439 
epidural,  in  labor,  143 
in  abruption  of  placenta,.  438 
in  cesarean  section,  995 
in  delivery  of  placenta,  me- 
chanism of  control,  203 


Hemorrhage  in  emptying  >iterus 
in  inevitable  ai;ortion,  431 
in  labor,  136 
in  placenta  pra-via,  448 
in  pregnancy,  374 
I)lacental,  554 
postpartum,  768 
adn-nalin  in,  787 
after-treatment,  789 
autotransfusioii  in,  790 
bandage  of  limbs  in,  790 
blood  transfusion  in,  790 
compression   of   aorta   in, 
781 
of  uterus  in,  783 
diagnosis  of,  774 
ergot  in,  782 
etiology  of,  768 

abnormal  blood  states, 

773 
diseases    of    blood-ves- 
sels, 773 
insufficient       retraction 
and     contraction     of 
uterus,  770 
lacerations,  769 
local,  771,  773 
Fritsch's  method  of  treat- 
ing, 787 
Henkel's  metliod  of  treat- 
ing, 788 
hot  uterine  douche  in,  782 
lacerations  in,  treatment, 

788 
late,  791 

tliagnosis  of,  792 
etiology  of,  791 
prognosis  of,  792 
treatment  of,  792 
massage  of  uterus  in,  781 
Momburg's  belt  in,  788 
packing  uterus  in,  784 
Parsenow's      method      of 

treating,  787 
pituitrin  in,  787 
prognosis  of,  775 
removal  of  placenta  in,  778 
manual   method,   778 
salt  solution  in,  789 
suprarenin  in,  787 
symptoms,  773 
general,  773 
treatment  of,  775 
after  control,  789 

removal  of  placenta, 
780 
in  tliird  stage  of  labor, 

776 
lacerations  in,  788 
preparations,  776 
preventive,  775 
routine,  781 
uterine  tamponade  in,  784 
puerperal.    See  Hemorrhage, 

posfpartum. 
retinal,  in  pregnancy,  505 
imavoidable,  437,  445 
Hemorrhoids     in     pregnancv, 

107,  379 
Henkel's   method    of    treating 
postpartum  hemorrhage,  788 
Hepatization  of  placenta,  551 
Hermann's  forceps,  983 
'  Hernia,  abdominal,  539 


1040 


INDEX 


Hernia  cerebri,  539 
in  pregnane}-,  494 
into  umbilical  cord,  561 
of  pregnant  uterus,  415 
spinalis,  539 
umbilical,  539 

utei'i     gravidi     abdominalis, 
398 
Herpes  gestationis,  376 
Hexen-]Milch,  335 
Heyernaux's     cord     repositor, 

632 
Hiccup,  fetal,  59 
Hicks'  sign  of  pregnancy,  259 
High  forceps,  9S3 

in  contracted  pelvis,  718 
stomach  in  puerperium,  213, 
230 
Hips,  double  dislocation,  688 

diagnosis,  689 
Hirst's   bag   for   dilatation   of 

cervix,  911 
Hirsuties  in  pregnancy,  376 
Hirudin  in  eclampsia,  368 
History    card    in    pregnancy, 

233 
Hodge's  manoeuver  in  occipito- 
posterior  position,  584 
sj'stem  of  pelvic  planes,  156 
Homologous  twins,  539 
Hook,  Braun's,  1011 
decapitation,  1012 
Jardine's,  1012 
Hormone,  mamma,  102 
Horseshoe  placenta,  46,  50 
Hot  packs  in  eclampsia,  367 
uterine   douche  in  postpar- 
tum hemorrhage,  782 
Hour-glass       contraction       of 

uterus,  772 
Houses,  private,  operations  in, 
arrangement  of  room, 
900 
preparations,  899 
of  patient,  900 
provisions  for  complica- 
tions, 905 
Humerus    of   fetus,    fractures, 

in  labor,  815 
Hunger,  influence  of,  on  quan- 
tity of  milk,  216 
Husband,    cause   of   puerperal 
fever,  825 
pregnancy  and,  224 
Hydatidiform  degeneration  of 
chorion,  544 
mole,  544 

clinical  course,  547 
diagnosis,  547 
etiology,  546 
prognosis,  547 
symptoms,  547 
treatment,  548 
Hydramnion,    562.     .See    also 

l^olijh  jidra  iit  n  ion . 
Hydranmios,  562 
Hydremia  in  pregnancy,  103 
Hydrocephalus,    dystocia   due 
to,  638 
course,  639 
diagnosis,  640 
treatment,  641 
Hydrorrhtt'a  gra\idarum,  417, 
518 


Hj^giene  and  conduct  of  preg- 
nancy, 223 
of  pregnancy,  225 
Hyperemesis  gravidarum,  343 
adrenalin  in,  351 
anesthetics,  350 
causes,  345 

depressomotors  in,  350 
diagnosis,  347 
diet  in,  350 
drugs  in,  350 
first  stage,  344 
induction  of  labor  in,  351 
lavage  of  stomach  in,  350 
pathologic   anatomy,   346 
prognosis,  348 
salt  solution  in,  351 
second  stage,  344 
serum  treatment,  351 
suggestion  treatment,  350 
suprarenal  extract  in,  351 
symptoms,  343 
third  stage,  344 
treatment,  349 
gynecologic,  351 
medical,  350 
obstetric,  351 
Hyperlactation,  885 
Hypertrophic     elongation     of 

cervix  in  labor,  414 
Hypertrophy  of  cervix  in  preg- 
nancy, 516 
of  heart  in  pregnancy,  104 
Hypnotism  in  labor,  295 
Hypospadias,  539 
Hysterectomy     in     puerperal 

fever,  881 
Hysteria,  epilepsy  and,  differ- 
entiation, 360 
Hysterostomotomy,  dilatation 

of  cervical  canal  by,  914 
Hysterotomy,  posterior,  in  ret- 
roversion and  retroflexion 
of  pregnant  uterus,  412 
vaginal,  916 


Icterus  gravis  in  pregnancy, 
370 
in  pregnancy,  492 
neonatorum,  333 
etiology,  334 
treatment,  334 

Ileus  in  pregnancy,  494 

tympany  of,  in  puerperium, 
896 

Iliococcygeal  portion  of  leva- 
tor ani,  161 

Immature  labor,  416 

Impaction  of  head,  forceps  in, 
974 

Impetigo  herpetiformis  in  preg- 
nancy, 37() 

Impregnation,  20 

Incarcei'ation  of  uterus  in  ret- 
roversion of  pregnant  uterus, 
407 

Incarnation,  20 

Incincta,  225 

Incisions,  Diihrssen's,  914 
in  cervix  for  purpose  of  dila- 
tation, 914 

Inclination  of  pelvis,  157 

Incomplete  abortion,  422,  423 


Incomplete  abortion,  diagnosis, 
424 
treatment,  433 
Indian  position,  716 
Indigestion,    gastric,    in   preg- 
nancy, 492 
intestinal,  in  pregnancy,  492 
Inertia  uteri,  567 
Inevitable  abortion,  422.     See 

also  Abortion,  inevitable. 
Infantile  genitals,  dystocia  due 
to,  648 
pelvis,  658 
Infarcts  of  placenta,  49,  551 
varieties,  551 
white,  of  placenta,  49, 551, 553 
Infection  in  cesarean  secliion, 
995 
in  labor,  796 
puerperal,     817.     See     also 

Puerperal  fever. 
specific,  in  puerperal  fever, 

862 
wound,  831 
Infectious   diseases,    acute,    in 
pregnancy,  476 
chronic,  in  pregnancy,  480 
Inflammation  of  breasts,  892 
Influenza  in  pregnancy,  479 
Innominate  bones,  dislocation 
of,  in  labor,  766 
lateral  pressure,  653 
transverse  tension,  652 
Insanity  in  pregnancy,  372,  373 

treatment,  373 
Insensible  labor,  91,  286 
Insertio  marginalis,  50 

velamentosa,  50 
Insertion,    abnormal,    of    um- 
bilical cord,  560 
treatment,  560,  561 
velamentous,    of    umbilical 
cord,  561 
Insomnia  in  pregnancy,  533 
Instructions    for     obstetric 

nurse,  248 
Instruments     for     operations, 
904 
for  perineorrhaphy,  729 
Insufflation,  mouth-to-lung,  in 

asphyxia  neonatorum,  807 
Intercourse.     See  Coitus. 
Interstitial  gland  in  ovary  in 
animals,  11 
pregnancy,  381,  383 
Intestinal  indigestion  in  preg- 
nancy, 492 
tract,   changes  in,  in  puer- 
perium, 221 
in  labor,  134 
in  new-born  infant,  331 
Intestines,  changes  in,  in  preg- 
nancy, 107 
Intoxication,  wound,  831  '^^ 
Intra-uterine  and  extra-uterine 
pregnancy  combined,  387 
douches  in  puerperal  fever, 

876 
pregnancy,      ectopic     preg- 
nancy and,  differentiation, 
389 
Inversion  of  fetus,  178 
of  uterus  in  labor,  759 
diagnosis,  761 


INDEX 


1041 


Inversion  of  uterus   in    labor, 
etiolo}i;y,  7oU 
funnel,  7;j9 
prognosis,  701 
spoilt aiieuu.s,  7')9 
syinploiiis,  7()() 
treat luciit,  701 
violent,  !')[) 
Inverted  nipples,  230 
Involution  in  puerperiuni,  205, 

212 
lrrital)ility  of  Madder  as  sign 

of  i)refi;naiicy,  -')'.i 
Irrital)le  bladder,  72o 

uterus,  417 
Iscliioeavernosus  muscle,  101 
Ischiocoeejffeal       portion       of 

levator  ani,  101 
Ischuria  paradoxa  in  retrover- 
sion of  uterus,  40o,  40S 
Isthnuis  of  uterus,  80,  92 


Jacquemin's  sifj;n  of  prcgnancv, 

2o4 
Japanese  forceps,  9t)2 
Jardine's  hook,  1012 
Jaundice,  492 
Jelly  of  Wharton,  49,  51 
Johnson  t\\ins,  540 
Joints,  pelvic,  in  pregnancy,  98 

injiu'ies   of,   in  labor,   765 

relaxation     of,     in     preg- 
nancy, 379 

rupture   of,    in   labor,  705 
Jonge's  position,  723 
Justoniinor  pelvis,  658 

diagnosis,  001 

etiology,  0()0 

mechanism    of    labor    in, 
699 

Karyokinesis  in  ovum,  30 
Kidneys,       changes       in,       in 
eclampsia,  359 
in  puerperium,  221 
decapsulation,  in  eclampsia, 

308 
enlarged   and   prolapsed,    in 

pregnancy,  532 
in  labor,  135 
of  fetus,  physiology,  OS 
of  pregnancy,  108,  226,  309 
symptoms,  309 
treatment,  370 
pains  of,  131 
Knots  in  umbilical  cord,  558 
false,  52,  558 
true,  52,  558 
Kolpoporrhexis,  749 
Kristeller's  expression  in  labor, 
-  572 

Kyphoscoliotic  pelvis,  074 
Kyphotic  pelvis,  077 


Labor,     abdominal    examina- 
tion in,  279 
muscles  in,  151 
palpation  in,  279 
powers  in,  anomalies,  509 

treatment,  571 
pressure  in,  151 

66 


Labor,  abnormal,  114.    See  also 

IhjHluviu. 
abnormalities     in,     internal 
examination  for  determin- 
ing, 2,SS 
accidents  of,  725 
to  child  in,  797 
action  of  uterus  in,  anoma- 
lies, 507 
advancement  of  head  along 
birth-canal,     internal    ex- 
aminalicjn  foi' determining, 
288 
albuminuria  in,  135 
anesthesia  in,  293 

choice  of  anesthetic,  294 
conditions,  294 
history,  294 
indications,  294 
method  of  administration, 

294 
objections  to,  293 
obstetric  degree,  293 
surgical  degree,  293 
anomalies  of  abdominal  pow- 
ers in,  509 
treatment,  571 
of  passages,  044 
of  passengers,  579 

classification,  579 
of  powers,  507 
anorexia  in,  134 
antisepsis  in,  273 
asepsis  in,  273 

of  environment  in,  277 
of  patient  in,  275 
of  physician  in,  273 
aseptic  conduct  of,  prepara- 
tion for,  231 
assistance    in,    question    of, 

272 
atony  of  uterus  in,  567 
attendance  of  physician  in, 

290 
auscultation  in,  284 
bag   of   waters   in,    rupture, 

291 
bath  before,  276 
bed  in,  277 
bladder  in,  134 

care  of,  291 
bowels  in,  care  of,  291 
caput  succedaneum  in,  143, 

144 
card,  289 
causes,  115 

influence  of  accident,  116 
of  anaphylactic  process, 

110 
of  irritabilit}-  of  uterus, 

115 
of   periodicity   of   men- 
struation, 115 
of    presenting   part   on 
lower   uterine    seg- 
ment, 115 
theories  of,  115 
changes   in   fetus   result   of, 
171 
wrought  on  fetal  head  by, 
142,  143 
chart.  1023-1025 
chills  in,  127,  133 
chloral  anesthesia  in,  295 


Labor,    chloroform    anesthesia 

in,  294 
circulation  in,  133 
clinical  cour.se,  110 
coccygodynia  in,  707 
collapse  in,  793 

diagnosis,  795 

symptoms,  795 

treatment,  795 
complicated,    in    contracted 

pelvis,  treatment,  723 
conduct  of,  270 
cramp  pains  in,  573 
cramps  in  leg  in,  134 
cystoceh;  in,  740,  703 
death  in,  sudden,  793 
etiology,  793,  794 
symptoms,  795 
definition,  114 

degree  of  effacement  and  dila- 
tation of  cervix  in,  280 
diet  in,  291 
dislocation  of  bladder  in,  763 

of  ribs  in,  707 
douche  before,  270 
dry,  120,  122 
duration,  132 
edema  of  cervix  in,  415 
effacement  of  cervix  in,  120 
effect  of,  on  child's  organism, 
138 

on  maternal  organism,  132 
engagement     of    presenting 

part  in,  283 
epidural  hemorrhage  in,  143 
ether  anesthesia  in,  294 
eversion  of  vaginal  walls  in, 

414 
examination  in,  first,  278 

internal,  285 
expulsion  of  feces  in,  care  of, 

302 
fainting  spells  in,  134 
fetal  axis  pressure  in,  150 
fever  in,  790 

treatment,  790 
first  examination  in,  278 

stage,  117 

conduct    of,    summary, 

319 
treatment,  291 
fissure  of  anus  in,  650 
fistulas  in,  763 
forces  involved  in,  149 
fracture  of  bones  of  extremi- 
ties of  fetus  in,  814 

of  clavicle  of  fetus  in,  814, 
815 

of  femur  of  fetus  in,  815 

of  humerus  of  fetus  in,  815 

of  long  bones  of  fetus  in, 
816 

of  sternum  in.  767 
full  bladder  in,  763 
gra\'ity  in,  151 
head,    unusual    mechanism, 

579 
heart  disease  in,  488 
treatment.  490 
hematoma  of  sternomastoid 
muscle  of  fetus  in,  812, 
813 

of  vagina  in,  743 
etiology,  743 


1042 


INDEX 


Labor,  hematoma  of  vagina  in, 
prognosis,  744 
symptoms,  743 
treatment,  744 
of  ^a^lva  in,   743 
etiology,  743 
prognosis,  744 
sjmiptoms,  743 
treatment,  744 
hemorrhage  in,  136 
hours  of  beginning,  132 

of  dehvery,  133 
hj'pertrophic    elongation    of 

cer\ax  in,  414 
hypnotism  in,  295 
immature,  416 
in  abruption  of  placenta,  441 
in  absolutely  contracted  pel- 
vis, treatment,  712 
in    contracted    pelvis,    me- 
chanism, 690 
first  stage,  691 
second  stage,  692 
third  stage,  694 
prognosis,  705 
for  cliild,  706 
for  mother,  705 
treatment,  709 
in  flat  pelvis,  findings,  697 

mechanism,  695 
in   funnel    pelvis,  diagnosis, 
701 
mechanism,  701 
in  generally  contracted  pel- 
vis, diagnosis,  700 
mechanism,  699 
in     moderately     contracted 
pelvis,  treatment,  713,  715 
in  obhquely  contracted  pel- 
vis, mechanism,  703 
in  relatively  contracted  pel- 
vis, treatment,  712 
in  slightly  contracted  pelvis, 

treatment,  722 
induction  of,  in  abruption  of 
placenta,  443 
in  eclampsia,  363,  364, 365 

anesthesia  in,  364 
in    hyperemesis    gravida- 
rum, 351 
in  inevitable  abortion,  428, 
432 
accidents  in,  431 
hemorrhage  in,  431 
perforation  of  uterus 
in,  431 
in  puerperal  fever,  877 
injuries  of  bladder  in,  763 
of  cervical  muscles  of  fetus 

in,  812 
of  coccyx  in, 766 
treatment,  767 
of   fetus    in,    medicolegal 

aspects,  816 
of  head  in,  809 
of  infant  during,  797,  809 
of  levator  ani  in,  726 
of  parturient  canal  in,  725 
of  pelvic  bones  in,  765 
floor  in,  726 
joints  in,  765 
of  perineum  in,  726 
of  rectum  in,  765 
of  trunk  of  fetus  in,  812 


Labor,    injuries    of   viscera   of 
fetus  in,  813 
of  vulva  in,  725 
insensible,  91,  286 
instructions  to  nurse  during, 
.248 
internal  examination  in,  285 

pelvimetry  in,  288 
intestinal  tract  in,  134 
inversion  of  uterus  in,  759. 
See  also  Inversion  of  uterus 
in  labor. 
kidneys  in,  135 
Kristeller's     expression     in, 

572 
laceration  of  cervix  in,  745 
prognosis,  745 
treatment,  745 
of  pelvic  connective  tissue 
in,  740 
treatment,  742 
of  perineum  in,  296,  726 
causes,  296 
etiology,  728 
history    of    prevention, 

305 
perineorrhaphy,  736 
treatment,  296,  734 
preventive,  734 
of  vagina  in,  739 
prognosis,  742 
treatment,  742 
lengthening  of  fetus  in,  171 
leukocytosis  in,  136 
levator  ani  in,  preservation, 

296 
list  of  articles  needed  for,  232 
location  of  placenta  in,  283 
loosening  of  sacrum  in,  766 
mechanism,  148 
fetal  head,  167 

trunk,  169 
fetus,  167 
formation    of    parturient 

canal,  163 
in     breech     presentation, 

603,  605 
in  brow  presentation,  589, 

592 
in  flat  pelvis,  695 
in  forehead  presentation, 

589 
in  funnel  pelvis,  701 
in     generally     contracted 

pelvis,  699 
in  median  vertex  presen- 
tation, 587 
in     obliquely     contracted 

pelvis,  703 
in  occipital  presentation, 

181,  191 
in  oc(;ipitodextra  posterior 

position,  197 
in   persistent   occipitopos- 

tcrior  position,  580 
in  transverse  presentation, 

615 
passages,  152 
passengers,  167 
powers,  149 
prognosis,  288 
soft  parts,  159 
mental  condition  in,  134 
metabolism  in,  136 


Labor,  method  of  delivery,  297 
of  head,  302 
of  shoulders,  304 
on  side,  298 
missed,  113,  474 
symptoms  of,  474 
treatment  of,  475 
moderately   contracted  pel- 
vis in,  treatment,  713,  715 
molding  of  head  in,  143 
morphin  anesthesia  in,   295 
myoclonia  uteri  in,  573 
Naegele's  rule  for  determin- 
ing day,  267 
nitrous  oxid  gas  anesthesia  ■ 

in,  295 
nurse  in,  248 
obstruction     of.      See     also 

Dystocia. 
painless,  131 
pains,  117,  129 
cramp,  573 
effect  of,   on  fetal  heart, 

138 
false,  567 
too  strong,  577 
paralysis  of  muscles  of  ex- 
tremities of  fetus  in,  813 
passages  in,  152 

anomahes  of,  644 
passengers  in,  167 
anomahes,  579 
classification,  579 
pathology,  565 
pelvimetry  in,  internal,  288 
perineum    in,    preservation, 
296 
history,  305 
periods,  117 
physiology,  114 
placental  stage,  117,  128 
plastic  changes  wrought  on 

fetus  by,  142 
polyuria  in,  135 
powers  im'-olved  in,  149 

anomalies,  567 
precipitate,  577 
dangers  of,  577 
treatment  of,  578 
prediction  of  day,  267 
premature,  416,  436 
definition,  114 
etiology  of,  419 
induction  of,  1014 
by  bougies,  1016 
by  dilatation  of  cervix, 

1016 
by  puncture  of  bag  of 

waters,  1016 
conditions  in,  1015 
in       moderately      con- 
tracted pelvis,  713 
in  prolonged  pregnancy 
and     overgrowth     of 
child,  1014 
indications,  1014 
prognosis,  1015 
technic,  1016 
preparation  for  aseptic  con- 
duct, 231 
preservation  of  levator  ani 
in,  296 
of  life  of  fetus  in,  295 
of  perineum  in,  296 


INDEX 


1043 


Labor,prosorvafion  of  perineum 
in,  history,  'M)~) 
pressure  necrosis  of  blutlder 

in,  763 
prognosis,  145 
for  infant,  147 
of  mcchanisiii,  "iSS 
prolapse  of  uterus  in,  740 
proloufrecl,  473 
pubic  segment  in,  164 
question  of  assistance  in,  272 
rectal  examination  in,  288 
rectovaginal   fistula  in,   763 
reduction    of    size    of    fetal 

head  in,  172 
regional  anesthesia  in,  295 
relaxation  of  pelvic  floor  in, 

727 
respiration  in,  133 
response  to  call  in,  273 
rigidity  of  cervix  in,  577 
Kit  gen's  mana'uver  in,  572 
room  in,  277 
rubber  gloves  in,  274 
rupture  of  bag  of  waters  in, 
determining,  286 
of  pelvic  joints  in,  765 
of    stcrnocleido  mastoid 

muscle  of  fetus  in,  812 
of  symphysis  pubis  in,  765 
of  uterus  in,  747 
after-treatment,  758 
diagnosis,  754 

clifferential,  755 
etiology,  747 
frequency,  750 
incomplete,     treatment 

of,  758 
pathology,  750 
prognosis,  755 
symptoms,  752 

the  rupture,  753 
threatened,      diagnosis, 

754 
treatment,  756 
after  rupture,  756 
preventive,  756 
sacral  segment  in,  164 
scopolamin-morphin    anes- 
thesia in,  295 
second  stage,  117,  122 
antisepsis  in,  317 
asepsis  in,  317 
conduct,  292 

summary,  319 
delivery    of    shoulders, 

304 
method  of  delivery,  297 

of  head,  302 
pains  in,  122 
show,  116 
soft  parts  in,  159 
spasm  of  cervix  in,  577 
stages,  117 

steriUzation  of  hands  in,  273 
stricture  of  cervix  in,  577 
of  uterus  in,  574 
treatment,  576 
sudden  death  in,  793 
etiology,  793,  794 
symptoms,  795 
syncope  in,  793 
diagnosis,  795 
symptoms,  795 


Labor,  syncoix;  in,  treatment, 
795 
temperature  in,  133 
tetamis  uteri  in,  573 

diagnosis,  575 
third  stage,  117,  128,  310 
antisepsis  in,  317 
ase])sis  in,  317 
con<luct     of,    summary, 

319 
examination  of  parts  for 

injuries,  319 
invasion  of  uterus  in,  316 
mechanism,  199 
mode  of  conduct,  310 
pain  in,  128 
treatment,  310,  313 
turgidity    and    swelling    of 

turbinate  bones  in,  134 
ureters  in,  134 
urethra  in,  134 
urinar}'  system  in,  134 
urine  in,  135 

uses  of  liquor  amnii  during,  53 
uterine  action  in,  anomalies, 
567 
contractions  in,  117,  119, 
129 
mechanism,  149 
visit  of  physician  before,  244 
vital  dilatation  in,  150 
vomiting  in,  134 
weight  in,  136 
Laceration    in    hebosteotomy, 
927 
in  postpartum  hemorrhage, 

treatment,  788 
of  cervix  in  labor,  745 
prognosis,  745 
treatment,  745 
of  pelvic  connective  tissue  in, 
in  labor,  740 
treatment,  742 
of  perineum  in  labor,  296, 726 
causes,  296 
etiology,  728 
history    of    prevention, 

305 
perineorrhaphy,  736 
treatment,  296,  734 
preventive,  734 
of  vagina  in  labor,  739 
prognosis,  742 
treatment,  742 
Lactation,  213 
absence  of,  213 
atrophy  in  puerperium,  212 
Lactosuria  in  pregnancy,  108 

in  puerperium,  221 
Lambdoid  suture,  167 
Langhans'  layer,  38 
Larynx,    changes   in,   in   preg- 
nancy, 106 
Lateral  pressure  of  innominate 

bones,  653 
Lavage  of  stomach  in  hyper- 

emesis  gra\'idarum,  350 
Law,  Colles',  485 

Pajot's,  of    accommodation, 
in  head  presentation,  178 
Profeta's,  483 

Sellheim's,  of  accommoda- 
tion in  anterior  rotation  in 
occipital  presentation,  187 


Lead  nipple-shield,  Wans- 

brough's,  891 
Lean  umbilictil  cord,  51 
Leroyeiiiie's  forceps,  983 
Ijcukemia  in  pregnancy,  374 
Leukocytheinia,  fetal,  (U 
Leukocytosis  in  labor,  136 
in  new-born  infant,  329 
in  pregnane}',  103 
in  puerperal  fever,  870 
in  puerperium,  220 
physiologic,    of    pregnancy, 
103 
Leukorrhea  in  pregnancy,  89 
Levator  ani,  160 

iliococcygeal  portion,  161 
injuries,  in  labor,  726 
iscliiococcygeal  portion, 

161 
preservation,  in  labor,  296 
pubococcygeal    portion, 

161 
puborectal  portion,  161 
Levret's  forceps,  962 
Ligaments,     broad,     in    preg- 
nancy, 95 
pubovesical,  763 
round,  in  pregnane}-,  94 
uterosacral,  in  pregnane}',  95 
Ligamentum  teres,  64 
Ligation    of    pelvic    veins    in 

puerperal  fever,  883 
Lightening,  83,  84 
diagnosis  of,  264 
Linea   albicantes   gravidarum, 
99 
lactea,  100 
nigra,  100,  110 
terminalis,  152,  153 
Line,  white,  160 
Lines    on    abdomen    in    preg- 
nancy, 99 
Liquor  amnii,  45,  52 
amount,  52 
bacteria  in,  53 
chemical  analyses,  52 
food  value,  53 
freezing-point,  52 
sources,  53 
urea  in,  53 
uses,  53 

during  labor,  53 
folliculi,  3 
Lithokelyphos,  387 
Lithopedion,  387 
Lithotomy    position,    exag- 
gerated, in  moderately  con- 
tracted pelvis,  716 
Little's  pipet,  865 
Litzmann's     classification      of 
contracted  pelves,  657 
system    of    classification    of 
bony  pelves,  654 
Liver,    acute   yellow   atrophy, 
in  pregnancy, 370 
diagnosis,  371 
pathology,  370 
prognosis,  371 
symptoms,  370 
treatment,  371 
changes  in,  in  eclampsia,  359 

in  pregnancy,  107 
of  pregnancy,  346 
Lochia,  210 


1044 


INDEX 


Locliia  alba,  210,  211 

bacteriology,  211 

odor,  210 

pumleiita,  210 

quantity  of,  212 

sanguinolenta,  210,  211 

sources,  212 
Lochiocolpos      in      puerperal 

fever,  83-1 
Lochiocytes,  211 
Lochiometra  in  puerperal  fever, 

835 
Locking  of  forceps,  971 
Long  umbiUcal  cord,  560 
Loosening  of  sacrum,  766 
Losing  the  periods,  IS 
Lumbar  glands,  changes  in,  in 
pregnancy,  104 

puncture  in  eclampsia,  367 
Lungs,  changes  in,  in  eclamp- 
sia, 360 
in  pregnancy,  106 
lAischka's  fibers,  161 
Lusk's  cephalotribe,  1006 
Lutein,  7 

cells,  7 
L^-mphangitis,  893 
Ijj'mphatics  of  uterus,  75 
Lysol    gauze    for    tamponade, 
1022 
sterilization,  1022 


Malacosteon    in    pregnancy, 

504 
Malaria  in  pregnancy,  478 
Mamma  hormone,  102 
Mammary  glands.    See  Breasts. 
Mania  in  pregnancy,  373 
Manual    dilatation    of    cervix, 

910 
Martin's  trephine,  1008 
Masculine  pelvis,  658 
Mask  of  pregnancy,  110 
Massage  in  puerperium,  326 

of  breasts,  885,  886 

of     uterus     in     postpartum 
hemorrhage,  781 
in  third  stage  of  labor,  310 
Mastitis,  892 

cellulitic.  893 

etiology,' 892 

forms,  893 

glandular,  893 

interstitial,  893 

parenchymatous,  893 

f)hl('griK)nous,  893 

purulent,  894 

symptoms,  893 

treatment,  895 
Maternal  impressions  in  preg- 
nancy, 228 

organism,    effects    of    labor 
on,  132 

organs,  changes  in,  in  preg- 
nan(;y,  103 

syphilis,    (effects,    on-  preg- 
nancy, 482 
Maurer's  treatment  of  placenta 

praivia,  455 
Mauriceau-Smellie-Veit  meth- 
od of  delivering  after-coming 

head,  955 
Measles  in  pregnancy,  478 


Meconium,  331 

Medicolegal  aspect  of  injuries 

of  fetus  in  labor.  816 
Melania  spuria,  891 
Melancholia  in  pregnancy,  373 
Membrana  decidua,  33 

granulosa,  3 
Membranes,  49 

tough,  dystocia  due  to,  641 
treatment,  642 
Menacme,  11 
Menarche,  1 

Meningisme   in   new-born   in- 
fant, 811 
Meningocele,  539 
Menopause,  18 

pregnancy  after,  19 

symptoms,  19 
Menses,    11.     See    also    Men- 
struation. 
Menstrual  cycle,  13 
Menstruation,  11 

after  conception,  251 

amount  of  flow,  17 

and    ovulation,     connection 
between,  14 

cause,  13 

cessation  of,  as  sign  of  preg- 
nancy, 251 

character  of  flow,  17 

clinical  aspects,  16 

duration  of  flow,  17 

influence   of   periodicity   of, 
on  production  of  labor,  115 

midperiod,     suppression    of 
flow,  19 

object  of,  15 

periodicity,  17 

pregnancy  and,  224 

pseudo-,  16 

in  new-born  infant,  335 

return,  after  cessation,  18 

symptoms,  17 

time  of  appearance,  16 

tubal,  16 

uterus  in,  13 

vicarious,  19 

without  pregnancy,  251 
Mental  condition  in  labor,  134 

occupation  in  pregnancy,  228 

state  of  fetus,  59 
Mercury    in    puerperal    fever, 

879 
Mesnard-Stein    bone    forceps, 

1010 
Mesol)last,  30 
Mesoderm,  30,  37 
Metal)olism,     diseases    of,    in 
pregnancy,  502 

in  labor,  136 

in  i)r(>gnancy,  107 
Metastatic  bacteremia  in  puer- 
peral fever,  853,  856 
Meteorism.     See  Tympany. 
Metreurynter,     (Hlatation      of 

cervix  willi,  911 
Metreurysis,  911 

conditions  for,  913 

dangers,  913 

disadvantages,  913 

in  placenta  pra-via,  455 

indications,  913 
Metritis     desiccans     in     puer- 
peral fever,  837 


Michaelis,  rhomboid  of,  236 
Microcephalus,  539 
]\lidperiod  suppressed  menses, 

19 
Midplane  of  pelvis,  155 
Military  attitude  of  fetus,  583 
Milk,  abnormal,  887 
secretion,  885 
drying  up,  890 
fever,  213,  219,  843,  884 
human,  214 

composition  of,  214 
drugs  in,  216 
lack  of,  887 

quantity  and  quaUty,  216 
influence    of    age    of 
patient  on,  216 
of  disease  on,  216 
of  drugs  on,  216 
of  emotions  on,  216 
of  foods  on,  217 
of  hunger  on,   216 
of  irritation  of  nip- 
ples on,  216 
of  nutrition  of  pa- 
tient on,  216 
of    pregnancy    on, 
216 
scarcity  of,  887 
secretion  of,  in.  puerperi- 
um, 213 
theory    of    puerperal    fever, 

818 
uterine,  32,  61 
Milk-leg    in    puerperal    fever, 

858,  859 
Milk-sugar  in  urine  in  puer- 
perium, 221 
Minor    disturbances    of    preg- 
nancy, 538 
Miscarriage,     416.     See     also 

Abortion 
Missed  abortion,  417,  423,  435 
labor,  113,  474 
symptoms,  474 
treatment,  475 
Mobility  of  fetus,  178 
Molding    in   breech   presenta- 
tion, 612 
in  brow  presentation,  592 
in  labor,  143 

in  median  vertex  presenta- 
tion, 588 
in  occipitoposterior  position, 
582 
Mole,  blood,  434 
destructive,  545 
fleshy,  in  abortion,  435 
hematoma,  in  abortion,  435 
hydatidiform,  544 
clinical  course,  547 
diagnosis  of,  547 
etiology  of,  546 
prognosis  of,  547 
symptoms  of,  547 
treatment  of,  548 
tubal,  383 
Mollifies  ossium  in  pregnancy, 

504 
Momburg's   tube   in   postpar- 
tum hemorrhage,  788 
in  rupture  of  uterus,  757 
Monathche  Reinigung,  16 
Monsters,  537 


INDEX 


1045 


Monsters,  classification  of,  'hi7 

clinical  aspects,  r)4\ 

(liau;M()sis,  .") 41 

(loui)k',  5o7,  'hV.) 

etiology  of,  ')'.i7 

single,  r)'.i7,  ooi) 

treatment,  542 
Monstra    per    defectum,    ri'ST, 
539 

per  excessum,  539 

per  fahricam  alienam,  53!) 
Monstrosities,  537 
Montf^omeiy's  tubercles.   101 
Monthlies,  11 
Monthly  sickness,  11 
Morales'  slinf!;-carrier,  943 
Morbus  ca'ruleus,  ()4 
Morninfi  sickness  in  diagnosis 
of  pregnancy,  252 
in  pregnancy,  IOC) 
Morphin  anesthesia  in  labor, 
295 

treatment  of  eclampsia,  366 
Mortality   of  puerperal   fever, 

870 
Morula,  20 

]\Iother,    death    of,    effect   on 
fetus,  53() 

prognosis  of  life  of,  in  con- 
tractefl  pelvis,  705 
Mouth-to-lung    insufflation   in 

asphyxia  neonatorum,  S07 
Mucous   membranes  of  fetus, 

changes  in,  due  to  syphilis,' 

485 
Multiple  pregnancy,  462.     See 

also  Prccjiuutcu,  multiple. 
Munmiification     of     umbilical 

cord,  334 
Murphy's  cord  repositor,  632 
Muscle,  bulbocavernosus,  161 

ischiocavernosus,  161 

sternocleidomastoid,  of  fetus, 
rupture,  in  labor,  812 

sternomastoid,  of  fetus,  hem- 
atoma of,  in  labor,  812,  813 

transverse    superficial    peri- 
neal, 161 
Muscle-fibers  of  uterus,  72 
Muscles,  cervical,  of  fetus,  in- 
juries, in  labor,  812 

of  extremities  of  fetus,  paral- 
ysis, in  labor,  813 
Mutilating  operations  on  child, 

1005 
Myoclonia  uteri  in  labor,  573 
Mj-oma  of  uterus  in  pregnancy, 

521.     See    also    Fibroids    of 

uterus  in  prcqtmncy. 
Myxoma  of  placenta,  557 


NAEfiELfc's  obHquity,  182 
pelvis,  670 
perforator,  1008 
rule  for  determining  day  of 
labor,  267 
Narcotics  in  eclampsia,  366 
Nausea  and  vomiting  in  diag- 
nosis of  pregnancy,  252 
in  pregnancy,  106 
pernicious,   in  pregnancy, 
344.      See    also   Hyper- 
emesis  gravidarum. 


Navel,  amnion,  334 

skin,  334,  5()2 
Neck,  arms  in  nai)e  of,  635 
N(!crosis,   pressure,  of  bladder 
in  labor,  763 
of  scalj)  of  fetus,  707 
Needle,  hebosteotomy,  924 
Neglected  transverse  presenta- 
tion, ()21 
treatment,  625 
Neoplasms.     See  Tumors. 
Nephritic  eclamp.sia,  356 
Nephritis   in   pregnancy,   369, 
496 
after  twenty-eighth  week, 

treatment,  498 
before     child     is     viable, 

treatment,  498 
chronic  interstitial,  497 
parenchymatous,  496 
diagnosis,  497 
in  eclampsia,  359 
primary  acute,  496 
prognosis,  497 
treatment,  498 
Nerve-centers  of  uterus,  78 
Nerves  of  uterus,  76 
Nervous  chills  in  puerperium, 
324 
shock  of  labor  as    cause  of 

syncope  and  death,  794 
system,  changes  in,  in  preg- 
nancy, 111 
in  puerperium,  218 
temperature     in     puerperal 
fever,  867 
Nest  building,  16 
Neuman    and    Ehrenfest's 
method  of  cliseometry,  244 
Neuritis  in  pregnancy,  373 
treatment,  374 
optic,  in  pregnancy,  505 
puerperal,  374 
New-born  infant,  albuminuria 
in,  331 
asphyxia    of,     797.      See 
also  Asphyxia    neonato- 
rum. 
bathing,  336 
blood  in,  329 
bowels  in,  care  of,  337 
breasts  of,  335 
care  of,  307,  336 
of  eyes,  303,  308 
general  rules,  339 
instructions    to    nurse, 

249 
summary,  339 
cause  of  first   respiration 

in,  139 
cerebral    hemorrhage    in, 

811 
changes  in,  in  fetal  circu- 
lation in,  140 
local,  334 
chart  for.  1027,  1028 
circulation  in,  330 
erythrocytes  in,  329 
eyes  of,  care,  336 
facial  paralysis  in,  811 
feeding,  337 
general  condition,  333 
icterus  of,  333 
injuries  of,  809 


New-born  infant,  injuries  of,  in 
labor,  797 
intestinal  tract  in,  331 
jaundice  in,  333 
leukocytosis  in,  329 
local  changes  in,  334 
meconium  of,  331 
meiiingisme  in,  811 
nursing,  323,  337 

contraindications,     323, 
324 
ophthalmia  in,  308 
pnn-ention,  308 
physiology,  329 
pseudo  -  menstruation   in, 

335 
pulse  of,  taking,  338 
respiration  in,  329 

taking,  338 
secretion    by    breasts    in, 

335 
separation     of     umbilical 

cord  in,  334 
skin  of,  333 
skin-eruptions  in,  333 
starvation  fever  in,  338 
stools  of,  331 
strophulus  of,  333 
temperature,  330 

taking,  338 
umbilical  cord  in,  care  of, 

336 
urination  in,  care  of,  337 
urine  of,  331 
vernix  caseosa,  333 
weighing,  338 
weight  of,  331 
Nipples,  accessory,  102 

changes    in,    in    pregnancy, 

253 
diseases  of,   in  puerperium, 

890 
inverted,  230 
irritation    of,    influence    on 

milk,  216 
sore,  890 

treatment  of,  892 
Nipple-shield,     Wansbrough's, 

891 
Nitabuch-Winkler,  closing  ring 

of,  36 
Nitrous  oxid  gas  anesthesia  in 

labor,  295 
Nose  and  tlu'oat,  diseases,  in 
pregnancy,  505,  506 
changes    in,    in    pregnane}', 
106 
Nourishment  of  fetus,  67 
Nuclein,  29 

in  puerperal  fever,  880 
Nucleus,  embryonal,  29 

segmentation.  29 
Numbness  in  pregnancy,  533 
Nurse,    obstetric,    engagement 
of,  248 
instructions  for,  248 
care  of  cliild,  249 
during  labor,  248 
during  puerperium,  248 
Nursing  in  syphilis,  487 
new-born  infant,  323,  337 
contraindications,     323, 
324 


1046 


INDEX 


Obesity  in  pregnane}^  503 
Oblique    diameters    of    pelvic 
inlet,  154 
presentations,  615 
Obliquely    contracted     pelvis, 
^667 
diagnosis,  673 
labor     in,     mechanism, 
703 
Obstetric  conjugate  diameter, 
154 
nurse,  engagement  of,  248 
instructions  for,  248 
care  of  child,  249 
during  labor,  248 
during  puerperium,  248 
satchel,  De  Lee's,  270 
list  of  articles  in,  271 
specula,  De  Lee's,  741 
Obstetrics,  operative,  897 
Occipital  presentation,  descent 
of  head,  183 
disengagement     of     head, 

187 
engagement  of  head,   181 
extension  of  head,  187 
external      restitution      of 

head,  188 
flexion  of  head,  183 
mechanism    of    labor    in, 
181 
observations  on,    191 
of  shoulders,  189 
over-rotation,  191 
rotation  of  head,  183 

internal  anterior,  184 
Occipitodextra   posterior  posi- 
tion, findings  in,  197 
mechanism  of  labor  in, 
197 
Occipitofrontal  diameter,  169 
Occipitomental  diameter,  169 
Occipitoposterior  position,  580 
correction,  930 
course,  580,  582 
diagnosis,  582 
forceps  in,  979 
Hodge's     mana'uver     in, 

584 
molding  in,  582 
persistent,  580 

mechanism  of  labor  in, 
580 
prognosis,  583 
treatment,  584 
unusual  mechanisms,  for- 
ceps in,  974 
Occipitosacral  position,  580 
molding  in,  5S2 
treatment,  584 
Occiput,  fetal,  168 
Ointment,    Crede's,    in    puer- 
peral fever,  879 
Oligohydramnion,  52,  564 
Olshausen's  theory  of  pulse-rate 

in  puerperium,  220 
Omphalomesenteric  duct,  45 
Opening  cervix,  operations  for, 

907 
Operating  telescope,  De  Lee's, 

903 
Operations,  897 
anesthesia  in,  898 
assistants,  898 


Operations,    contraindications, 
897 
diagnosis  before,  897 
feces  issuing  from  anus  in, 

care  of,  905 
for    enlarging   pelvic    canal, 

921 
for  opening  cervix,  907 
in  private  houses,   arrange- 
ment of  room,  900 
preparations,  899 
of  patient,  900 
provisions  for  complica- 
tions, 905 
indications,  897 
instruments  for,  904 
mutilating,  on  child,  1005 
of  delivery,  946 

general  conditions,  946 
indications,  946 
posture  of  patient,  902 
preparatory,  907 
preparing  pelvic  floor  for  de- 
livery, 920 
vagina  for  delivery,  920 
reflection  after,  898 
selection  of,  897 
Operative  obstetrics,  897 
Ophthalmia  neonatorum,   308 

prevention,  308 
Opsonins,  827,  881 
Optic    neuritis    in    pregnancy, 

505 
Osiander's  manoeuver  with  for- 
ceps, 982 
Osteochondritis,    syphilitic,   in 

fetus,  487 
Osteomalacia     in     pregnancy, 
504 
symptoms,  504 
treatment,  505 
physiologic,    of    pregnancy, 
109 
Osteomalacic  pelvis,  687 

diagnosis,  687 
Osteophytes,    puerperal,    104, 

109 
Otosclerosis,     effect    of    preg- 
nancy on,  106 
Ovarian  pregnancy,  385 
tubes,  Pflliger's,  3 
tumors  in  pregnancy,  529 
diagnosis,  529 
prognosis,  530 
treatment,  530 

during  labor,  531 
vaginal  ovariotomy  in, 
532 
Ovario-abdominal    pregnancy, 

381 
Ovariotomy,  vaginal,  in  ovar- 
ian tumors,  532 
Ovary,  smatomy,  2 

external  wandering,  24,  25 
functions,  3,  11 
germinal  epithelium,  3 
in  pregnancy,  96 
internal  secretion,  15 
interstitial  gland  in,  in  ani- 
mals, 11 
tunica  fibrosa,  4 
propria,  4 
Overgrowth  of  fetus,  induction 
of  premature  labor  in,  1014 


Over-rotation  in  occipital  pres- 
entation, 191 
Ovocytes,  3 
Ovulation,  2 

and    menstruation,    connec- 
tion between,  14 

definition,  2 
Ovum,  23 

and  spermatozoid,  union,  28 

blastula  formation,  30 

changes   in,    after   death  of 
fetus,  in  abortion,  434 

development,  28 

diseases  of,  535 

embedding,   in  uterine  mu- 
cous membrane,  31 

forceps,  429 

karyokinesis  in,  30 

method     of    spirochetse    in 
reaching,  483 

morula  stage,  30 

nine  weeks',  40 

six  weeks',  40 

three  weeks',  40 
Oxygen  in  eclampsia,  367 


Packing  cervix,  909 
forceps,  De  Lee's,  776 
uterus  in  postpartum  hemor- 
rhage, 784 
with   gauze   in   puerperal 
fever,  877 
Packs,  hot,  in  eclampsia,  367 
Pains,    after-,    in   puerperium, 
324 
cramp,  573 

treatment  of,  576 
false,  279,  567 
in   abdomen   in   pregnancy, 

533 
in  epigastrium  in  eclampsia, 

354 
labor,  117,  129 

effect  of,   on  fetal  heart, 

138 
false,  567 
too  strong,  577 
weak,  567 
of  the  kidneys,  131 
strong,  577 
weak,  567 

diagnosis  of,  568 
etiology  of,  568 
prognosis  of,  569 
treatment  of,  568,  571 
Pajot's  law  of  accommodation 
in  head  presentation,  178 
manoeuver  with  forceps,  982 
Palfyn's  forceps,  962 
Palpation,  abdominal,  in  labor, 
279 
of  fetal  body  in  diagnosis  of 
pregnancy,  260 
Paragomphosis,  705 
Paralysis,   facial,   in  new-born 
infant,  811 
of  muscles  of  extremities  of 
fetus  in  labor,  813 
Parametritis  in  puerperal  fever, 
840 
diagnosis,  845 
etiology,  840 
late,  844 


INDEX 


1047 


Parametritis  in  puerperal  fever, 
patholo{j;y,  841 
prognosis,  S4.5 
sN'iiiptonis,  S4;j 
treatment,  S4r),  Sol 
I'arathyroiil  extract  in  eclamp- 
sia, 'M')7 
Parathyroids,    changes    in,    in 

pregnancy,  104 
Parietal    l)()iie  presentation  in 
flat  pelvis,  ti'JG,  (597 
bones,  shape,  1G9 
bosses,  1()9 
Parsenow's  method  of  treating 
postpartum  hemorrhage,  787 
Partin-ient  canal,  117 
anomalies,  ()44 

dystocia  due  to,  644 
axial  stretching,  104 
axis  of,  1(H) 

contractile  portion,  1G4 
deformities,  509 
dilating  portion,  164 
formation,  UV.i 
injm-ies  to,  in  labor,  725 
position,  166 
Passages  involved  in  labor,  152 

anomalies,  644 
Passengers  in  labor,  167 
anomalies,  579 
classification,  579 
Passive  contraction  of  uterus, 

619 
Paternal    sj-philis,    effects    on 

pregnancy,  483 
Patterson's     abdominal     sup- 
porter, 400 
Pean's  forceps,  962 
Pelveocrural  cellulitis  in  puer- 
peral fever,  StK) 
Pelvic  bones,  injuries,  in  labor, 
765 
canal,  lejigth,  153 

operations    for    enlarging, 
921 
cellulitis  in  puerperal  fever, 
840.    See  also  Parametritis 
congestion  as  sign  of  preg- 
nancy, 253 
connective     tissue,     lacera- 
tion,    in     labor, 
740 
treatment,  742 
floor,  160 

in  pregnancy,  96 
injuries,  in  labor,  726 
operations  preparing,   for 

delivery,  920 
projection,  96 
relaxation,  in  labor,  727 
rigidity   of,   dystocia   due 
to,  647 
diagnosis,  647 
treatment,  648 
girdle  in  pregnancy,  98 
inclination,   anomalies,   d3-s- 

tocia  due  to,  656 
inlet,  diameters,  153 
obUque,  154 
plane  of,  153 
joints  in  pregnancy,  98 
injuries  of,  in  labor,  765 
relaxation  of,  in  pregnancy, 
379 


Pelvic  joints,  ru[)ture,  in  labor, 
7()5 
measurements  in  pregnancy, 
234 
internal,      in      pregnancy, 

2;;s 

technic,  239 
organs,     diseases,     dj'stocia 

due  to,  ()49 
outlet,  diameters,  156 

plane  of,  156 
I)laiies,  153 

Hodge's  system,  156 
narrow,  155 
wide,  155 
pre.sentation,  174,  176 

frequency,  178 
veins,  ligations,  in  puerperal 
fever,  883 
Pelvimeter,     Baudelocque- 
Breisky,  233 
De  Lee's,  236 
Pelvimeters,  internal,  237 
Pelvimetry,  internal,  in  labor, 

288 
Pelvis,  152 

ajquabiliter  justominor,  658 
anomalies  of,  Bonnaire's 
classification,  656 
Budin's  classification,  656 
classification,  654 
dystocia  due  to,  651 
Litzmann's    classification, 

654 
Schauta's  classification, 

654 
Tarnier's  classification, 
656 
assimilation,  679 
asymmetric,  682 
diagnosis,  683 
high,  680 
low,  680 
lower,  679 

midplane  contracted,  682 
transversely      contracted, 

681 
upper,  679 
biischiatic    diameter,    meas- 
urement, 242 
bituberal     diameter,     meas- 
urement, 242 
chief  plane,  156 
conjugate    diameter,    meas- 
urement, 242 
contracted,  657 
absolutely,  657 

treatment,  712 
at  inlet,  treatment  of  labor 

in,  722 
at    outlet,    treatment    of 

labor  in,  722 
caput  succedaneum  in,  708 
cesarean  section  in,  991 
extraperitoneal,  721 
classification,  657 
clinical  aspects.  690 
comphcated    labor     in, 

treatment,  723 
craniotomy  in,  713,  722 
definition,  657 
disproportion     between 
child   and   pehns,   diag- 
nosis, 709 


Pelvis,  contracted,  dystocia  due 
to,  657 
eclampsia    in, "  treatment, 

724 
forceps  in,  718 
frequency,  657 
generally,  658 
flat,  667 
laiior  in,  diagnosis,  700 
mechanism,  699 
liebosteotomy  in,  719 
liigh  f(jreep.s  in,  718 
in  pregnancy,  clinical  as- 
pects, 690 
labor      in,      complicated, 
treatment,  723 
mechanism,  690 
first  stage,  691 
second  stage,  692 
third  stage,  694 
prognosis,  705 
for  child,  706 
for  mother,  705 
treatment,  709 
Litzmann's    classification, 

657 
moderately,     exaggerated 
lithotomy  position  in, 
716 
induction  of  premature 

labor  in,  713 
treatment,  713 
during  labor,  715 
during  pregnancy,  713 
Walcher  position  in,  716 
obliquely,  667 
diagnosis  of,  673 
labor     in,     mechanism, 
703 
placenta  pra?via  in,  treat- 
ment, 724 
pubiotomj- in,  719 
relativel}',  657 

treatment,  712 
slightly,  treatment,  722 
symphysiotom>-^n,  719 
transversely,  675 
treatment,  709 

hospital     versus     home 
practice,  724 
version  in,  717 
coxalgic,  670 
dwarf,  658,  659 
excavation  of,  153,  155 
false,  152 
flat,  662 

generally  contracted,  667 
labor  in,  findings,  697 

mechanism,  695 
parietal  bone  presentation 

in.  696,  697 
rachitic,  663 
simple,  662 
funnel,  677 

diagnosis  of,  678 
labor  in,  diagnosis,  701 
mechanism,  701 
inclination,  157 
infantile,  658 
inlet,  diameters  of,  153 

oblique,  154 
justominor,  658 
diagnosis,  661  . 
etiologj",  660 


1048 


INDEX 


Pelvis,  kj'phoscoliotic,  674 
kyphotic,  677 
large,  152 
lower,  152 
masculine,  658 
midplane  of,  155 
minor,  152 
Xaegele,  670 
nimis  parva,  658 
obtecta,  677,  722 
osteomalacic,  687 

diagnosis,  687 
outlet,  diameters  of,  156 

plane  of,  156 
plana,  662 
plane  of  inlet,  153 
planes,  153 

Hodge's  system,  156 
pseudo-osteomalacic,  665 
quadrants  of,  174 
rachitic,  662,  663 
diagnosis,  665 
flat,  662,  663 
Robert,  676 
rubber,  504 
scohotic,  673 
simple  fiat,  662 
small,  152 
spUt  at  pubis,  689 
spondylohsthetic,  683 

diagnosis,  684 
too  large,    dystocia   due   to, 

656 
true,  152 
upper,  152 
Pendulous   abdomen  in  preg- 
nancy, 83,  398 
treatment,  399 
Peptonuria  in  pregnancy,  108 

in  puerperium,  221 
Perforation,     1005.     See    also 
Craniotomy. 
of  uterus  in  emptying  uterus 
in     inevitaVjle      abortion, 
431 
Perforator,  Burton's,  1006 

Xaegele's,  1008 
Perimetritis  in  puerperal  fever, 
846 
diagnosis,  850 
etiology,  846 
pathology,  847 
prognosis,  850 
symptoms,  849 
treatment,  851 
Perineal  body,  162 
Perineorrhaphy,  736 
after-care,  738 
instruments  for,  729 
Perineum,  fetal  head  on,  177 
injuries  of,  in  labor,  726 
laceration  of,  in  labor,  296, 
726 
causes,  296 
etiology,  728 
history    of    prevention, 

305 
treatment,  296,  734 
preventive,  734 
preservation,  in  labor,  296 

history,  305 
retraction  of,  in  breech  pres- 
entation, 958 
scissors,  306 


Perineum,  suture  of,  in  lacera- 
tions, 736 
Periods,  11 

Peritoneum  in  pregnancy,   95 
Peritonitis  in  pregnancy,  520 
in    puerperal    fever,    treat- 
ment, 851 
Pernicious    anemia    in    preg- 
nancy, 374 
vomiting  in  pregnancy,  343. 
See  also  Hyperemesis  grav- 
idarum. 
Perret's  cephalometer,  268 
Pfltiger  ovarian  tubes,  3 
Phlegmasia     alba     dolens     in 
puerperal    fever, 
858 
treatment,  860 
cradle,  861 
Phlegmonous  mastitis,  893 
Phthisis  in  pregnancy,  480 

treatment,  481 
Physician,  asepsis  of,  in  labor, 
273 
attendance  of,  in  labor,  290 
response  to   call,    in    labor, 
273 
Physician's     examinations     in 
pregnancy,  232 
visit  before  labor,  244 
in  puerperium,  324 
Physiologic  chill  in  puerperium, 
218 
diabetes  of  pregnancy,   108 
leukocytosis    of    pregnancy, 

103 
osteomalacia  of  pregnancy, 
109 
Physometra  in  transverse  pres- 
entation, 622 
Pica,  107 

Pinard's  method  of  breech  ex- 
traction, 951 
Pipet,  Little's,  865 
Pituitary    extract,    effect    on 

uterus,  104 
Pituitrin  in  postpartum  hemor- 
rhage, 787 
Pityriasis    versicolor   in   preg- 
nancy, 534 
in  puerperium,  377 
Placenta,  37,  39,  43,  45 
abruption  of,  437 

cesarean   section  in,    444, 

991 
concealed  hemorrhage  in, 

439 
diagnosis,  441 

differential,  441,  442 
emptying  uterus  in,  443 
etiolog}',  437 
frequency,  437 
hemorrhage  in,  438 

concealed,  439 
labor  in,  441 
pathology,  438 
placenta  pran-ia  and,  dif- 
ferentiation, 441,  442 
prognosis,  442 
pulse  in,  441 

rupture  of  uterus  and,  dif- 
ferentiation, 442 
symptoms,  440 
treatment,  442 


Placenta,  abruption  of,  vaginal 

cesarean  section  in,  444 
accessory  portions,  46 
accreta,  772 
albuminurique,  497 
angioma  of,  557 
at  term,  45 
atelectasis  of,  556 
battledore,  51 
bilobate,  46,  47,  50 
calcification  of,  556 
circular  sinus,  42 

rupture  of,  444 
circumvallata,  43,  552 
cirrhosis  of,  551 
cotyledons  of,  48 
cysts  of,  557 

delivery   of ,  Duncan's   me- 
chanism, 200,  201 

hemorrhage  in,  mechan- 
ism of  control,  203 

mechanism,  199 

Schultze's  mechanism,  200, 
201 
diseases  of,  551 

abortion  from,  417 
edema  of,  556 
examination  of,  314 
excretory  functions,   68 
expression,  128,  129,  310 

Ahlfeld's  method,  314 

Crede's  method,  312, 
313 

early,  311 
expulsion  of,  310 

mechanism,  200 
extra,  retention  of,  315 
fenestrata,  447 
fetal  surface,  49 
growth  of,  43 
hemorrhages,  554 
hepatization  of,  551 
horseshoe,  46,  50 
in  cesarean  section,  995 
infarcts,  49,  551 

varieties,  551 
insertion   of  imibihcal   cord 

in,  50 
isthmialis,  446 
location  of,  in  labor,  283 
low  insertion,  446 
marginata,  43,  552 
maternal  surface,  47 
membranacea,  46 
myxoma  of,  557 
nappiformis,  552 
prtevia,  445 

abortion  from,  449 

abi-upt  ion  of  pi  a  c  e  n  t  a 
and,  differentiation,  441, 
442 

accouchement  force  in, 
460 

Braun's  colpeurynter  in, 
456 

Braxton-Hicks'  version  in, 
454 

cesarean  section  in,  460, 
991 

centralis,  446 

colpeurynter  in,  456 

dangers  to  child,  449 

diagnosis,  449 
differential,  450 


INDEX 


1049 


Placenta  i)ticvia,  etiology,  447 
fro(iiieiicy,  447 
hemorrhage  in,  44S 
in  eontracted  pelvis,  treat- 
ment, 724 
in  tliinl  stage,  treatment, 

■ir>\) 
lateralis,  44() 
marginaiis,  44() 
Miiiirer's  treatment,  455 
metreurysis  in,  455 
partialis,  440 
prognosis,  45(J 
Puzos'  treatment,  452 
stillicidium    sanguinis    in, 

44S 
symptoms,  448 
totalis,  446 
treatment,  451 

during  third  stage,  459 
vaginal    cesarean    section 
in,  461 
prolapse  of,  439 
removal   of,   in   postpartum 
hemorrhage,  778 
manual   method,   in  post- 
partum hemorrhage, 
778 
ripe,  45 

scirrhus  of,  551 
separation  of,  310 
mechanism,  199 
shape,  46,  47 
spiu'ia,  46 

suecentm-iata,  46,  51,  315 
trefoil,  50 
trilobate,  46,  47 
tumors  of,  557 
variations  in  shape,  551 
venous  openings  in,  43 
villi  of,  37 
weight,  45 

white     infarcts,      49,      551, 
553 
Placentae  succenturiata?,  551 
Placental  circulation,  scheme, 
42 
hemorrhages,  554 
infarcts,  49,  551 
varieties,  551 
polyp,  invasive,  548 
site,  atony  of,  759 

in  puerperium,  208 
souffle  in  diagnosis  of  preg- 
nane}', 262 
Placentation,  37 
Placentitis,  551,  556 
Placentula?,  46,  551 
Plastic    changes    wrought    on 

fetus  by  labor,  142 
Plastron,  abdominal,  842 
Plethora,  serous,  in  pregnancy, 

103 
Pneumonia  in  prcgnancv,  479 
Podahc  version,  934,  936 
Point  of  direction,  579 

presentation,  172,  579 
Poisoning,  eclampsia  and,  dif- 
ferentiation, 360 
Polj'galactia,  885 
Polvglobulism    in    pregnancv, 

375 
Polyhydramnion,  52,  562 
acute,  562 


Polyhydramnion,    acute,   diag- 
nosis of,  563 
chronic,  563 
clinical  course,  562 
in  twins,  465 
I)rogn(jsis,  563 
treatment,  5(54 
Polymastia,  1(J2 
Polyneuritis  in  pregnancy,  373 
Polyp,  placental,  invasive,  548 
Polyuria  in  lal)or,  135 
Pomeroy's   bag   for   dilatation 

of  cervix,  911 
Porro  cesarean  section,  997 
intiications,  997 
technic,  998 
Portable    sterilizer,    De  Lee's, 

903 
Portio  vaginalis,  87 
Position,  169,  170,  172 
changes  in,  178 
chin,     persistent     posterior, 

596 
definition  of,  173,  579 
diagnosis,  by  abdominal  ex- 
amination, 279 
by   internal   examination, 
287 
frequency,  178 
Indian,  716 
Jonge's,  723 

lithotomy,    exaggerated,    in 
moderately  contracted  pel- 
vis, 716 
.   methods  of  improving,   930 
occipitoposterior,  580 
chnical  course,  582 
correction,  930 
course,  580 
diagnosis,  582 
forceps  in,  979 
Hodge's  manocuver  in,  584 
molding  in,  582 
persistent,  580 

mechanism  of  labor  in, 
580 
prognosis,  583 
treatment,  584 
unusual  mechanisms,  for- 
ceps in,  974 
occipitosacral,  580 
molding  in,  582 
treatment,  584 
of    fetus,    methods    of    im- 
proving, 930 
of  patient  for  operations,  902 
Walcher,  717 

in  moderately  contracted 
pelvis,  716 
Posterior  ear  presentation,  697 
Postmortem  delivery  of  fetus, 

795 
Postpartum  hemorrhage,  768. 
See   also   Hemorrhage,    post- 
partum. 
Poullet's  cord  repositor,  632 
Powers  involved  in  labor,  149 
Precipitate  labor,  577 
dangers,  577 
treatment,  578 
Precocious  pregnancy,  113 
Preeclamptic  toxemia,  354 
Pregnancy,  abdominal,  381 
secondary,  384 


Pregnancy,  abdominal  wall  in, 
99 
acetonuria  in,  108 
acne  in,  534 

acromegalic  changes  in,  104 
acute  yellow  atrophy  of  liver 
in,  370 
diagnosis,  371 
pathology,  370 
prognosis,  371 
symptoms,  370 
treatment,  371 
adrenalinemia  in,  104 
after  menoi)ause,  19 
albuminuria  in,  108,  369 
alcohol  in,  225 
amblyopia  in,  506 
ampullary,  385 
anemia  in,  374 
angular,  extra-uterine  preg- 
nancy and,  differentiation, 
390 
anorexia  in,  107 
appendicitis  in,  493 
diagnosis,  493 
treatment,  494 
appetite  in,  107 
areola  in,  101,  253 
I       axis  of  uterus  in,  83 
I       bacteriuria  in,  501 
I      ballot  tement  in  diagnosis  of, 
259 
bartholinitis  in,  514 
Basedow's  disease  in,  491 

treatment,  491 
batliing  in,  228 
bladder  in,  82,  96 
blindness  in,  505 
blood  diseases  in,  374 
bowels  in,  226 
Braxton  Hicks'  sign,  259 
breasts  in,  100 
care  of,  230 
broad  Ligaments  in,  95 
carcinoma  of  cervix  in,  527 
diagnosis,  528 
treatment,  528 
of  rectum  in,  532 
cervical,  421 
cessation  of  menstruation  in, 

251 
changes  due  to,  70 
local,  70 
in  blood  in,  103 
in  bone-marrow  in,  104 
in  bones  in,  109 
in  breasts  in  diagnosis  of, 

253 
in  cervix,  78,  79,  86 
in  circulatory  svstem  in, 

104 
in  digestive  tract  in,  106 
in  disposition  in,  252 
in  endometrium  in,  34 
in  form,  size,  consistence, 
and   position   of  uterus 
in  diagnosis  of,  256,  262 
in  hair  in.  111 
in  heart  in,  104 
in  intestines  in,  107 
in  larynx  in.  106 
in  liver  in,  107 
in  lower  uterine  segment, 
86 


1050 


INDEX 


Pregnancy,  changes  in  lumbar 
glands  in,  104 
in  lungs  in,  106 
in  maternal  organs  in,  103 
in  nervous  system  in.  111 
in  nose  in,  106 
in  parathj^roids  in,  104 
in  physiology  of  uterus,  94 
in  sebaceous  glands  in,  111 
in  shape  of  uterus,  78 

at  term,  80 
in  sldn  in,  110 

in  chagnosis  of,  262 
in  spleen  in,  104 
in  stomach  in,  107 
in  sweat-glands  in.  111 
in  tlu'oat  in,  106 
in  thyroid  gland  in,  104 
in  urine  in,  108 
in  uterus  in,  70 
in  weight  in,  107 
child  and,  223 
chloranemia  in,  103 
chlorosis  in,  374 
cholecystitis  in,  493 
cholera  in,  478 
chorea  in,  371 
prognosis,  372 
treatment,  372 
coitus  in,  224,  227 
colostrum  in,  102 
constipation  in,  107 

treatment,  226 
contracted  pelvis  in,  chnical 

aspects,  690 
contractility  of  uterus  in,  94 
convulsions     in,     353.     See 

also  Eclampsia. 
corset  in,  225 
cotton  spitting  in,  107 
cravings  in,  107 
cystitis  in,  501 
cystocele  in,  414 
darkening  of  eyehds  in.  111 
deafness  in,  106 
dental  caries  in,  492 
diabetes  in,  502 
diagnosis,  502 
prognosis,  503 
treatment,  503 

after  viability  of  child, 

503 
before    child   is   viable, 
503 
diagnosis,  250 

auscultatory  signs,  260 
ballottement,  259 
bluish      discoloration     of 
vagina,  vulva,  and  ves- 
tibule, 254 
Braxton  Hicks'  sign,  259 
cessation  of  menstruation, 

251 
changes  in  breasts,  253 
in  disposition,  252 
in   form,    size,    consist- 
ence, and  position  of 
uterus,  256,  262 
in  nipples  in,  253 
in  skin,  262 
death  of  fetus,  265 
fetal  heart-tones,  260 
movements,  259 
souffle,  261 


Pregnancy,  diagnosis,  Hegar's 
sign,  255 

intermittent  uterine  con- 
tractions, 259 

irritabihty  of  bladder,  253 

lightening,  264 

morning  sickness,  252 

multiparity,  266 

nausea  and  vomiting,  252 

palpation    of   fetal   body, 
260 

pelvic  congestion,  253 

placental  souffle,  262 

quickening,  258 

sahvation,  252 

softening    of    cervix    and 
vagina,  255 

sources  of  error,  250 

summary  of,  264 

time,  267 

uterine  souffle,  262 
diet  in,  225 

dilatability  of  uterus  in,  94 
diseases,  340 

accidental  to,  476 
local,  509 

classification,  340 

of  alimentary  tract  in,  492 

of  blood  in,  374 

of  circulatory  system  in, 
487 

of  ear  in,  506 

of  eye  in,  505 

of  heart  in,  487 

of  metabolism  in,  502 

of  nose  and  throat  in,  505, 
506 

of  skin  in,  375,  534 

of  urinary  system  in,  496 
diverticula  of  uterus  in,  514 
dizziness  in,  533 
dress  in,  225 

echinococcus    cysts   in,    532 
eclampsia  in,  353.     See  also 

Eclampsia. 
ectopic,       381.     See       also 

Extra-uterine  pregnancy. 
eczema  in,  534 
edema  in,  106,  376,  534 
effects  of  diabetes  on,  502 

of  fibroids  of  uterus  on, 
523 

of  heart  disease  on,  489 

of   maternal   syphilis    on, 
482 

of  paternal  syphiUs  on,  483 

on  diabetes,  502 

on  heart  disease,  488 

on  otosclerosis,  106 

on  syphilis,  482 
elasticity  of  uterus  in,  94 
endometritis  in,  516 

catarrhal,  517 

glandular,  517 

gonorrheal,  519 

interstitial,  517 

polyposa,  517 

syphilitic,  519 

tubero.sa,  517 
endometrium  in,  changes  in, 

34 
enlarged  and  prolapsed  kid- 
neys in,  532 
enlargement  of  cervix  in,  415 


Pregnancy,  epistaxis  in,  507 
erosions  of  cervix  in,  516 
erysipelas  in,  478 
erythrocytes  in,  103 
exercise  in,  227 
extra-uterine,  381.     See  also 

Extra-uterine    pregnancy. 
fainting  spells  in,  105,  111, 

533 
Fallopian  tubes  in,  96 
fetal  heart-tones  in  diagno- 
sis of,  260 

movements    in    diagnosis 
of,  259 

souffle  in  diagnosis  of,  261 
fever  of,  519 
fibroids   of   uterus   in,    521. 

See  also  Fibroids  of  uterus 

in  pregnancy. 
fibroma  molluscum  in,   376 
frequent  urination  in,  534 
gait  in,  110 
gall-stones  in,  492 
gingivitis  in,  107,  353 

treatment,  353 
glycosuria  in,  108 
gonorrhea  in,  514 

diagnosis,  516 

treatment,  516 
gonorrheal   endometritis  in, 

519 
Graves'  disease  in,  491 
heart  disease  in,  487 
prognosis,  489 
treatment,  489 
Hegar's  sign  in,  78,  255 
hematuria  in,  501 
hemophiha  in,  374 

treatment,  375 
hemorrhage  in,  374 
hemorrhoids  in,  107,  379 
hernia  in,  494 
herpes  in,  376 
hirsuties  in,  376 
histoi'y  card  in,  233 
husband  and,  224 
hydremia  in,  103 
hygiene,  225 

and  conduct,  223 
hypertrophy  of  cervix  in,  516 

of  heart  in,  104 
icterus  in,  492 

gravis  in,  370 
ileus  in,  494 
impetigo    herpetiformis    in, 

376 
in  retroverted  uterus,  extra- 
uterine    pregnancy     and, 

differentiation,  391 
in     rudimentary     horn     of 

uterus,  509 
in  uterus  arcuatus,  511 

bicornis  duplex,  510 
unicoflis,  511 
unolatere     rudimenta- 
rius, 512 

bilocularis,  511 

subseptus  unicollis,  511 

unicornis,  512 
infectious  diseases  in,  acute, 
476 
chronic,  480 
influence,  on    quantity   and 

quality  of  milk,  216 


INDEX 


1051 


Pregnancy,  influenzii  in,  IT'.' 
insaiiit}-  in,  1372 

(icatinont,  373 
in.sonniia  in,  533 
instriKitions  in,  general,  231 
intermittent      uterine     con- 

traetions   in  diagnosis  of, 

2.51) 
interstitial,  381,  383 
intestinal  indigestion  in,  492 
intra  -  uterine     and     extra- 
uterine, eunihined,  387 

eetopie  gestation  and,  dif- 
ferentiation, 389 
inverted  nipples  in,  230 
irritability     of     bladder     in 
diagnosis  of,  253 

of  uterus  in,  94 
jaundice  in,  492 
kidney    of,    108,    3G9.     See 

also  Kidney  of  pregnancy. 
Iddneys  in,  226 
lactosuria  in,  108 
late,  113 
length,  112 
leukemia  in,  374 
leukocytosis  in,  103 
leukorrhea  in,  89 
lightening,  S3,  84 

in  diagnosis  of,  264 
linea  nigra  in,  100,  110 
lines  on  abdomen  in,  99 
liver  of,  346 
local    diseases    incident    to, 

378 
location  of  cervix  at  term,  91 
malacosteon  in,  504 
malaria  in,  478 
mania  in,  373 
mask  of,  110 

maternal  impressions  in,  228 
measles  in,  478 
melancholia  in,  373 
menstruation  and,  224,  251 

without,    251 
mental  occupation  in,  228 
metat)oIism  in,  107 
minor   disturljances   of,   533 
mod(>ratcly    contracted   pel- 
vis in,  treatment,  713 
mollities  ossium  in,  504 
morning  sickness  in,  106 

diagnosis  of,  252 
multiparitj',     diagnosis     of, 

266 
multiple,  462 

anomalies  of,  472 

characteristics  of,  464 

clinical  course,  465 

diagnosis  of,  467 
differential,  469 

etiology,  462 

frequency  of,  462 

prognosis  of,  469 

symptoms  of,  465 

treatment  of,  470 
myoma    of    uterus    in,    521. 

See  also  Fibroids  of  uterus 

in  pregnancy. 
nausea  and  vomiting  in,  106 

diagnosis  of,  252 
nephritis  in,  369,  496 

after  twenty-eighth  week, 
treatment,  498 


I'regnaiicy,  nc|)hi'itis  in,  before 
child  is  viable,  treat- 
ment, 498 

chronic  interstitial,  497 
parenchymatous,  496 

diagnosis,  497 

in  eclampsia,  359 

primary  acute,  496 

prognosis,  497 

treatment,  498 
neuritis  in,  373 

treatment,  374 
numbness  in,  533 
nurse  in,  248 
obesity  in,  503 
optic  neuritis  in,  505 
osteomalacia  in,  504 

sj'mptoms,  504 

treatment,  505 
ovarian,  385 

tumors  in,  529.     See  also 
Ovarian  tumors  in  preg- 
nancy. 
ovaries  in,  96 
ovario-abdominal,  381 
pain  in  abdomen  in,  533 
parametritic  abscess  in,  532 
pathology  of,  340 

classification,  340 
pelvic  congestion  in  diagno- 
sis of,  253 

floor  in,  96 
projection,  96 

girdle  in,  98 

joints  in,  98 

measurements  in,  234 
internal,  238 
technic,  239 
pendulous  al)domen  in,  83 

treatment,  399 
peptonuria  in,  108 
peritoneum  in,  95 
peritonitis  in,  520 
pernicious  anemia  in,  374 
phthisis  in,  480 

treatment,  481 
physician's  examinations  in, 

232 
physics  of  abdomen  in,  100 
physiologic  diabetes  of,  108 

leukocytosis,  103 

osteomalacia  of,  109 
physiology,  1 
pica  in,  107 

pityriasis  versicolor  in,  534 
placental  souffle  in   diagno- 
sis of,  262 
pneumonia  in,  479 
polj'globulism  in,  375 
polyneuritis  in,  373 
precocious,  113 
preservation  of  figure  after, 

230 
presumable      toxemias     in, 

372 
pride  of,  110,  225 
projection,    pelvic    floor  in, 

96 
prolonged,  473 

induction     of     premature 
labor  in,  1014 

treatment  of,  474 
priu'igo  in,  375 
pruritus  in,  375 


Pregnancy,   pruritus   of  vulva 
in,  treatment,  375 
psychoses  in,  372 
ptyalism  in,  352 
treatment,  353 
puberty  and,  224 
pulmonary    tuberculosis    in, 
480 
treatment,  481 
pulse  in,  105 
pyelitis  in,  498 
diagnosis,  499 
treatment,  500 
pyelo-ureteritis  in,  498,  499 
ciuadruplets,    frequency    of, 

462 
quickening    in    diagnosis  of, 

258 
Cfuintuplets,     frequency     of, 

462 
rectal  stricture  in,  532 
rectocele  in,  414 
relation  of  cer^•ix   to  lower 

uterine  segment,  91 
relaxation    of    pehic    joints 

in,  379 
respiration  in,  106 

albuminurica  in,  506 
retinal  hemorrhage  in,  505 
retinitis  in,  505 
retractility  of  uterus  in,  94 
ringing  in  ears  in,  106 
round  ligaments  in,  94 
rules  for  women  in,  232 
rupture  of  uterus  in,  758 
chnical  course,  758 
diagnosis,  759 
treatment,  759 
salivary  secretion  in,  107 
sahvation  in,  352 

in  diagnosis  of,  252 
salpingitis  in,  520 
scarlatina  in,  477 
sensibility  of  utenis  in,  94 
sepsis  in,  478 
septate  vagina  in,  512 
serous  plethora  in,  103 
shape  of  breasts  in,  102 
shock  in,  507,  508 
signs  of,  251 

objective,  in  fii-st  trimes- 
ter, 253 
in  second  trimester,  258 
in  tliird  trimester,  263 
subjective,  in  fii-st  trimes- 
ter, 251 
in  second  trimester,  258 
in  tliird  trimester,  263 
skin  diseases  in,  375,  534 
sleepiness  in,  533 
smallpox  in,  477 
softening  of  bones  in,  504 
of  cervix,  87 

and  ^■agina  in  diagnosis 
of,  255 
spurious,  251 
stria?  in.  99,  101 
sugar  in  urine  in,  108 
sj-mptoms,  objective,  in  fii-st 
trimester,  253 
in  second  trimester,  258 
in   third  trimester,   263 
subjective,  in  first  trimes- 
ter, 251 


1052 


INDEX 


Pregnancy,  symptoms,  subjec- 
tive,    in    second    tri- 
mester, 258 
in  third  trimester,  263 
syphilis  in,  482 

treatment,  487 
syphilitic     endometritis    in, 
'519 

taste  in,  107 
teeth  in,  107 
time  of,  diagnosis,  267 
tingUng  in,  533 
toothache  in,  353,  492 
toxemia  of,  342 

presmnable,  372 

symptomatology,  343 

treatment,  343 
toxicoses  in,  372 
tramnatism  in,  507 
triplets,  frequency  of,  462 
tubal,  382 

coiu'se  of,  386 

hematocele  in,  383 

hematoma  in,  384 

ruptm-e  of  tube  in,  384 
treatment,  395 
tubo-abdominal,  381 
tubo-ovarian,  381 
tubo-uterine,  381 
tumors  of,  521 

of  bladder  in,  532 

of  uterus  in,  521 
twin,  462 

anomalies  of,  472 

characteristics  of,  464 

clinical  course,  465 

diagnosis  of,  467 
differential,  469 

etiology  of,  462 

fibroma  of  uterus  and,  dif- 
ferentiation, 469 

frequency  of,  462 

interlocking  in,  472 

polyhydramnion  in,  465 

prognosis  of,  469 

symptoms  of,  465 

treatment  of,  470 
typhoid  fever  in,  477 
ureteritis  in,  498 

diagnosis,  499 

treatment,  500 
ureteropyelitis  in,  498,  499 
ureters  in,  98 
urinalysis  in,  227 
urination  in,  frequent,  534 
urine  in,  108 
urticaria  in,  534 
uterine  souffle  in  diagnosis 

of,  262 
uterosacral  ligaments  in,  95 
vaccination  in,  477 
vagina  in,  96 
vaginal  douches  in,  228 

enterocele  in,  414 
vaginitis  in,  514 
varicose  veins  in,  105,  231, 
378 
treatment,  379 
variola  in,  477 
vesical  calcuh  in,  532 
vomiting  in,  106 

diagnosis  of,  252 

pernicious,  343.     See  also 
Hyperemesis  gravidarum. 


Pregnancy,  vulvitis  in,  514 
warts  in,  376 

with  ovarian  tumor,   retro- 
flexion of  pregnant  uterus 
and,  differentiation,  410 
Pregnant  uterus,  antefixation, 
401 
treatment,  403 
anteflexion,  398 

treatment,  399 
anteversion  of,  398 

treatment,  399 
displacements,  398 
anterior,  398 
posterior,  404 
distortion,  414 
hernia,  415 
procidentia,  414 
prolapse,  414 
retroflexion,  404 
bladder  in,  407 
chnical  course,  404 
diagnosis,  409 
etiology,  404 
gangrene  of  bladder  in, 
408 
treatment,  413 
ischuria     paradoxa    in, 

405,  408 
partial,  407 

pregnancy  with  ovarian 
tumor  and,    differen- 
tiation, 410 
prognosis,  410 
reposition  of  uterus  in, 

411 
retention    of    urine    in, 

405,  408 
symptoms,  404 
terminations,  406 
treatment,  410 
retroversion,  404 
bladder  in,  407 
chnical  course,  404 
diagnosis,  409,  410 
etiology,  404 
extra-uterine  pregnancy 
and,     differentiation, 
391 
gangrene  of  bladder  in, 
408 
treatment,  413 
ischuria     paradoxa    in, 

405,  408 
pregnancy  with  ovarian 
tumor  and,   differen- 
tiation, 410 
prognosis,  410 
reposition  of  uterus  in, 

411 
retention    of    urine    in, 

405,  408 
symptoms,  404 
terminations,  406 
treatment,  410 
sacciform   dilatation,    407 
vaginofixation,  402 
ventrofixation,  402 
ventrosuspension,  402 
Prematemity,  249 
Premature  labor,  416,  436 
definition,  114 
etiology,  419 
induction  of,  1014 


Prernatm-e  labor,  induction  of, 
by  bougies,  1016 
by  dilatation  of  cervix, 

1016 
by  puncture  of  bag  of 

waters,  1016 
conditions  in,  1015 
in  prolonged  pregnancy 
and     overgrowth     of 
child,  1014 
indications,  1014 
prognosis,  1015 
technic,  1016 
Preparatory    obstetric    opera- 
tions, 907 
Presentation,  172 

action  of  uterus  in  altering, 
diagrams  illustrating,  179 
at  outlet,  177 

back,  615.      See    also  Pres- 
entation, transverse. 
breech,  174,  176,  603 

abnormal  rotation  of  back 

in,  609 
asphyxia  in,  613 
cephalic  version  in,  942 
clinical  course,  610 
complete,  176,  605 
descent  in,  606 
deviated,  615 
diagnosis,  612 
double,  605 
etiology  of,  603 
external  restitution  in,  607 
flexion  in,  606,  607 
foothng,  605,  608 

prolapse     of     cord    in, 
treatment,  634 
frequency  of,  178,  603 
incomplete,  176,  605 
internal  anterior  rotation 

in,  606 
lateroflexion  in,  607 
mechanism   of,    603,    605, 
606 
unusual,  608 
molding  in,  612 
plastic  changes  in,  612 
prognosis,  613 
single,  176,  605,  610 
symptoms,  610 
treatment  of,  614 

manual  aid,  615 
wry-neck  in,  612 
brow,  176,  589 
correction  of,  932 

De  Lee's  method,  933, 
934 
diagnosis  of,  591 
forceps  in,  982 
frequency  of,  589 
mechanism  of,  589,  590 
molding  in,  592 
prognosis,  600 
treatment  of,  592 
cephalic,  174,  176.    See  Pres- 
entation, head 
definition  of,  172,  579 
degree  of  engagement  in,  177 
diagnosis,  by  abdominal  ex- 
amination, 279 
by   internal   examination, 
287 
divisions,  174 


INDEX 


1053 


Pre.sentatioii,  car,  posterior,  ti'J7 
fact',  17(i,  ')\)2 

chan^iiiif!;  of,   to  occipital, 

'j:i(),  '.Kil,  9:^2,  933 
clinical  course,  59G 
correction  of,  932 

De  Lee's   inetliod,   9:5;), 
934 
diagnosis  of,  r)97 
forceps  in,  9.S() 
fre(iuency  of,  17X,  .592 
niechanisMi  of,  092,  .")93 
plastic  chanjies  in,  (iOO 
prognosis  of,  (lOO 
treatment  of,  (lOO 

after    engagement,    (iOl 
before  engagement,  GOl 
footling,  ()()S 

prolajise  of  cord  in,  treat- 
ment, t)34 
forehead,  5X9 

mechanism  of  labor  in,  5S9 
frequency,  178 
head,  deviated,  615 

freciuency   of   causes,    178 
Pajot's  law  of  accommo- 
dation in,  178 
prolapse  of  arms  and  feet 

in,  ()34,  635 
version  in,  940 

conditions  necessary 

for,  941 
doul)le  manual  method, 

941 
indications,  940 
methods,  941 
in  inlet,  177 
location  in,  177 
oblique,  615 

occipital,   descent    of    head, 
183 
disengagement    of    head, 

187 
engagement  of  head,  181 
extension  of  head,  187 
external      restitution      of 

head,  188 
flexion  of  head,  183 
mechanism  of  labor  in,  181 
observations  on,    191 
shoulders,  189 
rotation  of  head,  183 

internal  anterior,  184 

occipitodcxtra   posterior, 

findings  in,  197 

mechanism  of  labor  in, 

197 

parietal  bone,  in  flat  pelvis, 

696,  697 
pelvic,  174,  176 

frequency  of,  178 
period  of  disengagement,  177 
point  of  direction,  definition, 

172 
shoulder,  176,  615.     See  also 

Prc.scHtalioti ,   transverse. 
station  in.  177 
transverse,  174,  176,  615 
anterior,  617 
attitude  in,  (>17 
bimanual  version  in,  936 
Braxton  Hicks'  method  of 

bipolar  version  in,  625 
cephalic    version    in,    624 


i'resenlaliori,    transverse,   clin- 
ical course,  616 
coMlraction-ring  in,  621 
couise  of,  618 
diagnosis  of,  622 
alxlominally,  622 
vaginally,  622 
etiology  of,  615 
f requeue}'  of,  178 
mechanism,  616 
of  lai)or  in,  615 
neglectetl,  621 

treatment  of,  625 
physometra  in,  662 
posterior,  617 
prognosis  of,  623 
prolapse  of  arm  in,  625 
retraction-ring  in,  621 
rupture  of  bag  of  waters 

in,  624,  625 
tetaims  uteri  in,  622 
threatened  rupture  of  ute- 
rus in,  621 
treatment  of,  624 
tympania  uteri  in,  622 
version  in,  624,  935 
Wright's  method  of  ver- 
sion in,  625 
vertex,  176 

freciuency  of,  178 
median,  587 

cHnical  course,  588 
diagnosis  of,  588 
mechanism  of  labor  in, 
587 
treatment,  589 
Presenting  part,  172.     See  also 

Presentalion. 
Pressure  necrosis  of  bladder  in 
labor,  763 
of  scalp  of  fetus,  707 
Pride  of  pregnane}',  110,  225 
Primordial  follicles,  3 
Private  houses,  operations  in, 
arrangement  of  room, 
900 
pi-eparation,  899 
of  patient,  900 
provisions  for  complica- 
tions, 905 
Prochownick's  diet  to  restrain 
growth  of  fetus,  715 
method   of   resuscitation   in 
asphyxia         neonatorum, 
806,  807 
Procidentia  of  pregnant  uterus, 

414 
Profeta's  law,  483 
Projection,  pelvic  floor,  96 
Prolapse   of   arm   in   shoulder 
presentation,  626 
of  arms  and  feet  with  head, 
634,  635 
treatment,  634 
of  placenta,  439 
of  pregnant  uterus,  414 
of  umbilical  cord,  626.     See 
also    Umbilical  cord,   pro- 
lapse. 
of  uterus  in  labor,  740 
Pronucleus,  female,  6 
Prophvlactic  version.  940 
Prostitutes'  colic,  382 
Prurigo  gestationis,  375 


Priuitus  in  pregnancy,  375 
of  \iilva  in  pregnancy,  treat- 
ment, 375 
Pseudo-corpus   hit  cum   forma- 
tion, 9 
Pseudocyesis,  251 
Pseudohelminth.s,  544 
Pseudo-menses,  16 
Pseudo-menstruation   in   new- 
born infant,  335 
Pseudo-osteomalacic       pelvis, 

(565 
Psychoses,  exhaustion,  in  puer- 
perium,  896 
in  pregnancy,  372 
Ptyalism  in  pregnancy,  3.52 

treatment,  353 
Puberty,  1 

pregnancy  and,  224 
Pubic  segment  in  labor,  164 
Pubiotomy,  921,  923.     See  also 

Hebosteoioiny. 
Pubococcygeal  portion  of  leva- 
tor ani,  161 
Puborectal  portion  of  levator 

ani,  161 
Pubovesical  ligaments,  763 
Puerpcra,   129,  204.     See  also 

Puerperi}im. 
Puerperal  artery,  75 
fever,  817 

abscess  of  fixation  in,  881 
antistreptococcus  serum 

in,  880 
autoinfection  in,  821 
bacillus  tetanus  in,  830 

typhosus  in,  830 
bacteremia  in,  828,  852 
metastatic,  853,  856 
pathology,  853 
symptoms,  854 
bacteriology,  820 
bacterium    coli    commune 

in,  829 
brushing    surface    of    en- 
dometrium in,  876 
classification  of  forms,  831 
clinical  types,  833 
collargol  in,  879 
colon  bacillus  in,  829 
Crede's  ointment  in,  879 
curage  of  uterus  in,  876 
curative  treatment,  875 
curetage  of  uterus  in,  876 
definition,  817 
diagnosis,  864 

ciifTerential,  867 
diet  in,  879 
diphtheria  in,  863 
drainage  of  uterus  in,  877 
emptying  uterus  in,  877 
endometritis  in,  834 
diagnosis,  839 
pathology,  835 
symptoms,  838 
etiology,  820 

predisposing  causes,  826 
exogenous     infection     in, 

824 
gas-forming    bacteria    in, 

831 
general  treatment,  878 
gonococcus  in,  829 
gonorrhea  in,  862 


1054 


INDEX 


Puerperal  fever,  gonorrhea  in, 

treatment,  862 
hetero-infection  in,  824 
history,  817 
hysterectomy  in,  881 
intramural     uterine     ab- 
scess in,  862 
intra-uterine   douches   in, 

876 
late,  843 

leukocytosis  in,  870 
ligation  of  pelvic  veins  in, 

883 
local  treatment,  875 
lochiocolpos  in,  834 
lochiometra  in,  835 
mercury  in,  879 
metastatic  bacteremia  in, 

856 
metritis  desiccans  in,  837 
milk  theory,  818 
milk-leg  in,  858,  859 
modes  of  transmission  to 

genital  tract,  821 
morbidity,  871 
mortality,  870 
nervous    temperature    in, 

867 
nuclein  in,  880 
packing  uterus  with  gauze 

in,  877 
parametritis  in,  840 

diagnosis,  845 

etiology,  840 

late,  844 

pathology,  841 

prognosis,  845 

symptoms,  843 

treatment,  845,  851 
pelveocrural    cellulitis   in, 

860 
pelvic    cellulitis    in,    840. 

See  also  Parametritis. 
perimetritis  in,  846 

diagnosis,  850 

etiology,  846 

pathology,  847 

prognosis,  850 

symptoms,  849 

treatment,  851 
peritonitis  in,   treatment, 

851 
phlegmasia  alba  dolens  in, 
858 
treatment,  860 
prognosis,  868 
prophylaxis,  873 
pyemia  in,  832,  853,  856 

diagnosis,  858 

symptoms,  856 
pyococci  in,  829 
reaction    of     organism 

against,  826 
salt  solution  in,  879 
sapremia  in,  827,  830,  832, 
839 

symptoms,  839 
Semmelweis'   theory,   818 
sepsis  in,  852 
septic     endocarditis      in, 

856 
septicemia  in,  832,  852 

pathology,  853 

symptoms,  854 


Puerperal  fever,  septicopyemia 
in,  856 
serum  treatment,  880 
silver  in,  879 
sources  of  infection,  821 
specific  infections  in,  862 

treatment,  879 
staphylococcus  in,  829 
streptococcus  pyogenes  in, 

828 
surgical  treatment,  881 
swabbing   out   uterus   in, 

876 
tetanus  in,  863 
theories  of,  818 
thrombophlebitis   in,    859 
thrombosis   of   saphenous 
and    femoral    veins    in, 
859 
toxinemia  in,  831,  839 
treatment,  873 
curative,  875 
general,  878 
local,  875 
of  bowels,  878 
of  chills,  879 
of  fever,  878 
of  mental  state,  879 
of  meteorism,  878 
prophylaxis,  873 
specific,  879 
surgical,  881 
vaccine  treatment,  880 
vaginitis  in,  833 
treatment,  834 
vulvitis  in,  833 
diagnosis,  834 
treatment,  834 
hemorrhage.        See   Hemor- 
rhage, postpartum. 
infection,    817.     See    also 

Puerperal  fever. 
insanity,  372,  373 
neuritis,  374 
osteophytes,  104,  109 
sepsis,  817.     See  also  Puer- 
peral fever. 
state,  204.     See  also  Puer- 

perium. 
wounds,  210 
Puerperium,  129,  204 
abdominal  Vjinder  in,  327 
acne  in,  377 
after-pains  in,  324 
asepsis  in,  321 
bladder  in,  221 
care  of,  322 

catheterization  of,  method, 
322 
blood  in,  220 
bowels  in,  care  of,  322 
breasts  in,  care  of.  323 
carunculaj    myrtiformes    in, 

210 
changes  in  abdominal  walls 
in,  212 
in  bladder  in,  221 
in  blood  in,  220 
in  breasts  in,  213 
in  cervix  in,  208 
in  endometriirm  in,  208 
in    external    genitalia    in, 

209 
in,  general,  218 


Puerperium,  changes,  in  intesti- 
nal tract  in,  221 

in  kidneys  in,  221 

in,  local,  204 

in  nervous  system  in,  218 

in  placental  site  in,  208 

in  pulse  in,  219 

in  respiration  in,  220 

in  skin  in,  220 

in  temperature  in,  218 

in  urinary  apparatus  in, 
221 

in  urine  in,  221 

in  uterine  serosa  in,  208 
vessels  in,  208 

in  uterus  in,  205 

in  vagina  in,  209 

weight  in,  222 
chart,  1025,  1026 
chill  in,  218,  324 
colostrum  in,  214 
conduct  of,  321 
constipation  in,  222 
diagnosis  of,  328 
diastasis  recti  in,  213 
diet  in,  321 

difficulty  of  urination  in,  896 
diseases  of  breasts  in,  884 

of  nipples  in,  890 

of  skin  in,  377 
drug  eruptions  in,  377 
eczema  in,  377 
enlargement    of   breasts   in, 

213 
erythema  multiforme  in,  377 
examination  in,  final,  327 
exercise  in,  326 
exhaustion  psychoses  in,  896 
fever  from  constipation  in, 

896 
final  examination  in,  327 
fissure  in  ano  in,  896 
foods  to  be  avoided  in,  322 
functional    disturbances    of 

breasts  in,  884 
furunculosis  in,  377 
general  changes  in,  218 
getting  up  in,  time  of,  326 
heart  disease  in,  488 
high  stomach  in,  213,  230 
instructions    to    nurse   dur- 
ing, 248 
intestinal  tract  in,  221 
involution  in,  205,  212 
kidneys  in,  221 
lactation  in,  213 

atrophy  in,  212 
lactosuria  in,  221 
leukocytosis  in,  220 
local  changes  in,  204 
lochia  in,  210 

alba  ill,  210,  211 

bacteriology,  211 

purulenta  in,  210 

quantity,  212 

sanguinolenta  in,  210,  211 

sources,  212 
massage  in,  326 
milk-sugar  in  urine  in,  221 
nervous  chills  in,  324 
pathology  of,  817 
peptonuria  in,  221 
physician's  visit  in,  324 
physiologic  chill  in,  218 


INDEX 


1055 


Pucrpcrium,  physiology,  204 
pityriasis  versicolor  in,  377 
pufsc  in,  21<>.  :j24 
respiration  in,  220 
secretion  of  milk  in,  21o 
skin  in,  220 

diseases  in,  377 
sleep  in,  32") 
suilaniina  in,  377 
sundry  complications,  896 
supcrinvolution  of  uterus  in, 

212 
tape-worms  in,  890 
temperature  in,  218,  324 
time  of  fiettiiifi;  up,  32G 
treatment,  general,  325 

summary  of  principles,  327 
tympany  in,  222 
of  ileus  in,  S9G 
urinary  apparatus  in,  221 
urine  in,  221 
urticaria  in,   377 
visitors  in,  320 
weight  in,  222 
wounds  in,  210 
Pulmonary  embolism  as  cause 
of  sudden  death  in  labor, 
793 
tuberculosis    in    pregnancy, 
4S0 
treatment,  481 
Pulse  in  abruption  of  placenta, 
441 
in  pregnancy,  10.5 
in  puerperium,  219,  324 
of  new-born  infant,   taking 
of,  338 
Puncture,  lumbar,  in  eclampsia 
3tJ7 
of  bag  of  waters,  induction 
of  premature  labor  by,  1016 
Purulent  mastitis,  894 
Puzos'   treatment  of  placenta 

previa,  452 
Pyelitis  in  pregnancy,  498 
diagnosis,  499 
treatment,  500 
Pvelo-ureteritis  in  pregnancy, 

498,  499 
Pyemia  in  puerperal  fever,  832, 
853,  856 
diagnosis,  858 
symptoms,  856 
Pygopagus,  540,  541 
Pvococci    in    puerperal  fever, 

"829 
Pyosalpinx,     ext  ra-ut  erine 
pregnancy  and,   differentia- 
tion, 392 


Quadrants  of  pelvis,  174 
Quadruplets,  frequency  of,  462 
Queen's  chloroform,  295 
Quickening     in     diagnosis     of 

pregnane}-,  258 
Quintuplets,  frequency  of,  462 


Rachischisis,  539 
Rachitic  flat  pelvis,  663 
pelvis,  662,  663 

diagnosis,  665 

flat,  662,  663 


Record    of    child,    chart    for, 
338,  1027,  1028 
of  labor,  chart  for,  289,  1023 
of     puerperiiun,     chart     for, 
325,  1025,  102r) 
Rectal    examination    in    labor, 
288 
stricture  in  pregnancy,   532 
Rectocele  in  pregnancy,  414 
Rectovaginal   fistula  in   labor, 

763 
Rectum,    cancer   of,    in    preg- 
nancy, 532 
diseases  of, -dystocia  due  to, 

f)49 
full,  dj'stocia  due  to,  649 
injuries  to,  in  labor,  765 
tumors  of,  tlystocia  due  to, 
650 
Regional  anesthesia  in  labor, 

295 
Relaxation   of  pelvic  floor  in 
labor,  727 
joints  in  pregnancy,  379 
Renal  decapsulation  in  eclamp- 
sia, 368 
Repercussion,  259 
Reposition  in  prolapse  of  um- 

bihcal  cord,  631,  632 
Respiration,    artificial,    in    as- 
phyxia   neonatormn,    807 
fetal  physiology,  67 
first,  cause  of,  139 
in  labor,  133 
in  new-born  infant,  329 

taking,  338 
in  pregnancy,  106 
in  puerperium,  220 
Respiratory  action  of  fetus,  59 
Restitution,  external,  in  occip- 
ital presentation,  188 
Retention  fever   in   puerperal 
infection,  839 
of  extra  placenta,  315 
of  urine  in  puerperium,  221 
in    retroversion    of    preg- 
nant uterus,  405,  408 
Retinal   hemorrhage   in   preg- 
nancy, 505 
Retinitis  albuminui-ica  in  preg- 
nancy, 506 
in  pregnancy,  505 
Retraction-ring   in    transverse 

presentation,  621 
Retroflexion       of       pregnant 
uterus,  404.     See  also  Preg- 
nant ulcrus,  retroflexion. 
Retroplacental  hematoma,  199 
Retroversion       of       pregnant 
uterus,  404.     See  also  Preg- 
nant uterus,  retroversion. 
Rheumatism  of  uterus,  517 
Rhomboid  of  Michaelis,  236 
Ribs,  thslocation  of,  in  labor, 

767 
Rigidity    of    cervix,    dystocia 
due  to,  644 
diagnosis,  646 
treatment,  646 
in  labor,  577 
of  pelvic  floor,  dvstocia  due 
to,  647 
diagnosis,  647 
treatment,  648 


Rigor  mortis  in  utero,  536 

of  fetus,  dystocia  due  to, 
638 
Ring,    closing,    of    Nitabuch- 
Winkler,  36 
of  Waldeyer,  43,  48 
Ringing  in  ears  in  pregnancy, 

106 
Ripe  placenta,  45 
Ritgen's  mancjeuver  in  forceps 
delivery,  973 
in  labor,  572 
Robert  pehis,  676 
Roederer's  method  of  sponta- 
neous evolution,  619 
Room  in  labor,  277 
Rotation,  abnormal,  in  breech 
delivery,  958 
(luring  fourth  act,  960 
during  third  act,  959 
arrested,  of  chin,  forceps  in, 

981 
in  occipital  presentation,  183 

internal  anterior,  184 
over-,  in  occipital  presenta- 
tion, 191 
super-,  internal,  584 
Round  ligaments  in  pregnancy, 

94 
Rubber  gloves  in  labor,  274 
sterilization  of,  1021 
De  Lee's  method,  1021 
pelvis,  504 
Rudford's  forceps,  962 
Rudimentary  horn  of    uterus, 

pregnancy  in,  509 
Rupture  of  bag  of  waters,  122, 
291 
determining,  286 
in  transverse  presenta- 
tion, 624,  625 
of  circular  sinus  of  placenta, 

444 
of  pelvic  joints  in  labor,  765 
of  sternocleidomastoid  mus- 
cle of  fetus  in  labor,  812 
of  symphysis  pubis  in  labor, 

765 
of  tube  in  extra-uterine  preg- 
nanc}',  384 
treatment,  395 
of  umbihcal  cord,  560 
of  uterus,  747 

abruption  of  placenta  and, 

differentiation,  442 
in  labor,  747 

after-treatment,  758 
diagnosis,  754 

differential,  755 
etiology,  747 
frequenc}',  750 
incomplete,     treatment 

of,  758 
patholog}',  750 
prognosis,  755 
symptoms,  752 

the  rupture,  753 
threatened,  diagnosis  of, 

754 
treatment,  756 
after  rupture,  756 
preventive,  756 
in  pregnancy,  758 
chnical  course,  758 


1056 


INDEX 


Rupture  of  uterus  in  pregnancy, 
diagnosis,  759 
treatment,  759 
threatened,   in   transverse 
presentation,  621 


Sacciform  dilatation  of  preg- 
nant uterus,  407 
Sacral  segment  in  labor,  164 
Sacropubic  diameter,  Breisky's 
method    of    measuring, 
243,  244 
measurement,  242 
Sacrum,  absence  of,  689 

loosening  of,  in  labor,  766 
Sagittal  suture,  167,  168 
Salivary     secretion     in     preg- 
nancy, 107 
Salivation  in  pregnancy,  252, 

352 
Salpingitis  in  pregnancy,  520 
Salt  solution  in  eclampsia,  367 
in    hyperemesis    gravida- 
rum, 351 
in      postpartmn      hemor- 
rhage, 789 
in  puerperal  fever,  879 
towel,  228 
Salvarsan  in  sj'philis  in  preg- 
nancy, 487 
Sanger's  cesarean  section,  990 

forceps,  983 
Santarelh's  forceps,  962 
Saphenous  veins,    thrombosis, 

in  puerperal  fever,  859 
Sapremia  in   puerperal  fever, 
827,  830,  832,  839 
symptoms,  839 
Sarcoma  deciduocellulare,  548 
Saw,  Gigh,  924 
Saxtorph's  forceps,  962 
Scalp  of  fetus,  pressure  necro- 
sis, 707 
Scanzoni-Fritsch     method     of 

forceps  delivery,  980 
Scaphocephalus,  169 
Scarlatina  in  pregnancy,  477 
Schatz's  pain   tracing   in   first 
stage  of  labor,  130 
in  second  stage  of  labor, 
130 
tokodynamometer,  130 
Schauta's  classification  of  bony 

pelvis,  654 
Schoeller's  cord  repositor,  632 
Schroder's  method  of  measur- 
ing bituberal  diameter,  242 
theory  of  pulse-rate  in  puer- 
pcrium,  220 
Schultze's  fold,  45,  48 

method  of  expulsion  of  pla- 
centa, 129,  200.  201 
swingings  in  asphyxia  neona- 
torum, 807,  808 
Scirrhus  of  placenta,  551 
Scissors,  decapitation,  1011 
Dubois,  1011 
perineum,  306 
SmeUie's,  1006 
Scoliotic  pelvis,  673 
Scopolamin-morphin    anesthe- 
sia in  labor,  295 


Sebaceous  glands,  changes  in, 

in  pregnancy.  111 
Secretion,    salivary,    in    preg- 
nancy, 107 
vaginal,  normal,  822 
pathologic,  823 
Segment,  pubic,  in  labor,  164 
sacral,  in  labor,  164 
uterine,  lower,  79,  83 

changes,  in  pregnancy,  86 
relation  of  cervix  to,  in 
pregnancy,  91 
Segmentation  nucleus,  29 
Sellheim's  law  of  accommoda- 
tion in  anterior  rotation  in 
occipital  presentation,  187 
Semen,  specific  gravity,  21,  22 
Semmelweis,  picture  of,  819 

theory  of  puerperal  fever,  818 
Sepsis  in  labor,  796 
Sepsis  in  pregnancy,  478 

puerperal,     817.     See     also 
Puerperal  fever. 
Septate  vagina  in  pregnancy, 

512 
Septic  abortion,  433 

endocarditis     in     puerperal 
fever,  8'56 
Septicemia  in  puerperal  fever, 
832,  852 
pathology,  853 
symptoms,  854 
Septicopyemia  in  puerperal 

fever,  856 
Septum,  urogenital,  161 
Serous  plethora  in  pregnancy, 

103 
Sertoh's  cells,  20 
Serima,    antistreptococcus,    in 
puerperal  fever,  880 
treatment     of     hyperemesis 
gravidarum,  351 
of  puerperal  fever,  880 
Sex,  determination,  68,  245 
Shock  in  pregnancy,  507,  508 
nervous,   of  labor,   as  cause 
of  syncope  and  death,  794 
Short  umbilical  cord,  560 
Shoulder     presentation,      615. 
See     al.so    Presentation, 
transverse. 
Shoulders,   circumference,   169 
delivery  of,  304 
dystocia  due  to,  988 

treatment,  988 
mechanism,  in  occipital  pres- 
entation, 189 
Show,  116 
Siamese  twins,  540 
Siginundine's    double    manual 
method   of  version  in   head 
presentation,  941 
Silver  in  puerperal  fever,  879 
nitrate  in  ophthalmia  neona- 
torum, 308 
Simpson's  forceps,  963 
Sinciput,  fetal,  168 
Sinus  lactiferus,  101 
Skin,  changes  in,  in  pregnancy, 
110,  262 
in  puerperium,  220 
diseases  in  pregnancy,  375, 
534 
in  puerperium,  377 


Skin  eruptions  in  new-born  in- 
infant,  333 
in  eclampsia,  care  of,  363 
navel,  334,  562 
of  fetus,  changes  in,  due  to 

sypliilis,  485 
of  new-born  infant,  333 
Skull,  fetal.     See  Fetal  head. 

trephining,  in  eclampsia,  367 
Sleep  in  puerperium,  325 
Sleepiness  in  pregnancy,  533 
Sling-carrier,  Morales',  943 
Slipping  of  forceps,  986,  987, 
988 
axial,  987 
exaxial,  987 
Smallpox  in  pregnancy,  477 
Smellie's  forceps,  962 

scissors,  1006 
Soft  parts  in  labor,  159 
Softening    of    bones    in    preg- 
nancy, 504 
of  cervix  and  vagina  in  preg- 
nancy, 255 
in  pregnancy,  87 
Somatopleure,  30 

external,  44 
Sore  nipples,  890 

treatment,  892 
Souffle,  fetal,   in  diagnosis  of 
pregnancy,  261 
placental,    in    diagnosis    of 

pregnancy,  262 
uterine,  in  diagnosis  of  preg- 
nancy, 262 
Spasm  of  cervix  in  labor,  577 
Specific  gravity  of  semen,  22 
Specula,  De  Lee's,  741 
Spermatoblasts,  20 
Spermatogones,  20 
Spermatozoid,  20 

and  ovum,  union,  28 
Spermin,  21,  22 
Spermiogones,  20 
Spermocytes,  20 
Sphincter  ani,  162 
externus,  162 
cunni,  161 
urogenital,  161 
Spina  bifida,  539 
Spinal  hernia,  539 
Spirochete  carrier,  483 

method  of    reaching   ovum, 
483 
Splanchnopleure,  30 

internal,  44 
Spleen,    changes    in,    in    preg- 
nancy, 104 
Spondylolisthetic  pelvis,  683 

diagnosis,  684 
Spondyiolizcma,  677 
Spondylotomy,  1005,  1013 
Spongy    layer    of   uterine   de- 

cidua,  32,  35 
Spontaneous  evolution,  619 
Denman's  method,  620 
Douglas'  method,  ()20 
Roederer's  method,  619 
inversion  of  uterus  in  labor, 

759 
rectification,  618 
version,  618 
Spurious  pregnancy,  251 
Stadtfeld,  asymmetry  of,  144 


INDEX 


1057 


Staphylooorpu.s     in     puerperal 

foNor,  S2!) 
Starvation   fever   in   new-horn 

infant,  '.VAS 
Statio  in  aditu,  177 

in  exitu,  177 
Station  in  prosontation,  177 
Stenosis    of    vagina,    dystocia 
due  to,  tj4(3 
diagnosis,  ()47 
etiology,  ()-l(> 
treatment,  ()47 
of  vulva,  dystocia  due  to,  048 
trmilnieiit,  048 
Stercorriieniia,  feljrile,  89G 
Sterility,    operations    to    pro- 
cure, 25 
Sterilization    in  cesarean  sec- 
tion, 996 
methods,  99(3 
of  gauze,  1022 
of  hands,  273 

Ahlfeld's     hot-water-alco- 
hol method,  273 
Fiirbringer's   method,  273 
Halsted's  method,  273 
of  rubber  gloves,  1021 

De  Lee's  method,  1021 
Sterilizer,    De   Lee's   portable, 
903 
glove,  1021 
Sternocleidomastoid  muscle  of 
fetus,  rupture,  in  labor,  812 
Sternomastoid  muscle  of  fetus, 
hematoma,  in  labor,  812,  813 
Sternopagus,  541 
Sternum,  fracture  of,  in  labor, 

7(57 
Stethoscope,  monaural,  260 
Stillicidium   sanguinis   in   pla- 
centa pra3via,  448 
Stimulation,     external,    in 
asphyxia   neonatorum,    805, 
806 
Stomach,  changes  in,  in  preg- 
nancy, 107 
high,  in  puerperium,  213,  230 
lavage,  in  hyperemesis  grav- 
idarum, 350 
Stone  child,  387 
Stools  of  new-born  infant,  331 
Stowe's  bag  for  dilatation   of 

cervix,  911 
Streptococcus   pyogenes    in 

puerperal  fever,  828 
Striir,  1 

gravidarum,  99 
on  breasts  in  pregnancy,  101 
Stricture  of  cervix  in  labor,  577 
of  uterus  in  labor,  574 

treatment,  576 
rectal,  in  pregnancy,  532 
Strong  pains.  577 
Strophulus  of  new-l)orn  infant, 

333 
Submammary  abscess,  894 
Suboccipitolircgmatic     diame- 
ter, 169 
Sudamina  in  puerperium,  377 
Sudden  death  in  labor,  793 
etiology,  793,  794 
symptoms,  795 
Sugar  in  urine  in  pregnancy, 
108 

67 


Suggestion  in  treatment  of  hy- 
peremesis   gravidarum,    350 
Superfecundation,  465 
Superfetal  ion,   165 
Supei'iiixolution    of    uterus    in 

I)ueri)eriuiii,  212 
Super-rotation,  internal,  584 
Suprarenal    extract   in    hyper- 
emesis gravidarum,  351 
Suprarenin      in      postpartum 

hemorrhage,  787 
Suture,  coronary,  lli7 

frontal,  168 

lambdoid,  167 

of   perineum   in   lacerations, 
736 

sagittal,  167,  168 

temporal,  168 
Sutures  of  fetal  skull,  167 
Swabbing  out  uterus  in  puer- 
peral fever,  87() 
Sweat-glands,    changes    in,   in 

pregnancy.  111 
Symphysiotomy,  921 

after-care,  927 

bed,  926 

in  contracted  pelvis,  719 

prognosis,  929 
Symphysis  pubis,  rupture,   in 

labor,  765 
Synclitism,  182 
SjTicope  in  labor,  793 
diagnosis,  795 
symptoms,  795 
treatment,  795 
SjTicytial  giant-cells,  36 
Syncj' tioma  malignum,  548 
Syncytium,  32,  38 

cilia  of,  38,  39 
Syphilis,  effects  of  pregnancy 
on,  482 

in  pregnancy,  482 
treatment,  487 

maternal,  effects  of,  on  preg- 
nancy, 482 

nursing  in,  487 

paternal,  effects  of,  on  preg- 
nancy, 483 
Syphihtic  changes  in  fetus,  485 

endometritis   in    pregnancy, 
519 

osteochondritis  in  fetus,  487 


Tabes  lactea,  886 
Tamponade,    lysol   gauze   for, 
1022 
stcrihzation,  1022 
uterine,  in  postpartum  hem- 
orrhage, 784 
Tapeworms  in  puerperium,  896 
Tapir-nosed  cer\-ix,  648 
Tarnier's  axis-traction  forceps, 
984 
bag  for  artificial  dilatation  of 

cervix,  911 
basiotribe,  1006 
classification  of  bony  pelvis, 

656 
embryotome,  1011 
Taste  in  pregnane}-,  107 
Teeth  in  pregnancy,  107 
Telescope,  operating,  De  Lee's, 
903 


Temperature  in  labor,  133 

in  [)uerj)erium,  218,  324 
nervous,  in  puerperal  fever, 

S67 
{)(  new-born  infant,  330 
taking,  338 
Temporal  sutures,  168 
Terala  anadidytna,  539 
kata-anadidyma,  539 
katadidyma,  539 
Teratology,  537 
Tetanus  bacillus  in  puerperal 
fe\-er,  830 
in  puei-peral  fever,  863 
uteri,  573 

diagnosis,  575 
in  transverse  presentation, 
622 
Teterelle,  891 
Theca  folliculi,  5 
Therapeutic  abortion,  1018 
Therapeutics,  antenatal,  249 
Thoracogastroschisis,  539 
Thorn's   method   of   changing 
face  to  occipital  position,  93(3 
Threatened  abortion,  422,  423 
diagnosis,  423 

differential,  424 
treatment,  425 
rupture  of  uterus  in  labor, 
diagnosis,  754 
Throat  and  nose,  diseases,  in 
pregnancy,  505,  506 
changes    in,    in    pregnancy, 
106 
Thrombophleliitis  in  puerperal 

fever,  859 
Thrombosis  as  cause  of  sudden 
death  in  labor,  793 
in  eclampsia,  360 
of    saphenous    and    femoral 
veins  in   puerperal   fever, 
859 
ThjToid  extract  in  eclampsia, 
367 
gland,  changes  in,  in  preg- 
nancj-,  104 
Tight-rope  walker's  tread,  686 
Tingling  in  pregnane^',  533 
Tissue  forceps,  729 
Tokodynamometer,     Schatz's, 

130 
Toothache  in  pregnancy,  353, 

492 
Torsion  of  umbilical  cord,  558 
Tough    membranes,    dystocia 
due  to,  641 
treatment,  642 
Toxemia,  preeclamptic,  354 
of  pregnancy,  342 
symptomatology,  343 
treatment,  343 
presumable,    in    pregnancy, 
372 
Toxicoses  in  pregnancy,  372 
Toxinemia,  827 

in  puerperal  fever,  831.  839 
Trachea,  catheterization  of,  in 

asphyxia  neonatorum,  805 
Tracheal  catheter,  804 

method     of     introducing, 
805 
Transfusion  of  blood  in  post- 
partum hemorrhage,  790 


1058 


INDEX 


Tl•anij^"el•se   arrest,    deep,    for- 
ceps in,  97-i 
in  O.  D.  P.,  forceps  in,  976 
presentations,  174,  176,  615. 
See  also  Presentation, 
transverse. 
tension  of  innominate  bones, 
6.52 
Transversely  contracted  pelvis, 

675 
Traumatism  in  pregnancy,  507 
Travail  insensible,  117    ' 
Trefoil  placenta,  50 
Trephine,  Braun's,  1006 

Martin's,  1008 
Trepliining  skull  in  eclampsia, 

367 
Triangle,  fetal,  282 
Trigonocephalus,  169 
Triplets,  frequency  of,  462 
Trophoblast,  32,  37 
Trophosphere,  33,  35 
True  corpus  luteum,  9 

knots  on  umbilical  cord,  52 
Trunk    of    fetus,    injuries,    in 

labor,  812 
Tubal  abortion,  383 
treatment,  395 
menstruation,  16 
moles,  383 
pregnancy,  382 
course,  386 
hematocele  in,  383 
hematoma  in,  384 
rupture  of  tube  in,  384 
treatment,  395 
Tubera  parietalia,  169 
Tubercles,  Montgomery's,  101 
Tuberculosis  in  fetus,  480 
pulmonary,     in    pregnancy, 
480 
treatment,  481 
Tubo-ovarian  pregnancy,   381 
Tubo-utorino  pregnancy,  381 
Tumors  in  pregnancy,  521 
of  bladder,  dystocia  due  to, 
649 
in  pregnancy,  532 
of  placenta,  557 
of  rectum,  diseases  due  to, 

650 
of  umbilical  cord,  560 
of  uterus  in  pregnancy,  521 
ovarian,  in  pregnancy,  529. 
See  also  Ovarian  tumors  in 
pregnancy. 
Tunica  fibrosa  of  ovary,  4 

propria  of  ovary,  4 
Turbinate  bones,  turgidity  and 

swelling,  in  labor,  134 
Twilight  sleep,  295 
Twin     pregnancy,     462.     See 

also   Frerjnancy,  tvin. 
Twins,  Blazek,  540 
homologous,  539 
Johnson,  540 
Siamese,  540 
Tympania  uteri  in  transverse 

presentation,  622 
Tympany   in   puerperal   fever, 
treatment,  878 
inpuerperium,  222 
of     ileus     in     puerpjerium, 
896 


Typhoid  bacillus  in  puerperal 
fever,  830 
fever  in  pregnancy,  477 


Umbilical  cord,  51 

abnormal    insi  "tion,     560 

treatment,  56"    '  f 
anomalies,  553     --. 
arteries,  44,  51,  52 
coiling  of,  558 

diagnosis,  559 
cysts,  560 
development,  44 
diseases,  abortionf  rom,  417 
false  knots,  52 
fat,  51 

gangrene,  334 
hernias  into,  561 
in  new-born  infant,    care 

of,  336 
insertion  in  placenta,  50 
knots,  52,  558 
false,  52,  558 
true,  52,  558 
lean,  51 
length,  51 
ligation,  307 
long,  560 

mummification,  334 
prolapse,  626 

cesarean  section  for,  634 
course,  627 
diagnosis,  628 
etiology,  626 
in  breech  presentation, 

treatment,  634 
in  footling  presentation, 

treatment,  634 
prognosis,  627 
reposition  in,  631,  632 
treatment,  629 

forelying  cord,  629 
when     prolapse     has 
occurred,  630 
version  in,  630,  631 
rupture  of,  560 
separation  of,  334 
short,  560 
spiral  twists,  51 
true  knots,  52 
tumors,  560 
tying,  307 
veins,  44,  51,52 
velamentous  insertion,  561 
hernia,  539 
vein,  44 
vesicle,  45 
Unavoidable  hemorrhage,  437, 

445 
Urea  in  liquor  amnii,  53 
Uremia,  eclampsia  and,  differ- 
entiation, 360 
Ureteritis  in  pregnancy,  498 
-  diagnosis,  499 
treatment,  500 
Uret(!ropyehtis   in   pregnancy, 

498,  499 
Ureters  in  labor,  134 

in  pregnancy,  98 
I'rothra  in  labor,  134 
Urinalysis  in  pregnancy,  227. 
Urinary  .system,  changes  in,  in 
puerperium,  221 


Urinary  system,  diseases  of,  in 
pregnancy,  496 
in  labor,  134 
Urination,     difficulty     of,     in 
puerperium,  896 
frequent,  in  pregnancy,  534 
in  new-born  infant,  care  of, 
337 
Urine  in  labor,  135 

in  new-born  infant,  331 
in  pregnancy,  108 
in  puerperium,  221 
retention  of,  in   puerperium, 
221 
in    retroversion    of    preg- 
nant uterus,  405,  408 
sugar  in,  in  pregnancy,  108 
Urogenital  diaphragm,  161 
septum,  163 
sphincter,  161 
Urticaria  in  pregnancy,  534 

in  puerperium,  377 
Uterine  abscess,  intramural,  in 
puerperal  fever,  862 
artery,  74 
atony,  770 

contractions   in   labor,    117, 
119,  129 
mechanism,  149 
intermittent,  in  diagnosis 
of  pregnancy,  259 
curet,  De  Lee's,  427 
douche,  hot,  in  postpartum 

hemorrhage,  782 
milk,  32,  61 

mucous  membrane,  embed- 
ding of  ovum  in,  31 
segment,  lower,  79,  83 

changes,  in  pregnancy, 

86 
relation  of  cervix  to,  in 
pregnancy,  91 
serosa,  changes  in,  in  puer- 
perium, 208 
souffle  in  diagnosis  of  preg- 
nancy, 262 
tamponade    in    postpartum 

hemorrhage,  784 
vessels,  changes  in,  in  puer- 
perium, 208 
Uterosacral  ligaments  in  preg- 
.    nancy,  95 

Uterus,  action    of,  anomalies, 
in  labor,  567 
in    altering    presentation, 
diagrams      illustrating, 
179 
in  labor  with   contracted 
pelvis,  691,  692 
arcuatus,  82,  509,  511 
arteries  of,  74 
atony  of,  in  labor,  567 
axis,  in  pregnancy,  83 
bicornis  duplex,  510,  511 
unicollis,  511 

unolatere     rudimentarius, 
512 
bilocularis,  511 
blood-supply,  74 
changes  in,  in  extra-uterine 
pregnancy,  387 
in  form,  size,  consistence, 
and  position,  in  diagnosis 
of  pregnancy,  256,  262 


INDEX 


1059 


Uterus,  ch;iiiK<'.s  in  physiology 
of,  in  pregnancy,  '.M 
ill  pregnancy,  70 
in  pueiperiuin,  'JO') 
in    sliape,    in    pregnancy, 
78 
at  term,  80 
compression  of,  in  postpar- 
tum liemorrliage,  783 
contractions  of,  in  labor  117, 
ll'.t,  I'J!) 
mechanism,  149 
in  pregnancy,  04 
curetage    of,    in    ine\itable 
abortion,  427 
in  puerperal  fever,  876 
didelphj's,  500 
dilatation    of,    in    emptying 
uterus  in  inevitable 
abortion,  432 
in  pregnancy,  94 
diverticula  of,  in  pregnancy, 

514 
double,  513 

drainage     of,     in     cesarean 
section,  995 
in  puerperal  fever,  877 
dropping,   in  pregnancy,  84 
effect  of  pituitaiy  extract  on, 

104 
elasticity,  in  pregnancy,  94 
emptying.     See    Labor,    in- 

(luclion  of. 
fibro-elastic  tissue,  72 
fibroids    of,    in    pregnancy, 
521.     See  also  Fibroids  of 
uterus  in  pregnancij. 
fibroma  of,  twins  and,  dif- 
ferentiation, 469 
hour-glass  contraction,  772 
in  menstruation,  13 
incarceration,  in  retroversion 

of  pregnant  uterus,  407 
invasion  of,  in  third  stage  of 

labor,  316 
inversion   of,   in   labor,  759. 
See      also     Inversion      of 
uterus  in  labor. 
involution  of,  in  puerperium, 

212 
irritable,  417 

in  pregnancy,  94 
influence   of,    on   produc- 
tion of  labor,  115 
isthmus,  86,  92 
lightening,  83,  84 
lymphatics,  75 
massage  of,   in  postpartum 
hemorrhage,  781 
in    third    stage   of  labor, 
310 
mucous  membrane,  embed- 
ding of  ovum  in,  31 
muscle-fibers  of,  72 
myoclonia  of,  in  labor,  573 
myoma  of,  in  pregnancy,  521. 
See  also  Fibroids  of  uterus 
in  pregnancy. 
nerve-centers,  78 
nerves,  76 

packing   of,    in   postparttmi 
hemorrhage,  784 
with  gauze,   in  puerperal 
fever,  877 


Uterus,  passive  contraction  of, 
619 
perforation  of,  in  emptying 
uterus  in  inevitable  abor- 
tion, 431 

pregnant.     See   Pregnant 

i:  Ictus. 
.toL.p.se  of,  in  labor,  740 

reposition,  in  retroversion 
and  retroflexion,  411 

retractility,  in  pregnancy, 
94 

retroversion  of,  pregnancy 
in,  extra  -  uterine  preg- 
nancy and,  differentiation, 
391 

rheumatism  of,  517 

rudimentaiy,  pregnancy  in 
one  horn,  509 

rupture  of,  747.  See  also 
Rupture  of  uterus. 

sensibilit}^,  in  pregnancy,  94 

septus  duplex,  511 

settling,  in  pregnancy,  84 

stricture  of,  in  labor,  574 
treatment,  576 

subseptus  unicollis,  511 
unicor]:)orcus,  511 
uniforis,  511 

superinvolution  of,  in  puer- 
perium, 212 

swabbing  out,  in  puerperal 
fever,  876 

tamponade  of,  gauze  for, 
1022 

tetanus  of,  in  labor,  573 
diagnosis,  575 
in  transverse  presentation, 
622 

tumors  of,  in  pregnancy,  521 

unicornis,  512 

veins,  75 

virgin,  shape,  79 


pregnancy. 


Vaccination 

477 
Vaccine  treatment  of  puerperal 

fe^-er,  880 
Vagina,  bacteria  in,  291,  822 
bluish  discoloration,  in  preg- 
nane}', 254 
changes  in,   in  puerperium, 

209 
double,  513 

hematoma  of,  in  labor,  743 
etiolog}-,  743 
prognosis,  744 
symptoms,  743 
treatment,  744 
in  pregnancy,  96 
laceration  of,  in  labor,  739 
prognosis,  742 
treatment,  742 
operations  preparing,  for  de- 

\\\QV\,  920 
septate,  in  pregnancy,  512 
softening  of,  in  diagno.sis  of 

pregnancy,  255 
stenosis  of,  dvstocia  due  to, 
646 
diagnosis,  647 
etiology,  646 
treatment,  647 


Vaginal  cesarean  section,  916 

dang<"rs,  919 

in  abruption  of  placenta, 

444 
in  [liacenta  pra-via,  461 
indications,  920 
preparations  for,  916 
technic,  916 
douches  in  pregnancy,  228 
enterocc'le  in  pregnancy,  414 
hysterotomy,    916 
ovariotomy       in       ovarian 

tumors,  532 
secretion,  normal,  822 

pathologic,  823 
walls,     eversion,     in     preg- 
nancy, 414 
'S'aginitis  in  pregnancy,  514 
in  puerperal  fever,  833 
treatment,  834 
Vaginofixation  of  pregnant 

uterus,  402 
Vagi t us  uteri nus,  801 
Van   Hoorn's   method   of   de- 
livering after-coming  head, 
960 
Varicose  veins  in  pregnancy, 
105,  231,  378 
treatment,  379 
Variola  in  pregnane}-,  477 
Vasa  omphalomesenterica,   45 
Vedder's  forceps,  983 
Veins,  femoral,  thrombosis  of, 
in  puerperal  fever,  859 
of  uterus,  75 

pelvic,  ligation  of,  in  puer- 
peral fever,  883 
saphenous,     thrombosis    of, 

in  puerperal  fever,  859 
umbiUcal,  44,  51,  52 
varicose,  in  pregnane}-,  150, 
231,  378 
treatment,  378 
Velamentous  insertion  of  um- 
bilical cord,  561 
Venereal  cUsease,  communica- 
tion   to    wife    by  husband, 
224 
Venesection  in  eclampsia,  367 
Venter  propendens,  398 
Ventre  en  besace.  99,  398 
Ventrofixation  of   pregnant 

uterus,  402 
Ventrosuspension  of  pregnant 

uterus,  402 
Veratrone  in  eclampsia,  367 
Veratrum  ^■iride  in  eclampsia, 

367 
Vernix  caseosa,  52,  333 
^'ersion,  934 
bimanual,  936 

in  transverse  presentation, 
936 
bipolar,  934 

Braxton  Hicks',  942,  944 
in  placenta  prsevia,  454 
in  transverse  presenta- 
tion, 625 
cephalic,  934 

in  breech  presentaton.  942 
in  transverse  presentation, 
624 
combined,  934 
conditions  necessary  for,  936 


1060 


INDEX 


Version,  external,  934 
in  contracted  pelvi.s,  717 
in  head  presentation,  940 
conditions  necessary 

for,  941 
double  manual  method, 

941 
indications,  940 
methods,  941 
in  prolapse  of  umbilical  cord, 

630,  631 
in    transverse    presentation, 

624,  935 
internal,  934 
podahc,  934,  936 
prognosis,  945     • 
prophylactic,  940 
spontaneous,  618 
AViegand's  method,  935 
Wright's  method,   in  trans- 
verse presentation,  625 
Vertex,  fetal,  169 
presentation,  176 
frequency,  178 
median,  587 

clinical  course,  588 
diagnosis,  588 
mechanism  of  labor  in, 
587 
treatment,  589 
Vesicle,  blastodermic,  30 

umbilical,  45 
Vesicalar  mole,  544.     See  also 

Hydatidiform  mole. 
Vestibule,  bluish  discoloration, 

in  pregnancy,  254 
Vibratory   massage   of   uterus 
ii^  postpartum  hemorrhage, 
781 
Vicarious  menstruation,  19 
Vienna  School  forceps,  963 
Vilh,  anchoring,  40,  41,  42 

of  placenta,  37 
Violent  inversion  of  uterus  in 
labor,  759 


Virgin  uterus,  shape,  79 
Viscera  of  fetus,    changes  in, 
due  to  syphilis,  485 
injuries,  in  labor,  813 
Visit,  physician's,  before  labor, 
244 
in  puerperium,  324 
Visitors  in  puerperium,  326 
Vital  dilatation,  259 

in  labor,  150 
Vitelhne  circulation,  61 

sac,  45 
Vitellus,  45 

Vomiting  in  labor,  134 
in  pregnancy,  106,  252 
pernicious,  343.     See  also 
Hyperemesis       gravida- 
rum. 
Voorhees'  bag  for  dilatation  of 

cervix,  911 
Vulva,  hematoma  of,  in  labor, 
743 
etiology,  743 
prognosis,  744 
symptoms,  743 
treatment,  744 
injmies  of,  in  labor,  725 
pruritus    of,    in    pregnancy, 

treatment,  375 
stenosis  of,  dystocia  due  to, 
648 
treatment,  648 
Vulvitis  in  pregnancy,  514 
in  puerperal  fever,  833 
diagnosis,  834 
treatment,  834 


Walcher  position,  717 

in  moderately  contracted 
pelvis,  716 
Waldeyer's    closing    ring,    43, 
48 
germinal  epithehum,  3 


Wansbrough's  lead  nipple- 
shield,  891 

Warts  in  pregnancy,  376 

Weak  pains,  567 

treatment  of,  571 

Wehen,  117 

Weighing  new-born  infant,  338 

Weight,   changes  in,   in  preg- 
nancy, 107 
in  puerperium,  222 
chart,  infant's,  332 
in  labor,  136 
of  fetus,  54 

at  term,  57 
of  new-born  infant,  331 

Wellenbewegung,  18 

Wharton's  jelly,  49,  51 

White  infarcts  of  placenta,  49, 
551,  553 
hue,  160 

Wiegand-Martin  method  of  de- 
livering after-coming  head, 
950 

Wiegand's  method  of  version, 
935 

Winkler,  edge  of  closing  plate 
of,  43 

Winkler-Nitabuch,  closing  ring 
of,  36 

Wormian  bones,  168 

Worms,  tape-,  in  puerperium, 
896 

Wound  infection,  831 
intoxication,  831 

Wounds,  puerperal,  210 

Wright's  method  of  version  in 
shoulder  presentation,  625 

Wry-neck  in  breech  presenta- 
tion, 612 


Xiphopagus,  541 
X-rays  in  diagnosis  of  ectopic 
pregnancy,  394 


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